继发性高血压筛查的意义及诊断策略

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,*,继发性高血压诊断意义及筛查策略,什么是高血压,2013 ESH/ESC Guidelines for themanagement of arterial hypertension The Task Force for the management ofarterial hypertension of the,European Society ofHypertension(ESH)and of the European Society of Cardiology(ESC),高血压症状,大多数高血压没有明显症状,部分高血压患者会出现如下症状,头痛、头晕,失眠,耳鸣,手脚麻木、颈背部肌肉酸痛、紧张,高血压风险等级,2013 ESH/ESC Guidelines for themanagement of arterial hypertension The Task Force for the management ofarterial hypertension of the,European Society ofHypertension(ESH)and of the European Society of Cardiology(ESC),高血压的危害,Kearney PM,Whelton M,Reynolds K,Muntner P,Whelton PK,He J.Global burden of hypertension:analysis of worldwide data.Lancet.,2005;365(9455):217-23.,高血压人群状态,中国,中国,中国高血压人群,Kearney PM,Whelton M,Reynolds K,Muntner P,Whelton PK,He J.Global burden of hypertension:analysis of worldwide data.Lancet.,2005;365(9455):217-23.,继发性高血压筛查历史,继发性高血压筛查现状,The prevalence of secondary forms of,hypertension was,10.2%,including,renovascular hypertension(3.1%),primary aldosteronism(1.4%),Cushings syndrome(0.5%),pheochromocytoma(0.3%),primary hypothyroidism(3.0%),Conclusions:,Increasing age and coexisting atherosclerosis have significant effects on the prevalence of secondary forms of hypertension,.,The effect of age on prevalence of secondary forms of hypertension in 4429 consecutively referred patients,Anderson,Gunnar H.Jr;Blakeman,Nancy;Streeten,David H.P.,继发性高血压筛查现状,继发性高血压的发病率为,10.2%,包含肾血管性高血压,3.1%,，,原发性醛固酮增多症,1.4%,，,库欣综合征,0.5%,，,嗜铬细胞瘤,0.3%,，,原发性甲状腺功能减退,3.0%,；,结论：年龄的增长及伴随的动脉粥样硬化疾病，与继发性高血压的发病率存在明显的关系。,继发性高血压筛查意义,继发性高血压诊断的意义在于，将有可能将不可治愈的疾病变成可以治愈的疾病。哪怕潜在疾病可能无法治愈，也可通过提供特异性的治疗方案使血压得到更好的控制，同时，潜在的疾病通常会造成比血压升高更加严重的后果，因此需要对其进行治疗。,常见的内分泌高血压,Prospective Study on the Prevalence of Secondary Hypertension among Hypertensive Patients,Visiting a General Outpatient Clinic in Japan Masao OMURA,Jun SAITO,Kunio YAMAGUCHI,Yukio KAKUTA,and Tetsuo NISHIKAWA,原发性醛固酮增多症,库欣综合征,嗜铬细胞瘤,肢端肥大症,肾素,-,血管紧张素,-,醛固酮系统（,RAAS,）,RAAS,系统,原发性醛固酮增多症,症状,高血压,原因未知的低血钾,特点,症状无特异性,与麻痹、肌无力临床,症状相似,筛查项目,肾素活性,PRA,肾素浓度,PRC,醛固酮浓度,ALD,药物在原醛筛查中的影响,药物种类,临床常用药物,对,ARR,比值影响,-,受体阻断剂,美托洛尔、阿替洛尔及,艾可洛尔等,肾素,ARR,ACE,抑制剂、,AT1,受体拮抗剂,依那普利、西拉普利、,缬沙坦、氯沙坦等,醛固酮,肾素,ARR,钙通道阻断剂,硝苯地平、氨氯地平等,无显著影响,利尿剂,呋塞米、乙噻嗪等,无显著影响,原发性醛固酮增多症筛查,The PAC/PRC ratio offers several practical advantages compared with the PAC/PRA screening method.The present study offers preliminary evidence that it may be a useful screening test for PHA.,针对原发性醛固酮增多症，,PAC/PRC,的比值,，相比于,PAC/PRA,的筛查方法更加有效和实用，目前的研究已经提供了其可以作为一个有效筛查工具的初步证据。