高血压(英文版)课件

HypertensionHypertensionHypertension1IntroductionHypertension is a major public health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease.Approximately 100 million Chinese have elevated BP.Of these,77%are aware of their diagnosis,70%are receiving treatment,and only 33%are under control.IntroductionHypertension is a 2Definition Hypertension Hypertension is is defined defined as as a a SBP SBP of of 140 140 mmHg mmHg or or greater greater and/or and/or a a DBP DBP of of 90 90 mmHg mmHg or or greater greater in in subjects subjects who who are are not not taking taking antihypertensive antihypertensive medication.medication.Essential Essential or or primary primary hypertension hypertension is is a a hypertension of hypertension of ununknown cause.known cause.Isolated Isolated systolic systolic hypertension hypertension is is defined defined as as SBP SBP of of 140 140 mmHg mmHg or or greater greater and and diastolic diastolic BP BP less less than than 90 90 mmHg.mmHg.Definition Hypertension is def3ClassificationofBloodPressureLevels(mmHg)Category Category Systolic DiastolicSystolic 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 Classification of Blood Pressu4Notes1.When a patients SBP and DBP fall into different categories,the higher category should apply.e.g.154/100 mmHg is defined as grade 2 hypertension.180/82 mmHg is defined as grade 3 isolated systolic hypertension.Notes1.When a patients SBP a5Notes(Continue)2.BP is based on the average of two or more readings taken at each of two or more visits after an initial screening(筛查).e.g.12/2 first visit:172/102 mmHg,168/104 mmHg.13/2 second visit:158/98 mmHg,158/96mmHg.The average BP is 164/100 mmHg,which is defined as grade 2 hypertension.Notes(Continue)2.BP is based 6Notes(continue)3.The patient should be clearly informed that a single elevated reading does not constitute a diagnosis of hypertension but is a sign that further observation is required.For instance:21/3 1st visit:146/98mmHg,150/98mmHg23/3 2nd visit:128/84,126/8027/3 3rd visit:130/80,130/82 Notes(continue)3.The patient 7Notes(continue)4.Optimal BP with respect to cardiovascular risk is less than 120/80 mmHg.However,unusually low readings should be evaluated for clinical significance.For example,70/50 mmHg is less than 120/80 mmHg,but it is not optimal.Notes(continue)4.Optimal BP w8ClassificationofBloodPressureLevels(mmHg)Category Category Systolic DiastolicSystolic DiastolicHypotension?90 60Optimal 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 Classification of Blood Pressu9EpidemiologyPrevalence ratePrevalence rate（患病率）of hypertension in China:of hypertension in China:In 1959,5.11%In 1959,5.11%In 1979,7.73%In 1979,7.73%In 1991,11.88%In 1991,11.88%The prevalence of high BP increases with age.The prevalence of high BP increases with age.Hypertension Hypertension is is more more common common in in men men than than in in women women up up to to age age 50,50,after after that that age,age,hypertension hypertension is is more more common in mon in women.Hypertension Hypertension is is more more common common in in northern northern China China than than in southern China.in southern China.EpidemiologyPrevalence rate（患病（患病10EtiologyandpathogenesisofEHNo cause can be establishedNo cause can be establishedPossible mechanismsPossible mechanisms Genetic tendency Genetic tendency Spontaneous hypertension rat Spontaneous hypertension rat EH tends to cluster in families EH tends to cluster in families High salt intake High salt intake some hypertensives some hypertensives Vascular endothelium dysfunction Vascular endothelium dysfunction nitric oxidenitric oxide endothelinendothelin Etiology and pathogenesis of E11PathogenesisofEH(Continue)Insulin Insulin resistance(resistance(胰岛素抵抗胰岛素抵抗)sodium sodium reabsorptionreabsorption,sympathetic sympathetic nervous nervous