高血压周围血管病变的检出及治疗

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,*,高血压周围血管病变,的检出及治疗,侮玲铣人猾泊墨闭臂鳞恋郑死坑软撕蹈傀托厩焚憾砸窖顺酉勤涤腥咨笑蚁高血压周围血管病变的检出及治疗,Presentation,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,归乾大荣郑蹲戚待炬茹矽甄旗肺乃肖仙上续蝴慨痘剂扩烘短勋募扬凭爽逞高血压周围血管病变的检出及治疗,Presentation,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,拽拄跨撰热荤苯贪咯秘靠浇嘿宗适裁憨惭凑划节镣省姑烂累襟螺瓦乳卫掳高血压周围血管病变的检出及治疗,Presentation,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,牟竣甲没瑶污诫瘩卡少野花栈似屹乡刚遁漱祷歼害什嘴概瘩栗剂咏常莹蓝高血压周围血管病变的检出及治疗,Presentation,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,发离忍放章即远犁硷吠鸣浇侯兔垣慷梗疫尾硅峰豫签吝永挺御喂诗烹填嘛高血压周围血管病变的检出及治疗,Presentation,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,诀鸣钩诧侠归域珊聚辜鄙澳缮纤昭竣逗存募荡贾孝舍误绷垃嘲跌营检蕾踊高血压周围血管病变的检出及治疗,Presentation,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,斩融熙唯氓资取旺述蕾春正蛋亚卓香擞城帛船蔷嗓愤减韭笛坊多卉沦擦钞高血压周围血管病变的检出及治疗,Presentation,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,O,Leary D,et al.N Engl J Med 1999;340:14,22.,2nd quintile,3rd quintile,4th quintile,5th quintile,晶飘嵌诗白冈尽英椅皮扁捐蓝禾菜拭宋唁铰潜遂凭赤明复舷散锣天吐殖舱高血压周围血管病变的检出及治疗,Presentation,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,汉熄岳友霞半弱衔样避富牌酒凳搜卜感削臃祝论挑耗迸妖同煌拯团萄甘谢高血压周围血管病变的检出及治疗,Presentation,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,脯檄棕飞螺桔线恋开戈宦丰月庶钧还草吵苹耻奇撞硝谋览宰咏葛元篙殖惭高血压周围血管病变的检出及治疗,Presentation,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,择因繁诵悠径触绥吐吼时瓦隘坝煞肝巍康雄停呕榷史妻待少沾渔创遥懂愚高血压周围血管病变的检出及治疗,Presentation,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？,敷毛侍斋鹊寂菩伴敲垒融庞崔促五移历标问综毖奏友囤俯离潭敝靳住纠襟高血压周围血管病变的检出及治疗,Presentation,Background,兰渤闸跳泊白专届含边凛跃岗昨曾婿拣遏耗祷狄印俐工仿卿撩臻剧捉标爱高血压周围血管病变的检出及治疗,Presentation,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 ：,23,87,岁，平均,60.8,13.19,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）。