中国高血压防治指南培训手册

单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,Hypertension,高血压,D,efinition,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 established,Possible 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 remolding,Vascular,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 EH,Symptoms-,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 85,24,小时动态测压, 130 80,Normal reference of ABPM (,mmHg）,24,h Daytime Nighttime,SBP DBP SBP DBP SBP DBP,Staessen 133 82 140 88 125 76,JNC-7 135 85 120 75,China,3,130 80 135 85 125 75,Laboratory investigations,Routine investigations,Urinalysis,（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,ECG,UCG,ventricular hypertrophy,Chest X-ray,ventricular enlargement,Funduscopic 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 level,To,identify secondary causes of hypertension,To,determine the presence of target-organ damage and to quantify its extent,To,search for other cardiovascular risk factors & clinical conditions that may influence prognosis & treatment,C,lassification of Blood Pressure Levels (mmHg),Category Systolic Diastolic,Optimal 120 80,Normal 130 85,High-normal 130-139 85-89,Grade 1 hypertension(mild) 140-159 90-99,Subgroup: borderline 140-149 90-94,Grade 2 hypertension(moderate),160-179 100-109,Grade 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,正常,120,和,160,或,100,血压分类,收缩压,mmHg,舒张压,mmHg,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,120,139 80,89,高血压, 140 90,1,级高血压（轻度,) 140,159 90,99,2,级高血压,(,中度,) 160,179 100,109,3,级高血压,(,重度,) 180 110,单纯收缩期高血压,140 55 years,Women65 years,Smoking,TC5.72mmol/L,Diabetes,Family history of premature cardiovascular disease,（,早发心血管病家族史）,（,Men55 years,，,Women177,mol/L,）,Vascular disease,Dissecting aneurysm,Artery disease,Advanced hypertensive retinopathy,Hemorrhage or exudates,Papilledema,高血压,危险度分层,其他危险,因素和病史,血压,1级,轻度高血压,SBP140-159,或,DBP90-99,2级,中度高血压,SBP160-179,DBP100-109,3级,重度高血压,SBP180,DBP110,I,无其他危险因素,II 1-2,个危险因素,III,3,个危险因素或,TOD,或糖尿病,IV ACC,低危,中危,高危,极高危,中危,中危,高危,极高危,高危,极高危,极高危,极高危,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 ACEI,Renal angiography,（,肾,血管造影术）,is the best diagnostic test.,Pheochromocytoma,(,嗜铬细胞瘤),Clinical clues:,Paroxysmal,（,阵发性）,hypertension,Episodes of diaphoresis,(,出汗),palpitation,headache, pallor,(,苍白)。,Laboratory investigations:,Blood catecholamines,（,儿茶酚胺）,are elevated,Urinary vanillylmandelic acid,（,香草基杏任酸）,CT or MRI(magnetic resonance imaging),Primary hyperaldosteronism,Slight to moderate blood pressure elevated,Episodes 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 syndrome,Coarctation of the aorta,(,主动脉缩窄),Drug u,se,Pregnancy,(,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 (,130/80,mmHg,) in young, middle-aged or diabetic subjects,Nonpharmacological treatments,I,nclude:,Weight reduction,Complex dietary changes,Increased physical activity,Moderation of alcohol consumption,Smoking cessation,Others (,psychologic equilibrium),Pharmacologic therapy,Principles of drug treatment,The use of low doses of drugs to initiate therapy,The use of long-acting drugs providing 24h efficacy on a once-daily basis,The 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:,Ateno,lol, Metopro,lol,Ca antagonists: Nife,dipine, Amlo,dipine,ACE inhibitors:,Enala,pril, Capto,pril,AII antagonists: Lo,sartan, Val,sartan,-blockers:,Pra,zosin, Tera,zosin,Antihypertensive drug therapy for patients with co-morbid conditions,Indication Drug treatment,Diabetes with proteinuria ACEI, ARB,Heart failure ACEI, ARB, diuretics,Isolated systolic hypertension Diuretics, Ca blockers,Myocardial infarction -blocker, ACEI, ARB,Angina -blocker, Ca blockers,Benign 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。,