综览单纯收缩期高血压ISH课件

,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,综览单纯收缩期高血压(,ISH),刘国仗,北京阜外医院 2010-06,老年高血压主要为,ISH,SBP,而不是,DBP,随年龄增长持续升高,随着年龄的增长，,SBP,持续升高，而,DBP,呈降低趋势，,SBP,呈线性升高，,DBP,较平稳升高，经过平台期，在70岁左右缓慢下降,mmHg,y,主动脉弹性好的重要意义,弹性好主动脉易扩张、缓冲了心脏收缩时主动脉压力骤然升高,把动能转为势能,储于血管壁,在心室舒张时释放,势能转为动能,使主动脉回缩、推动动脉内血流持续向前,ISH,高血压,发病机理,主动脉弹性减退+潜在的血管收缩,小动脉收缩以帮助在收缩期阻抗血流,舒张期主动脉回缩力减退，血流量小,增加主动脉的容积和主动脉壁张力,收缩压,脉压,僵硬血管的压力曲线比弹性血管陡,心脏收缩,心脏舒张,心脏收缩,心脏舒张,血管弹性好,血管僵硬,大动脉,The American Journal of Medicine,Vol,121,No 3,March 2008,老化、内皮功能障碍、,RAS,与,SBP,ISH,病理生理表现更严重,Drugs Aging 2008;25(1):1-8,ISH,的临床特点,血压,：,昼夜节律：双峰双谷状,波动范围大,晨峰现象,常合并靶器官损害,：,心室肥厚、,CHD、,心力衰竭,肾功能不全,卒中,ISH,是,CHD,、,卒中和其他,CV,并发症重要危险因素,ISH,的,CV,危险与降压获益,60,岁后,SBP,成为,CV,风险的预测因素,SBP,20mmHg,心血管死亡率,2,倍,SBP,2 mmHg,心肌缺血死亡,7,卒中风险,10,与,DBP,相关性最强,与,SBP,正相关与,DBP,负相关,年龄,心血管预后与收缩压和舒张压的关系,过渡期,50y,60y,Odds Ratio for CV Mortality,experimental/reference treatment,Difference in SBP,mmHg,1.50,1.25,1.00,0.75,0.50,0.25,0,5,10,15,20,25,HOPE,MIDAS/NICS/VHAS,UKPDS C,vs,A,INSIGHT,HOT L,vs,H,HOT M,vs,H,STOP,ACEIs,STOP,CCBs,CAPPP,UKPDS L,vs,H,MRC1,MRC2,SHEP,HEP,EWPHE,RCT70-80,STOP-1,PART 2/SCAT,ATMH,5,Staessen,JA,et al.Cardiovascular protection and blood pressure reduction:a meta-analysis.,Lancet,2001;358:130515,STONE,Syst,-,Eur,NORDIL,Syst,-China,降低收缩压，减少心血管死亡,脉压由心脏与血管因素共同决定,血管横断面结构异常（直径和血管成分,）,：,中膜厚度,与血管僵硬度,、,PWV,、,内膜成分不影响管壁机械特性，但影响其传导途径的重要介导。,脉压增大机制（1）,脉压由心脏与血管因素共同决定,脉压增大机制（2）,心脏和血管轴向因素,心脏射血产生压力波以恒定速度 传导、老年高血压患者血管僵硬度,，,PWV,，致反射波于收缩期返回，反射波形,、,SBP,DBP,脉 压,(mmHg),Framingham,心脏研究,30,年随访脉压与心血管事件风险增加呈正相关,35-64,岁,年龄校正后的事件发生率,/1000,患者,0,50,40,30,20,10,女性,男性,20-39,40-49,50-59,60-69,70,65-94,岁,20-39,40-49,50-59,60-69,70,60,Am J,Cardiol,2000;85:251255,巴黎前瞻性研究,平均随访,17,年,IPC,队列研究,平均随访,13.5,年,校正后的心血管死亡相对风险,脉压大的心血管死亡风险高于,SBP/DBP,联合升高,SBP,正常,DBP,SBP,DBP,SBP,DBP,正常,SBP,DBP,0.5,1,2,5,0.5,1,2,5,脉压大,ISH,J Am,Coll,Cardiol,.2000;35:673-80.,校正了年龄、总胆固醇、吸烟、糖尿病和体重指数后,P,0.05,P,0.05,P,0.05,P=,n.s,P=,n.s,P=,n.s,P=,n.s,P,0.001,治疗,ISH,的关键，更多降低收缩压！,荟萃分析：降压有效减少,ISH,患者心脑血管事件,200,1000,800,600,400,卒中事件,冠心病事件,所有,CV,事件,总死亡,非致死性事件,死亡,发生事件的患者数,治疗组,对照组,8,项大型试验，平均随访,3.8,年,Lancet.2000;355:865872,n=15,693,治疗组,对照组,治疗组,对照组,治疗组,对照组,所有患者基线血压,174/83,与对照组相比，降压治疗使血压,10.9/4.1 mmHg,100,279,136,387,193,293,244,373,329,647,835,656,734,392,HYVEY,研究,The,HYpertension,in the Very Elderly Trial,N,Engl,J Med 2008;358.,多中心、,随机双盲、安慰剂对照研究,共纳入,3 845,名年龄超过,80,岁,、来自欧洲、澳大利亚、亚非等国患者,计划随诊,10 500,患者,-,年,Cardiovascular death,Double-blind trials,All trials,Total mortality,Double-blind trials,All trials,Major