难治性高血压课件

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Resistant Hypertension:,Diagnosis, Evaluation, and Treatment,JENNY,(A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research),Resistant Hypertension: JENNY(,1,Objective,Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.,Objective Expanding our un,2,1,Contents,2,3,Diagnosis,Evaluation,Treatment,1Contents23DiagnosisEvaluation,3,Definition,blood pressure,remains above goal,three anti-hypertensive agents of different classes,one of,the 3 agents should be a diuretic,all agents should be,prescribed at optimal dose amounts.,Resistant,hypertension,Definition blood pressurethree,4,Prevalence,1,NHANES,53%,Framingham,Heart Study,48%,ALLHAT,2,50%,Prevalence1NHANESFramingham AL,5,Patient Characteristics,Patient Characteristics Associated,With Resistant Hypertension,Older age,High baseline blood pressure,Obesity,Excessive dietary salt ingestion,Chronic kidney disease,Diabetes,Left ventricular hypertrophy,Black race,Female sex,Residence in southeastern United States,Patient CharacteristicsPatient,6,Pseudoresistance,Poor Blood,Pressure,Technique,Poor,Adherence,Lifestyle,Factors,White-Coat,Effect,Secondary,Causes,PseudoresistancePoor BloodPoor,7,measuring the blood pressure before letting the patient sit quietly,use of too small a cuff,Poor Blood,Pressure,Technique,measuring the blood pressure b,8,a major cause of lack of blood pressure control,Poor Adherence,less than 40%,of patients,40% of,patients,the first year,of treatment,4,5 to 10 years of follow-up,3,a major cause of lack of blood,9,White-Coat Effect,Studies indicate that a significant white-coat effect (when clinic blood pressures are persistently elevated while out-of-office values are normal or significantly lower) is as common in patients with resistant hypertension as in the more general hypertensive population, with a prevalence in the range of 20% to 30%.,5,White-Coat Effect Studies,10,Lifestyle,Factors,Obesity is a common feature of patients with resistant hypertension.,Excessive dietary sodium intake,Heavy alcohol intake is associated with both an increased risk of hypertension, as well as treatment-resistant hypertension.,Lifestyle Obesity is a common,11,Non-narcotic analgesics,Non-steroidal anti-inflammatory agents, including,aspirin, selective COX-2 inhibitors,Sympathomimetic agents (decongestants, diet,pills, cocaine),Stimulants (methylphenidate, dexmethylphenidate,dextroamphetamine, amphetamine, methamphetamine,modafinil),Alcohol,Oral contraceptives,Cyclosporine,EPO,Natural licorice,Herbal compounds (ephedra or ma huang),Drug-Related Causes,Non-narcotic analgesicsDrug-Re,12,Renal artery,stenosis,Primary,aldosteronism,Renal parenchymal,disease,Hyperparathyroidism,Cushings disease,Pheochromocytoma,Secondary,Causes,Obstructive Sleep Apnea,Aortic coarctation,Renal arteryPrimary Renal pare,13,Evaluation,Medical History:,duration,severity,progression of the hypertension;,treatment adherence;,response to prior medications,Assessment of Adherence,Blood Pressure Measurement,sit quietly,correct cuff size; support the arm at heart level,the average of 2 readings,supine and upright blood pressures,Physical Examination,EvaluationMedical History: dur,14,A mean ambulatory daytime blood pressure of 135/85 mm Hg is considered elevated.,Evaluation,Ambulatory Blood Pressure Monitoring,Biochemical Evaluation,A routine metabolic profile,Urinalysis,A paired, morning plasma aldosterone,Plasma renin activity,Noninvasive Imaging,A mean ambulatory daytime bloo,15,Treatment,Maximize Adherence,the use of a long-acting combination of products,2.,Non pharmacological Recommendations,Weight Loss,Dietary Salt Restriction,Moderation of Alcohol Intake,Increased Physical Activity,Ingestion of a High-Fiber, Low-Fat Diet,3.Treatment of Secondary Causes of Hypertension,4.,Pharmacological Treatment,TreatmentMaximize Adherence2.,16,Aliskiren,Effects of aliskiren and valsartan on plasma ANG I and II levels.,Aliskiren alone or in combination with valsartan was tested in 120 mildly sodium depleted,Nor-motensive adults (age, 18 to 35 years) in a double-dummy, double blind, randomized, placebo-controlled, 4-period crossover study. Subjects received single doses of aliskiren 300 mg alone, aliskiren 150 mg in combination with valsartan 80 mg, valsartan 160 mg alone, and placebo separated by 2-week washout periods,AliskirenEffects of aliskiren,17,There is no doubt that aliskiren is an effective antihypertensive agent and that at effective doses it is well tolerated. It appears to be safe, but this statement is made with the obvious qualification for any novel drug or class that rare or long-term adverse events may take time to become apparent.,7,Aliskiren,DOSE:,75mg-300mg qd p.o,There is no doubt that ali,18,Darusentan,Darusentan provides additional reduction in blood pressure in patients who have not attained their treatment goals with three or more antihypertensive drugs. As with other vasodilator drugs, fluid management with effective diuretic therapy might be needed .,Darusentan Darusentan prov,19,a Vaccine Against Hypertension Targeting Angiotensin II, Reduces Early-Morning and Day-Time Blood Pressure,CYT006-AngQb,a virus-like-particle based conjugate vaccine targeting (Ang II),72 mild-to-moderate hypertensive patients.,the vaccine with an optimized dose regimen,injections of either 100 or 300 g,a Vaccine Against Hypertension,20,CYT006-AngQb,reduced blood pressure in situations where the renin-angiotensin-aldosterone system is stimulated, and was particularly effective in the morning hours when most cardiovascular events occur.,CYT006-AngQb,CYT006-AngQb reduced blood,21,1.Catheter ablation of renal,sympathetic nerve,2. Implantable pulse generator to stimulate the carotid sinus baroreceptor,Other Therapies,1.Catheter ablation of renal 2,22,T H A N K S !,T H A N K S !,23,