,原发性醛固酮增多症,Rapid Screening Test for Primary Hyperaldosteronism:Ratio of Plasma Aldosterone to Renin Concentration Determined by Fully,Automated Chemiluminescence Immunoassays,Frank Holger Perschel,1*Rudolf Schemer,3 Lysann Seiler,4 Martin Reincke,4,Jaap Deinum,5 Christiane Maser-Gluth,6 David Mechelhoff,1 Rudolf Tauber,1 and Sven Diederich2,Clinical Chemistry,2004,国外的研究进展及结论,ARR,比值的应用和现状,基层临床机构原醛症的普及筛查,高端医疗机构的原醛症的,确认,诊断,标准化降压药物药效研究和对,AARR,筛查的影响,单一降压药物对,AARR,筛查比值的影响,研究方法,学,一致性,Cut-off,无法实现互换性，,PA,筛查率差异很大,ARR,与,AARR,的差异,AARR-Aldosterone Active Renin Ratio,醛固酮,/,活性肾素比值,-PAC/PRC,ARR-Aldosterone Renin Ratio,血液醛固酮,/,活性肾素,-PAC/PRA,ARR,单位,ng/ml/hour,酶活力单位,ARR,参考范围,20-30ng/ml/hour,AARR,参考范围,32,Recent studies using the ratio of plasma aldosterone concentration,(PAC)to PRA as the screening test for primary aldosterondism in,hypertensive populations suggested that the prevalence may be as,high as 515%.,-Prevalence of Primary Aldosterondism among Asian Hypertensive Patients in Singapore,KEH-CHUAN LOH,EVELYN S.KOAY,MIN-CHEH KHAW,SHANTA C.EMMANUEL,AND WILLIAM F.YOUNG,JR.,ARR,筛查发展,ARR,比值,20ng/dl,，且,PAC,浓度,15pg/ml,原醛症检出率,4.6%,-Loh,2000,Mayo Clinic,PA,筛查率,4.6%,Stowasser M,调整对,ARR,筛查影响小的降压药物后，确认,PA,检出率,18%,影响因素,样本人群,药物种类和干扰,原醛症筛查思路,血钾浓度,检测系统特异性,原醛症的筛查思路,原醛症的筛查和诊断策略,Minireview:Primary AldosteronismChanging Concepts in Diagnosis and Treatment WILLIAM F.YOUNG,JR.,Professor of Medicine,Mayo Medical School;Consultant,Division of Endocrinology,Metabolism,Nutrition and Internal Medicine,Mayo Clinic and Mayo Foundation,Rochester,Minnesota 55905,原醛症的确认诊断,盐抑制试验,盐水负荷试验,氟氢可的松抑制试验,Comparison of Confirmatory Tests for the Diagnosis of Primary Aldosteronism Paolo Mulatero,Alberto Milan,Francesco Fallo,Giuseppe Regolisti,Francesca Pizzolo,Carlos Fardella,Lorena Mosso,Lisa Marafetti,Franco Veglio,and Mauro Maccario,原醛症的确认诊断,Salt Loading Test is a reasonably good alternative to the more expensive and complex FST for the diagnosis of PA after a positive screening test.,J Clin Endocrinol Metab,91:26182623,2006,操作简单、实用性高,可对门诊病人进行操作,可替代氟氢可的松抑制试验，可信度高,Comparison of Confirmatory Tests for the Diagnosis of Primary Aldosteronism Paolo Mulatero,Alberto Milan,Francesco Fallo,Giuseppe Regolisti,Francesca Pizzolo,Carlos Fardella,Lorena Mosso,Lisa Marafetti,Franco Veglio,and Mauro Maccario,筛查常用辅助筛查手段,CT,影像学的局限性,CT Scanning,therefore clearly localizes adenomas in 50%of histologically proven cases,and can also produce misleading results.,-,Role for adrenal venous sampling in primary aldosteronism,William F.You