system activitysystem activity,intracellular Na Ca,intracellular Na Ca Cigarette smoking Cigarette smoking by by increasing increasing plasma plasma norepinephrine(norepinephrine(去甲肾上腺素)Excessive use of alcohol Excessive use of alcohol perhaps perhaps by by increasing increasing plasma plasma catecholaminescatecholamines儿茶酚胺So,So,the the pathogenesis pathogenesis of of EH EH is is multifactorialmultifactorial.Pathogenesis of EH(Continue)12ClinicalfindingsSymptoms:Symptoms:Mild Mild to to moderate moderate EH EH is is usually usually associated associated with normal health for many years.with normal health for many years.Some Some patients patients have have headache,headache,tinnitustinnitus（耳耳鸣鸣）,palpitation,palpitation,tirednesstiredness（疲劳）（疲劳）,and so on.and so on.Signs:Signs:BP is elevated.BP is elevated.Some Some patients patients have have a a loud loud aortic aortic second second sound sound and and an an early early systolic systolic ejection ejection clickclick(收缩期喷射喀喇音).Clinical findingsSymptoms:13Clinicalfindings(Continue)Complications:Complications:Hypertensive cardiovascular diseaseHypertensive cardiovascular disease Hypertensive cerebrovascular disease Hypertensive cerebrovascular disease Hypertension Hypertension is is the the major major predisposing predisposing cause of stroke.cause of stroke.Hypertensive renal diseaseHypertensive renal disease Chronic Chronic hypertension hypertension leads leads to to nephrosclerosis(nephrosclerosis(肾硬化症)Aortic dissection Aortic dissection Clinical findings(Continue)Com14LaboratoryinvestigationsRoutine investigationsRoutine investigationsHemoglobin,Hemoglobin,urinalysis urinalysis&renal renal function function studies,studies,to detect hematuria,proteinuria,and casts,to detect hematuria,proteinuria,and casts,Serum Serum potassium,potassium,since since hypokalemiahypokalemia is is typical typical of of hyperaldosteronismhyperaldosteronism（醛固酮增多症）（醛固酮增多症）Fasting Fasting glucose,glucose,since since hyperglycemia hyperglycemia is is noted noted in in diabetes and pheochromocytomadiabetes and pheochromocytoma（嗜铬细胞瘤）（嗜铬细胞瘤）Plasma Plasma cholesterol,cholesterol,as as an an indicator indicator of of atherosclerosisatherosclerosis riskriskLaboratory investigationsRouti15Laboratoryinvestigations(Continue)(Continue)Serum Serum uric uric acid(acid(尿酸),since since if if elevated elevated it it is is a contraindication to diuretic therapya contraindication to diuretic therapyElectrocardiography,Electrocardiography,to to detect detect ventricular ventricular hypertrophyhypertrophyChest Chest X-ray,X-ray,to to detect detect left left ventricular ventricular enlargementenlargementFunduscopic examination:Funduscopic examination:retina arteriolar narrowing retina arteriolar narrowing arteriovenous nicking(arteriovenous nicking(动静脉交叉压迫)hemorrhage,exudate(hemorrhage,exudate(渗出)papilledema(papilledema(视神经乳头水肿)Laboratory investigations(Cont16Laboratoryinvestigations(Continue)(Continue)Optional investigationsOptional investigations Plasma Plasma reninrenin(肾肾素素)activity activity&aldosterone aldosterone(醛固酮),urinary urinary VMAVMA（香草杏仁酸），to to identifyidentify secondary hypertensionsecondary hypertension Echocardiography,Echocardiography,to to detect detect ventricular ventricular hypertrophyhypertrophy Vascular Vascular ultrasonography ultrasonography should should be be performed performed if if arterial arterial disease disease is is suspected.suspected.Renal Renal ultrasonography ultrasonography should should be be performed performed if renal disease is suspected.if renal disease is suspected.Laboratory investigations(Cont17ClinicbloodpressuremeasurementWith With the the patients patients sitting sitting after after 5 5 or or more more minutes of rest.minutes of rest.Two Two or or three three measurements measurements should should be be taken taken at at each