β受体阻滞剂在高血压治疗中的意义课件

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,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,*,受体阻滞剂在高血压治疗中的意义,北京协和医院心内科 严晓伟,受体阻滞剂在高血压治疗中的意义北京协和医院心内科 严晓,1,血压 =心排血量 x 周围血管阻力,高血压 =心排血量增加 和/或 周围血管阻力增加,前负荷,体液容量,肾：钠潴留,外源性钠摄入,遗传因素,心肌收缩力,心率,血管收缩,交感神经系统,肾素-,血管紧张素-,醛固酮系统,Kaplan NM.Curr Opin Nephrol Hypertens 1994,血压的控制,血压 =心排血量 x 周围血,2,Schlaish MP Hypertension 2004;43:169-75,去甲肾上腺素释放增加,肌肉交感兴奋,BP 107/58,BP 148/102,ECG,MSNA,BP,(mmHg),B,A,48 y.o.female,BP:107/58 mmHg,MSNA:32 bursts per min,45 bursts per 100 hb,49 y.o.female,BP:148/102 mmHg,MSNA:42 bursts per min,77 bursts per 100 hb,150,100,50,p 0.01,MSNA(bursts/100 heartbeats),100,80,60,40,20,0,NT,EH,A,800,600,400,200,0,Total body NE spillover(ng/min),Cardiac NE spillover(ng/min),Ronal NE spillover(ng/min),B,80,60,C,40,20,0,250,200,150,100,50,0,NT,EH,NT,EH,NT,EH,高血压时交感活性增加,Schlaish MP Hypertensio,3,伴糖尿病（,DM2,）的高血压患者,交感神经兴奋性显著升高,110,100,90,80,70,60,50,40,30,20,10,0,EHT+DM2,EHT,DM2,NT,P,0.001,P,0.01,P,0.001,P,0.001,交感活性,(Impulses/100 beats),Huggett et al,Hypetens.2004,伴糖尿病（DM2）的高血压患者110100908070605,合并代谢综合征（MS）的高血压患者交感神经兴奋性显著升高,80,60,40,20,0,P0.05,P0.01,P0.001,Huggett et al,Hypetens.2004,交感活性,(Impulses/100 beats),无MS和EHT,EHT,MS,MS+EHT,合并代谢综合征（MS）的高血压患者交感神经兴奋性显著升高8,诺贝尔医学奖 1988,James W.Black博士,“200年来继发现洋地黄以来最伟大的发现”,诺贝尔医学奖 1988James W.Black博士“20,阻滞剂在心血管领域的应用,缺血性心脏病,稳定性心绞痛,不稳定性心绞痛,急性心肌梗塞,高血压,心律不齐,非对称性窦性心动过速,在心房纤颤或扑动中的心室率的控制,阵发性室上性心动过速,室性快速型心律失常,/,心室纤维性颤动,(,索,他洛尔,),先天性长 QT 综合征,慢性心力衰竭,肥厚性梗阻性心肌病,主动脉疾病 Marfans,-,主动脉壁夹层形成,二尖瓣下垂,二尖瓣狭窄,法洛氏四联症,手术期间高危,阻滞剂在心血管领域的应用 缺血性心脏病 慢性心力衰竭,阻滞剂其他方面的应用,神经学方面,焦虑,特发性震颤,偏头痛预防,戒酒,内分泌病症,甲状腺毒症,嗜铬细胞瘤,(使用,阻滞剂后),胃肠道病症,食管血管曲张,门静脉高血压,眼科方面,青光眼(局部),阻滞剂其他方面的应用神经学方面内分泌病症胃肠道病症眼科方面,阻滞剂的作用机制,抑制过度激活的交感神经,儿茶酚胺对心肌的毒性作用,主要通过,1,受体通路介导,与RAS 间的相互作用,长期治疗,延缓、逆转心肌重构的生物学效应,冠脉血流有利的重分配,阻滞剂的作用机制 抑制过度激活的交感神经,阻滞剂的作用机制,减慢心率,即刻作用 改善心肌缺血,增加舒张期灌注,长期作用改善预后,心率是独立的心血管危险因素,抗心律失常作用,自律性、折返激动、触发激动,室颤阈,独有的作用防止猝死,阻滞剂的作用机制 减慢心率,阻滞剂保护伴高血压的,2,型糖尿病患者,受体阻滞剂/非糖尿病,受体阻滞剂/糖尿病,无,受体阻滞剂/非糖尿病,无,受体阻滞剂/糖尿病,生存率,%,时间（天数）,100,90,80,0,0,60,120,180,240,300,360,Kjekshus J Eur Heart J 1990;11:43,阻滞剂保护伴高血压的2型糖尿病患者受体阻滞剂/非糖尿病生,2006年NICE高血压指南新确诊高血压患者选择药物流程图,年龄,55岁,55岁,ACEI,CCB或利尿剂,ACEI+CCB或ACEI+利尿剂,ACEI+CCB+利尿剂,加用:利尿剂,或,受体阻滞剂,或受体阻滞剂,第一步,第二步,第三步,第四步,ACEI+CCB或ACEI+利尿剂,2006年NICE高血压指南新确诊高血压患者选择药物流程图,2007 ESH/ESC,高血压指南,NICE,has advised the use of,-blockers,only as fourtth line antihypertensive agents.,These conclusions must be considered,with care but also with a critical mind.,2007 ESH/ESC高血压指南,2007 ESH/ESC 高血压指南NICE has