高血压周围血管病变的检出及治疗精品课件

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,*,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,2020/9/14,#,高血压周围血管病变,的检出及治疗,北京大学人民医院 心内科、高血压科,peoples hospital,Peking University,孙宁玲,Sun Ning-ling,1.,Coccheri S.,Eur Heart J,1998;19(suppl):P1268.,Coronary,disease,Cerebrovascular disease,Peripheral arterial disease,24.7%,3.8%,11.8%,29.9%,3.3%,7.4%,19.2%,*,Data from CAPRIE study(n=19,185),脑血管合并,CHDPAD,约39.2%,心脑血管疾病的发生,周围血管病变：,部位：,冠状动脉、脑动脉以外的,中间终点：,血管,IMT、,血管的内斑块形成,终未终点：,间歇性跛行、肢体坏疽,心脑血管的主要临床事件 是与动脉硬化及血栓有关,Adapted from:Drouet L.,Cerebrovasc Dis,2002;13(suppl 1):16.,Transient ischemic attack,Angina:,Stable,Unstable,Ischemic,stroke,Myocardial infarction,Peripheral arterial,disease:,Intermittent claudication,Rest Pain,Gangrene,Necrosis,动脉粥样硬化血栓形成:,具,共同病理基础的进展性过程,正常,脂肪条纹,纤维斑块,粥样硬化斑块,斑块破溃/裂隙和血栓形成,心肌梗死,缺血性中风/,TIA,严重的,下肢缺血,临床无症状,心血管死亡,年龄增长,稳定性心绞痛,间歇性跛行,不稳定性,心绞痛,ACS,*,ACS,急性冠脉综合征;,TIA,一过性脑缺血发作,高血压所致的压力应切力是导致动脉硬化重要原因,Internal Carotid,External Carotid,Flow Divider,Common Carotid Artery,ESC/ESH,危险因素阶段,靶器官损害阶段,临床疾病阶段,终末疾病阶段,高血压,糖尿病,其它危险因素,颈动脉中内膜增厚,冠状动脉病变,血管内皮功能紊乱,左室肥厚,蛋白尿,心绞痛,心肌梗塞,脑卒中,肾脏损害,心力衰竭,肾功能衰竭,卒中后功能障碍,死亡,中间终点,逆转中间终点的目的是减少终末终点发生,终末终点,Carotid artery IMT and CV risk,n=4476(65 years)with no CVD;median follow-up 6.2 years,Quintiles of maximal common carotid artery and internal carotid artery intima-media thickness,0.5 1.0 2.0 5.0,Adjusted relative risk for combined endpoint of stroke or MI,1st quintile,OLeary D,et al.N Engl J Med 1999;340:14,22.,2nd quintile,3rd quintile,4th quintile,5th quintile,1.,OLeary DH.,N Engl J Med,1999;340:1422.,1.0,x 3.61,0.0,0.5,1.0,1.5,2.0,2.5,3.0,3.5,4.0,1,2,3,4,5,Quintiles of carotid artery media thickness,Risk increase,Carotid IMT,与心肌梗死的关系,高血压患者中颈动脉病变如何？,国外及国内的筛查给我们的提示,国人高血压病人颈动脉斑块的患病率,29%,50%,0,20,40,60,80,100,血压正常者,高血压患者,%,赵冬 等,高血压患者除了颈动脉外,其他动脉疾病也,是否也有问题？,也具有临床意义？,Background,高血压相关周围血管病变检出率,高血压科住院患者 ：207例,年龄 ：2387岁，平均60.813.19岁,高血压病年限：11.9年,观察目标：,颈动脉超声、股动脉超声、,血压（包括,ABPM)、,危险因素。,血管观察指标：内膜增厚、斑块（硬斑、软斑）。,高血压患者的颈动脉病变,高血压患者颈动脉病变检出率,增厚,硬斑,软斑,异常,正常,46.4,54.6%,8.1%,8.1%,83.8%,颈动脉病变与高血压分级关系,0,10,20,30,40,50,60,病变组,1级,2级,3级,50.5,24.3,25.2%,颈动脉病变与高血压危险分层关系,颈动脉病变组:,低危0.9%,中危7.2%,高危23.4%,极高危68.5%,0,10,20,30,40,50,60,70,80,病变组,低危,中危,高危,极高危,各种危险因素在颈动脉血管病变分布,p,0.01,p,0.01,血脂对颈动脉血管病变的影响,诊室血压对颈动脉病变影响,p,0.01,动态血压对颈动脉病变影响,p,0.01,高血压患者的股动脉病变,危险因素在股动脉血管病变的分布,p,0.05,p,0.01,诊室血压对股动脉病变影响,p,0.05,动态血压对股动脉病变影响,p,0.01,高血压患者多部位血管病变,动态血压对外周血管联合病变的影响,p,0.01,对周围血管病变的分析小结,1、在危险因素中周围血管病变与血压及高龄关系最密切，,血脂影响因素较小。,2、血压水平较高及危险分层高的患者周围血管病变越明显，,3、颈动脉病变特点：颈膨大处以硬班检出率较高，颈总,动脉以内膜增厚（,IMT）,为主。,对周围血管病变的 分析小结,4、24小时动态血压增高及脉压增高是周围血管病变的,主要血压形态。,5、多部位的联合周围血管病变与血压、糖尿病及高龄,关系最密切，而24小时全天平均血压增高是导致血,管损伤重要因素。,提出问题,降压是否就能改善预后？,138,mmHg,82,mmHg,180,160,140,120,100,80,60,0,2,4,8,12,18,36,70,87,mmHg,第1年,周,收缩压,舒张压,173,mmHg,99,mmHg,第2年,第3年,第4年,拜新同,利尿剂联合用药,WHO/ISH,推荐的目标收缩压,WHO/ISH,推荐的目标舒张压,INSIGHT,INSIGHT nifedipine GITS reduces c,arotid artery intima-media thickness,*p0.01;*p0.001 vs zero within treatment group,Carotid artery IMT progression(mm/year),0.008,0.006,0.004,0.002,0,0.002,Year 2,Year 3,Year 4,Study end,*,*,*,*,Nifedipine GITS,Co-amilozide,INSIGHT,substudy nifedipine GITS reduces,coronary calcification,0,25,50,75,100,Baseline,Year,1,Increase in maximum total calcium score(%),Nifedipine GITS,Co-amilozide,Year 2,Year 3,p=0.02,络活喜与赖诺普利对颈动脉内膜中层厚度的降低的比较,-60,-50,-40,-30,-20,-10,0,氨氯地平,赖诺普利,治疗14周,治疗26周,治疗50周,P=0.044,与基线相比*,P0.05，*P0.001,与,基,线,相,比,的,平,均,变,化,(,nm),*,*,*,*,*,经常,不断地学习,你就什么都知道。你知道得越多,你就越有,力量,Study Constantly,And You Will Know Everything.The More You Know,The More Powerful You Will,Be,写,在最后,Thank,You,在别人的演说中思考,，,在自己的故事里成长,Thinking,In Other,PeopleS Speeches,，,Growing,Up In Your Own,Story,讲师,：,XXXXXX,XX,年,XX,月,XX,日,