CV events,Double-blind trials,All trials,Major coronary events,Double-blind trials,All trials,Heart failure,Double-blind trials,All trials,(n=5,RR=1.14,p=0.05),(n=5,RR=1.11,p=0.42),(n=7,RR=1.14,p=0.99),(n=4,RR=0.77,p=0.03),(n=6,RR=0.78,p=0.01),(n=4,RR=0.85,p=0.45),(n=6,RR=0.78,p=0.21),(n=5,RR=1.14,p=0.05),Treatment better,Control better,0,0.2,0.4,0.6,0.8,1.0,1.2,1.4,1.6,1.8,2.0,老老年患者降压治疗的,Meta-analysis,Gueyffier,F et al:Lancet 1999,(n=6,RR=0.61,p=0.01),(n=4,RR=0.58,p=0.01),安慰剂组,(n=1912),治疗组,(n=1933),年龄,(,岁,),83.5,83.6,女性,60.3%,60.7%,血压,:,坐姿收缩压,(mmHg),173.0,173.0,坐姿舒张压,(mmHg),90.8,90.8,直立性高血压,8.8%,7.9%,单纯收缩期高血压,32.6%,32.3%,基线,特征,Fall in SBP 20mmHg and/or fall in DBP 10mmHg,HR,95%CI,0.70,(0.49,1.01),0.61,(0.38,0.99),0.79,(0.65,0.95),0.81,(0.62,1.06),0.77,(0.60,1.01),0.71,(0.42,1.19),0.36,(0.22,0.58),0.66,(0.53,0.82),所有卒中,卒中死亡,全因死亡,非,CV/,不明原因死亡,CV,死亡,心脏原因死亡,心衰,CV,事件,0,2,0.5,0.2,0.1,ITT,分析：积极降压组患者显著获益,积极降压组血压控制显著优于对照组（,15 mmHg,/,6 mmHg,）,N,Engl,J Med 2008;358.,对照组更优,积极降压组更优,结论及其局限性,积极,降,压可降低超高龄者卒中死亡率和总死亡率,在降低心衰和心血管事件联合终点方面有重大收益,对,SBP,160mmHg,者,，,治疗益处需进一步研究,靶,血压是,150/80 mmHg,、,降得,更低,有否,益处还需,进一步,证实,局限性,结论,N,Engl,J Med 2008;358.,研究提前结束,中国高血压患者盐摄入量较高,中国人食盐摄入量,较,高,中国高血压四大诱因：年龄增长、体重超标、,过量,饮酒和食盐过量,我国一般人群中盐敏感者占15%-42%；在已确诊高血压患者中,则高达,60%,盐敏感性高血压特点,高血压发病与食盐过多有密切关系,患病率随年龄增长而增加，且病情逐渐加重,更易引起,LVH、HF、,卒中、肾功能不全等,多有,ISR，,常并发,DM,与血脂异常等代谢性疾病，最终促发,AS,和冠心病,对利尿剂与,CCB,疗效较好,高盐摄入对肾脏的影响,肾高灌注,肾内高压状态,肾小球率过滤,Ritz E,et al.Journal of Renal Nutrition,2009,19(1):61,62.,肾血管阻力,肾血浆流量,致血管内皮损伤、系膜增生、肥大、膜基质及大分子积沉、致,肾小球,硬化,盐负载,SNS,醛固酮（,ALD）,致心脑血管疾病机制,Aldosterone,Sodium,reabsorption,and water retention,K,+,and Mg,2,loss,Vascular compliance,Inflammation reaction,Progressive,Renal disease,Heart rate,Variability,Ventricular,arrhythmia,Endothelial,dysfunction,Catecholamine,potentiation,Cardiovascular Disorders,Stroke,Hypertension,Ischemia,End-stage,Renal disease,Heart failure,(LVH),Prothrombotic,effects(PAI-1 ),Vascular injury,and fibrosis,Aldosterone,Cardiovascular Disorders,Insulin,resistance,Myocardial fibrosis,and remodeling,在接受最佳冠心病基础治疗之上，,CCB,能否使,CHD,伴,ISH,患者进一步获益,对,ISH,特殊人群-,CHD,ACTION,研究,ACTION,研究,风险因素,侧重于高血压,安慰剂,(n=3840),硝苯地平控释片,(n=3825),糖尿病,胰岛素治疗,吸烟,体重指数,30,总胆固醇,5,mmol,/l,周围心血管疾病,ISH,140/,90mmHg,高血压,BP 140/90 mmHg,患者均接受强化的冠心病基础治疗,ESH 2009 Congress,冠心病伴,ISH,拜新同显著减少终点事件,*,*,*,P0.05,P0.01,n=2343,新发,心衰,心血管事件,死亡和操作,致残性,卒中,冠脉,造影,顽固性,心绞痛,16%,16%,17%,40%,*,*,0,10,20,30,40,23%,主要终点,18%,*,血压多降低,4.7/3.3 mmHg,Elliott&Meredith,2009,Elliott&Meredith,2009,主要终点,疗效,主要终点,安全性,任何心血管事件,死亡、