visit.each visit.The The systolic systolic reading reading is is taken taken as as the the level level of of BP BP at at which which clear clear sounds sounds are are heard heard with with each each heartbeat.heartbeat.The The diastolic diastolic reading reading is is taken taken at at the level when sounds the level when sounds disappeardisappear.Clinic blood pressure measurem18AmbulatoryBPmonitoring(动态血压监测)Noninvasive automatic device is available for ambulatory BP monitoring over periods of 24 h or more.ABPM offers the advantages of providing a more realistic setting for BP measurements.There are limited data available about the prognostic value of ABPM.ABPM is not a substitute for office measurement.Ambulatory BP monitoring(动态动态血血压监压监19NormalreferenceofABPM(mmHg）24h 24h Daytime NighttimeDaytime Nighttime SBP DBP SBP DBP SBP DBPStaessen1 133 82 140 88 125 76JNC-VI2 135 85 120 75China3 130 80 135 85 125 751.J Hyperten.1994;12:(Suppl 7):S1;2.Arch Intern Med.1997;157:2413;3.中华心血管杂志，1995；23：325。Normal reference of ABPM(mmHg20SituationsinwhichABPMshouldbeconsideredUnusual Unusual variability variability of of blood blood pressure pressure over over the same or different visitsthe same or different visitsOffice Office or or white white coat coat hypertensionhypertension(白大衣性高血压)Symptoms suggesting hypotensive episodesSymptoms suggesting hypotensive episodesHypertension resistant to drug treatmentHypertension resistant to drug treatmentSituations in which ABPM shoul21Diagnosis&differentialdiagnosisTo To confirm confirm a a chronic chronic elevation elevation of of blood blood pressure pressure and determine its leveland determine its levelTo To determine determine the the presence presence of of target-organ target-organ damage damage and to quantify its extentand to quantify its extentTo To search search for for other other cardiovascular cardiovascular risk risk factors factors&clinical clinical conditions conditions that that may may influence influence prognosis prognosis&treatmenttreatmentTo identify secondary causes of hypertensionTo identify secondary causes of hypertensionDiagnosis&differential diagn22Classificationofhypertension(mmHg)Category Category Systolic DiastolicSystolic DiastolicGrade 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 55 yearsMen55 yearsWomen65 yearsWomen65 yearsSmokingSmokingTC5.72mmol/L TC5.72mmol/L DiabetesDiabetesFamily Family history history of of premature premature cardiovascular cardiovascular diseasedisease（早发心血管病家族史）（Men55 yearsMen55 years，Women65 yearsWomen177mol/L）Vascular diseaseDissecting aneurysmAdvanced hypertensive retinopathyHemorrhage or exudatesPapilledemaAssociated clinical conditions28StratificationofRisktoQuantifyPrognosis Blood Pressure（mmHg）Other Risk Factors Grade 1 Grade 2 Grade 3&Disease History SBP140-159 SBP160-179 SBP180 or or DBP90-99 or DBP100-109 DBP110I no other risk factors Low Risk MED Risk High RiskII 1-2 risk factors MED Risk MED Risk Very-High-RiskIII 3 risk factors or TOD High Risk High Risk Very-High-Risk or DiabetesIV ACC Very-High-Risk Very-High-Risk Very-High-RiskStratification of Risk to Quan29Treatmentstrategies&riskstratificationLow-risk Low-risk group:group:monitor monitor BP BP and and other other risk risk factors factors for for 6 6 monthsmonths，if if goal goal BP BP is is not not attained,attained,drug drug treatment treatment should should be be initiated.initiated.Medium-risk group:begin drug treatment Medium-risk group:begin drug treatment High-risk High-risk group group&Very-high-risk Very-high-risk group group:should begin drug treatmentshould begin drug treatment Lifestyle Lifestyle modification modification should should be be used used in in all hypertensive patientsall hypertensive patientsTreatment strategies&risk st30ExampleA A patient patient with with diabetesdiabetes（糖尿病）&BP BP of of 140/94 140/94 