中国高血压防治指南培训手册.ppt

Hypertension高血压,Definition,Hypertension is defined as a SBP of 140 mmHg or greater and/or a DBP of 90 mmHg or greater in subjects who are not taking antihypertensive medication.95%Essential or primary hypertension 5%Secondary hypertension,Epidemiology,Prevalence rate（患病率）of hypertension in China:In 1959-5.11%In 1979-7.73%In 1991-11.88%In 2004-18.80%The prevalence of high BP increases with age.Hypertension is more common in men than in women up to age 50,after that age,hypertension is more common in women.Hypertension is more common in northern China than in southern China.,Etiology and pathogenesis of EH,No cause can be establishedPossible factors Genetic tendency Spontaneous hypertension rat EH tends to cluster in families Environemnts,高血压,遗 传,环 境,高 盐 饮 食,肥胖,精神压力过重,饮 酒,体育锻炼少,Pathogenesis of EH,sympathetic nervous system activity RAAS肾脏潴钠Vessel remoldingVascular endothelium dysfunction nitric oxide endothelin Insulin resistance(胰岛素抵抗)sodium reabsorption,sympathetic nervous system activity,intracellular Na Ca,病 理,血管：全身细小动脉病变大中动脉病变 心：左心室后负荷增加心肌肥厚 与扩大心力衰竭；动脉粥样硬化脑：脑小动脉硬化。脑血栓、脑出血、脑水肿肾：肾细小动脉硬化。肾单位萎缩 肾功能衰竭,Clinical findings,BP波动-，White coat EHSymptoms-Mild to moderate EH is usually associated with normal health for many years.Some patients have headache,tinnitus（耳鸣）,palpitation,tiredness（疲劳）,and so on.Signs-BP is elevated.Some patients have a loud aortic second sound and an early systolic ejection click(收缩期喷射喀喇音).,Clinical findings(Continue),Complications:Hypertensive cardiovascular disease,CHD Hypertensive cerebrovascular disease Hypertension is the major predisposing cause of stroke.Hypertensive renal disease Chronic hypertension leads to nephrosclerosis(肾硬化症)Aortic dissection（主动脉夹层）,blood pressure measurement,WHO不同测量方法的高血压定义 SBP DBP 诊室偶测血压 140 90 在家测量血压 135 8524小时动态测压 130 80,Normal reference of ABPM(mmHg）,24h Daytime Nighttime SBP DBP SBP DBP SBP DBPStaessen 133 82 140 88 125 76JNC-7 135 85 120 75China3 130 80 135 85 125 75,Laboratory investigations,Routine investigationsUrinalysis（尿液检查）Serum potassium,BUN（尿素氮),Cr（肌苷),Serum uric acid(尿酸),Fasting glucose,Plasma cholesterol,and so on.,Laboratory investigations,ECGUCG ventricular hypertrophyChest X-ray ventricular enlargementFunduscopic examination retina arteriolar narrowing arteriovenous nicking(动静脉交叉压迫)hemorrhage,exudate(渗出)papilledema(视神经乳头水肿),Diagnosis&differential diagnosis,To confirm a chronic elevation of blood pressure and determine its levelTo identify secondary causes of hypertension To determine the presence of target-organ damage and to quantify its extentTo search for other cardiovascular risk factors&clinical conditions that may influence prognosis&treatment,Classification of Blood Pressure Levels(mmHg),Category Systolic DiastolicOptimal 120 80Normal 130 85High-normal 130-139 85-89Grade 1 hypertension(mild)140-159 90-99 Subgroup:borderline 140-149 90-94Grade 2 hypertension(moderate)160-179 100-109Grade 3 hypertension(severe)180 110 Isolated systolic hypertension 140 90 Subgroup:borderline 140-149 90,2003 美国JNC-7 血压水平分类,中国2004高血压指南,类 别 收缩压(mmHg)舒张压(mmHg)正常血压 120 80 正常高值 120139 8089 高血压 140 901级高血压（轻度)140159 90992级高血压(中度)160179 100109 3级高血压(重度)180 110单纯收缩期高血压 140 90,Stratification of Risk to Quantify Prognosis,危险分层 The prognosis(预后)of patients with hypertension should not be based on the level of BP alone,but also on the presence of other risk factors,target organ damage as well as concomitant diseases such as diabetes,&cardiovascular or renal disease.,Risk factors used for risk stratification,Levels of SBP and DBP(grades 1-3)Men55 yearsWomen65 yearsSmokingTC5.72mmol/L DiabetesFamily history of premature cardiovascular disease（早发心血管病家族史）（Men55 years，Women65 years）,Target-organ damage,Left ventricular hypertrophy（ECG、echocardiography or chest X-ray）Proteinuria(蛋白尿)and/or slight elevation of plasma creatinine（肌酐）concentration(106-177mol/L)Ultrasound or radiological evidence of atherosclerotic plaque(动脉粥样斑块)(carotid、femoral arteries（股动脉）and aorta）Generalized or focal