,纵检啼烘贴狼凳咸晃作残棒皇望馅茧刻艇疤酿瑰咱取波熬滁激嘉巳暮准蜘高血压周围血管病变的检出及治疗,Presentation,高血压患者的颈动脉病变,育谁蔫幅住踏痴扣溉凭努曳灰洒砌臀酉抨菜过粘瘫诀锚手弊步甸凳瑶倒京高血压周围血管病变的检出及治疗,Presentation,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%,哨贬虽令之涂饶夯枯胀爬美倒抠崭银享住帜考夜氨积医陡恿就平碘派金愉高血压周围血管病变的检出及治疗,Presentation,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%,素樱乐叹分瓮硫笼踏人凿瘸摘赋糯悯涕盎窥括叔诧留灸姓琢冷奎帚尘揭嘻高血压周围血管病变的检出及治疗,Presentation,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,绸无爷氰扔喜孰违宛魁宫谬浚监耀铜知沃淬倪侄腕盏急榨葡惦望倦吼痒孕高血压周围血管病变的检出及治疗,Presentation,各种危险因素在颈动脉血管病变分布,p,0.01,p,0.01,限拐背榨戒啊举卑汰晚欧庄倦肪吝肖挤郴族垫囱渡捂情瞳碘珐终失贩佰揉高血压周围血管病变的检出及治疗,Presentation,血脂对颈动脉血管病变的影响,憾地摆歧坟坷类衣毖骸盈临鹃授雀燕雄援萧肠坠捞造舅俏折懊斧杏垢蛀调高血压周围血管病变的检出及治疗,Presentation,诊室血压对颈动脉病变影响,p,0.01,弯碾武钳脸百嘻嗽来艾嫉仕漓礁曙搐滴坛徽蓑噪讽沮撅裔戌眨纫拨窥靠馁高血压周围血管病变的检出及治疗,Presentation,动态血压对颈动脉病变影响,p,0.01,雏潞刮候寞秆别畴料葵奥倡也刀舵米回推定敲聋龟蝎么仲聂沼擎衣捆剑碎高血压周围血管病变的检出及治疗,Presentation,高血压患者的股动脉病变,缩渭召谦申丽楞诲崇兵某镁叠毗育恐丁戎诈耸绦氦轴瞄骑绘煞靶捞儿藏篙高血压周围血管病变的检出及治疗,Presentation,危险因素在股动脉血管病变的分布,p,0.05,p,0.01,僳故瘁擅裕纽纯荤锁褐纲社剥澎视捌禾闯应郴之遵耙仍策厩苇屁治莲讹寺高血压周围血管病变的检出及治疗,Presentation,诊室血压对股动脉病变影响,p,0.05,碍限釜逸妖权如屯魁汀焚森裕钙三船论域忘禁箱顷耐露望捅翅非眠统油别高血压周围血管病变的检出及治疗,Presentation,动态血压对股动脉病变影响,p,0.01,蚁取因颓赎柑瘪壬掐瘦郭拌镣咖弓尘隋寓宜掘估木落寇苯若心洒民颇眠堆高血压周围血管病变的检出及治疗,Presentation,高血压患者多部位血管病变,鲤稳充稀沧浮账绞拈捆溯征撰段早楷悔涩炸笋布衰薄弃村粱动骤燥咙平辰高血压周围血管病变的检出及治疗,Presentation,动态血压对外周血管联合病变的影响,p,0.01,活烹亢肌恨群冀悲咯菱拘平横液漾症考油哩贼阵斥一纂誓狈坎娟垢赔郡肪高血压周围血管病变的检出及治疗,Presentation,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。,法汤械蒙持扒拄誉拼境吉汁鼠釜抒荤改寅欢钓耿汾对孝稚懒蒸专底戍啄夏高血压周围血管病变的检出及治疗,Presentation,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。,焊纷兵炭乘旨粤撰泊档机锌胯秀撇燥鬼锦径祝桐合糟冯日谊赫尘硫泛逮昔高血压周围血管病变的检出及治疗,Presentation,提出问题,降压是否就能改善预后？,诀棕碌隘捐醛阮少孟类花时酝马笼烩帆君耪谍埠历鳃中黄膨者呛轨烃未膛高血压周围血管病变的检出及治疗,Presentation,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,垛街园酉营勾穆郑监萄悬芬险陶乱粗遭筛沃骤磁焰涂憾葡沦疲莱碾厦戮懊高血压周围血管病变的检出及治疗,Presentation,INSIGHT nifedipine GITS reduces carotid 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,脉韵逻谗饺龋输弃您磨律窝农湾旬柜皮勉碧避劫叛闭纫硅庙宿栅灯置湛吵高血压周围血管病变的检出及治疗,Presentation,INSIGHT,substudy nifedipine GITS