mmHg mmHg plus plus left left ventricular ventricular hypertrophy hypertrophy should should be be classified classified as as having having grade grade 1 1 hypertension hypertension with with target target organ organ disease disease and and with another major risk factor.with another major risk factor.would would be be categorized categorized as as“grade“grade 1 1 hypertension,high-risk”hypertension,high-risk”would would be be recommended recommended for for immediate immediate initiation initiation of of drug drug treatment treatment and and also also lifestyle modificationlifestyle modificationExampleA patient with diabete31Treatment The The The The goal goal goal goal of of of of antihypertensive antihypertensive antihypertensive antihypertensive therapy therapy therapy therapy is is is is to to to to reduce reduce reduce reduce cardiovascular cardiovascular cardiovascular cardiovascular morbiditymorbiditymorbiditymorbidity(发病率)&mortality&mortality&mortality&mortality(死亡率).The BP goal of antihypertensive therapy The BP goal of antihypertensive therapy The BP goal of antihypertensive therapy The BP goal of antihypertensive therapy To To achieve achieve high high normal normal BP BP(below(below 140/90 140/90 mmHg)in elderly patientsmmHg)in elderly patients To To achieve achieve normal normal BP BP(below(below 130/85mmHg)130/85mmHg)in in young,middle-aged or diabetic subjectsyoung,middle-aged or diabetic subjectsTreatmentThe goal of antihype32Nonpharmacologicaltreatments S Should hould be be used used in in all all hypertensive hypertensive patients,patients,either either as as definitive definitive treatment treatment or or as as an an adjunct adjunct to drug therapy.to drug therapy.Should Should be be tailored tailored to to the the individual individual characteristics characteristics of of each each patient,patient,such such as as weight weight reduction for an overweight patient.reduction for an overweight patient.I Include:nclude:Weight reductionWeight reduction Complex dietary changesComplex dietary changes Increased physical activityIncreased physical activity Smoking cessationSmoking cessation OthersOthersNonpharmacological treatments 33Lifestylemodification(Continue)(Continue)Weight reductionWeight reductionThrough Through a a combination combination of of dietary dietary caloric caloric restriction restriction&increased increased physical physical activityactivitySustained Sustained weight weight reduction reduction is is so so difficult difficult to to achieve,achieve,so,so,more more emphasis emphasis should should be be placed placed on on prevention prevention of of weight weight gain.gain.Patients Patients should should avoid avoid appetite appetite suppressant suppressant drugdrug（食食欲欲抑抑制制药药）and and diet diet pillpill(减肥药丸减肥药丸)Lifestyle modification(Contin34Lifestylemodification(Continue)(Continue)Complex dietary changes Complex dietary changes Reduction in salt intake Reduction in salt intake 6g/d of sodium chloride(3*6*30=540)6g/d of sodium chloride(3*6*30=540)Reducing fat intakeReducing fat intake Increasing fruit and vegetableIncreasing fruit and vegetable Moderation of alcohol consumption for a heavy drinkerModeration of alcohol consumption for a heavy drinkerLifestyle modification(Contin35Lifestylemodification(Continue)(Continue)Increased physical activityIncreased physical activity Regular Regular aerobic aerobic physical physical activity activity can can lower lower BP BP and and is is recommended recommended for for all all hypertensive individuals.hypertensive individuals.Patients Patients with with advanced advanced cardiovascular cardiovascular disease disease may may require require medical medical evaluation evaluation before initiation of exercisebefore initiation of exerciseKeeping psychologic equilibriumKeeping psychologic equilibriumSmoking cessationSmoking