narrowing of the retinal arteries（视网膜动脉）,Associated clinical conditions,Cerebrovasculardisease Ischemic stroke Cerebral hemorrhage Transient ischemic attackHeart disease Myocardial infarctionAnginaCongestive heart failure,Renal diseaseDiabetic nephropathyRenal failure（plasma Cr 177mol/L）Vascular diseaseDissecting aneurysmArtery diseaseAdvanced hypertensive retinopathyHemorrhage or exudatesPapilledema,高血压危险度分层,Secondary hypertension,It is a hypertension of known cause.The importance of identifying patients with SH is that they can sometimes be cured by surgery or by specific medical treatment.,Renal parenchymal diseases,The most common causes of SH Any diseases of the renal parenchyma(肾实质):glomerulonephritis(肾小球肾炎),diabetic nephropathy(肾病),polycystic kidneys(多囊肾).Most cases are related to increased intravascular volume or increased activity of the RAS,Renovascular hypertension,Diagnostic clues:The onset is below age 20 or after age 50 The hypertension is difficult to control Upper abdominal bruit(杂音)Abrupt deterioration（恶化）in renal function after administration of ACEIRenal angiography（肾血管造影术）is the best diagnostic test.,Pheochromocytoma(嗜铬细胞瘤),Clinical clues:Paroxysmal（阵发性）hypertensionEpisodes of diaphoresis(出汗),palpitation,headache,pallor(苍白)。Laboratory investigations:Blood catecholamines（儿茶酚胺）are elevatedUrinary vanillylmandelic acid（香草基杏任酸）CT or MRI(magnetic resonance imaging),Primary hyperaldosteronism,Slight to moderate blood pressure elevatedEpisodes of generalized muscular weakness or paralysis(瘫痪)polyuria and nocturia(夜尿)Hypokalemia Aldosterone（醛固酮）concentrations in urine Patients with a solitary(孤立的)adenoma(腺瘤)should undergo resection of the tumor Patients with bilateral adrenal hyperplasia(增生)are treated with spironolactone(螺内酯),Other causes of secondary hypertension,Cushings syndromeCoarctation of the aorta(主动脉缩窄)Drug usePregnancy(妊娠),Treatment strategies&risk stratification,Low-risk group:monitor BP and other risk factors for 6-12 months，if goal BP is not attained,drug treatment should be initiated.Medium-risk group:monitor BP and other risk factors for 3-6 months，if goal BP is not attained,begin drug treatment High-risk group&Very-high-risk group:should begin drug treatment Lifestyle modification should be used in all hypertensive patients,Treatment,The goal of antihypertensive therapy is to reduce cardiovascular morbidity&mortality.The BP goal of antihypertensive therapy To achieve high normal BP(140/90 mmHg)in elderly patients To achieve normal BP(130/80mmHg)in young,middle-aged or diabetic subjects,Nonpharmacological treatments,Include:Weight reduction Complex dietary changes Increased physical activity Moderation of alcohol consumption Smoking cessation Others(psychologic equilibrium),Pharmacologic therapy,Principles of drug treatmentThe use of low doses of drugs to initiate therapyThe use of long-acting drugs providing 24h efficacy on a once-daily basisThe use of appropriate drug combinations to maximize hypotensive efficacy while minimizing side effects,Six main drug classes,Diuretics(利尿剂):DHCT,Furosemide(呋塞米)-blockers:Atenolol,Metoprolol Ca antagonists:Nifedipine,Amlodipine ACE inhibitors:Enalapril,Captopril AII antagonists:Losartan,Valsartan-blockers:Prazosin,Terazosin,Antihypertensive drug therapy for patients with co-morbid conditions,Indication Drug treatment Diabetes with proteinuria ACEI,ARBHeart failure ACEI,ARB,diureticsIsolated systolic hypertension Diuretics,Ca blockersMyocardial infarction-blocker,ACEI,ARBAngina-blocker,Ca blockersBenign prostatic hyperplasia-blocker Dyslipidemia-blocker Tachyarrhythmias-blocker,Ca blockers,高血压药物治疗步骤第一步：单药应用 根据病情，选择一种一线药物，从小剂量开始，逐步达到有效剂量。方案选择：选用下列药物中的一种利尿剂（双克、吲哒帕胺）、受体阻滞剂、CCB、ACEI、ARB。JNC-7推荐噻嗪类利尿剂可作为大多数无合并症的高血压患者的首选，但在有合并症存在的高危情况下，应首选其它类型的降压药。,第二步 联合用药,利尿药,ACE抑制剂,钙拮抗剂,阻滞剂,AT1受体阻滞剂,阻滞剂,高血压危象（Hypertensive crisis）,高血压急症（Hypertensive urgencies）急进型恶性高血压 血循环儿茶酚胺水平过高 围手术期高血压高血压危症（Hypertensive emergencies）伴急性靶器官损害,治疗要点,静脉给药 口服给药，长期控制；综合治疗，因病、因人而异；降压迅速-适度；高血压危症应立即降压；高血压急症在数小时至24小时逐渐降血压降至安全水平。,