ad,受体阻滞剂在高血压治疗中的意义课件,受体阻滞剂在高血压治疗中的意义课件,受体阻滞剂在高血压治疗中的意义课件,Reappraisal of European guidelines on hypertension management,Box 5.Choice of antihypertensive drugs,(1)Large-scale meta-analyses of available data confirm that,major antihypertensive drug classes,that is,diuretics,ACE inhibitors,calcium antagonists,angiotensin receptor antagonists,and,b-blockers,do not differ significantly,for their overall ability to reduce BP in hypertension.,Reappraisal of European guidel,Reappraisal of European guidelines on hypertension management,Box 5.Choice of antihypertensive drugs,(2)There is also,no undisputable evidence,that major drug classes,differ in their ability to protect against overall cardiovascular risk or cause-specific cardiovascular events,such as stroke and myocardial infarction.The 2007 ESH/ESC guidelines conclusion that diuretics,ACE inhibitors,calcium antagonists,angiotensin receptor antagonists,and,b-blockers can all be considered suitable for initiation of antihypertensive treatment,as well as for its maintenance,Reappraisal of European guidel,Reappraisal of European guidelines on hypertension management,Box 5.Choice of antihypertensive drugs,(4)Each drug class has contraindications as well favorable effects in specific clinical settings.The choice of drug(s)should be made according to this evidence.The traditional ranking of drugs into first,second,third,and subsequent choice,with an average patient as reference,has now little scientific and practical justification and should be avoided.,Reappraisal of European guidel,Reappraisal of European guidelines on hypertension management,Box 6.Combination therapy,(6)Despite trial evidence of outcome reduction,the,-blocker/diuretic combination favors the development of diabetes and should thus be avoided,unless required for other reasons,in predisposed patients.,Reappraisal of European guidel,Reappraisal of European guidelines on hypertension management,Box 7.Antihypertensive treatment in the elderly,(2)Data from meta-analyses,do not support the claim that antihypertensive drug classes significantly differ,in their ability to lower BP and to exert cardiovascular protection,both in younger and in elderly patients.,The choice of the drugs to employ should thus not be guided by age.,Thiazide diuretics,ACE inhibitors,calcium antagonists,angiotensin receptor antagonists,and,-blockers,can be considered for initiation and maintenance of treatment also in the elderly.,Reappraisal of European guidel,Reappraisal of European guidelines o