cessationLifestyle modification(Contin36PharmacologictherapyPrinciples of drug treatmentPrinciples of drug treatmentPrinciples of drug treatmentPrinciples of drug treatmentThe The use use of of low low doses doses of of drugs drugs to to initiate initiate therapytherapyThe The use use of of long-acting long-acting drugs drugs providing providing 24h 24h efficacy on a once-daily basisefficacy on a once-daily basisThe The use use of of appropriate appropriate drug drug combinations combinations to to maximize maximize hypotensive hypotensive efficacy efficacy while while minimizing minimizing side effectsside effectsPharmacologic therapyPrinciple37SixmaindrugclassesDiureticsDiuretics(利尿剂):DHCT,Furosemide:DHCT,Furosemide(呋塞米)-blockers:Ateno-blockers:Atenolollol,Metopro,Metoprolollol CCB:Nife CCB:Nifedipinedipine,Amlo,Amlodipinedipine ACE inhibitors:EnalaACE inhibitors:Enalaprilpril,Capto,Captoprilpril AII antagonists:Lo AII antagonists:Losartansartan,Val,Valsartansartan -blockers:-blockers:PraPrazosinzosin,Tera,TerazosinzosinSix main drug classesDiuretics38GuidelinesforselectingdrugtreatmentofhypertensionClass of drug Indications(适应证)Possible indications ContraindicationsDiuretics Heart failure Diabetes Gout Systolic hypertension -Blockers Angina MI Asthma and COPD Tachyarrhythmias Pregnancy Heart block ACEI Heart failure Pregnancy Diabetic nephropathy Hyperkalemia After MI Renal artery stenosisCCB Angina Systolic hypertension-blockers Prostatic hypertrophy Glucose intolerance （前列腺肥大）DyslipidemiaA antagonists ACEI cough same as ACEIGuidelines for selecting drug 39Antihypertensivedrugtherapyforpatientswithco-morbidconditions Indication Indication Drug treatment Drug treatment Diabetes Diabetes with with proteinuria proteinuria ACE ACE inhibitorsinhibitorsHeart Heart failure failure ACE ACE inhibitors,diureticsinhibitors,diureticsIsolated Isolated systolic systolic hypertension hypertension Diuretics,Diuretics,Ca blockersCa blockersMyocardial Myocardial infarction infarction -blocker,-blocker,ACE inhibitorsACE inhibitorsAngina Angina -blocker,Ca blockers-blocker,Ca blockersBenign prostatic hyperplasia -blockerBenign prostatic hyperplasia -blocker Dyslipidemia Dyslipidemia -blocker-blocker Tachyarrhythmias Tachyarrhythmias -blocker,Ca blockersblocker,Ca blockersAntihypertensive drug therapy 40SecondaryhypertensionIt is a hypertension of known causeIt is a hypertension of known cause.The The importance importance of of identifying identifying patients patients with with SH SH is is that that they they can can sometimes sometimes be be cured cured by by surgery surgery or or by by specific specific medical medical treatment.treatment.Secondary hypertension includes:Secondary hypertension includes:Renal parenchymal diseasesRenal parenchymal diseases(肾实质病变)Renovascular hypertension Renovascular hypertension Adrenal diseasesAdrenal diseases（肾上腺疾病）Secondary hypertensionIt is a41RenalparenchymaldiseasesThe most common causes of SHThe most common causes of SHAny Any diseases diseases of of the the renal renal parenchyma parenchyma(肾肾实实质质):):glomerulonephritisglomerulonephritis(肾肾小小球球肾肾炎炎),diabetic diabetic nephropathynephropathy(肾肾病病),),polycystic polycystic kidneyskidneys(多多囊囊肾肾).).Most Most cases cases are are related related to to increased increased intravascular intravascular volume or increased activity of the RASvolume or increased activity of the RASRenal parenchymal diseasesThe 42RenovascularhypertensionDiagnostic clues:Diagnostic clues:The onset is below The onset is below ageage 20 or after age 50 20 or after age 50 Upper abdominal bruit Upper abdominal bruit(杂音杂音)Abrupt Abrupt deteriorationdeterioration（恶 化）in in renal renal function after administration of ACEIfunction after administration of ACEI The hypertension is difficult to control.The hypertension is difficult to control.Renal Renal angiographyang