课件：继发性高血压筛查的意义及诊断策略.pptVIP

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,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. Young, Jr, MD, Anthony W. Stanson, MD, Geoffrey B. Thompson, MD, Clive S. Grant, MD, David R. Farley, MD, and Jon A. van Heerden, MB, ChB, Rochester, Minn,筛查常用辅助筛查手段,Magnetic Resonance Imaging-磁共振成象,磁共振成象在诊断醛固酮分泌腺瘤APA时具有高度的特异性。正如非功能性亢进肿瘤一样，醛固酮分泌腺瘤APA和双侧肾上腺增生BAH，能够通过磁共振成象显示出细胞内脂质移动的图象。,Role for adrenal venous sampling in primary aldosteronism William F. Young, Jr, MD, Anthony W. Stanson, MD, Geoffrey B. Thompson, MD, Clive S. Grant, MD, David R. Farley, MD, and Jon A. van Heerden, MB, ChB, Rochester, Minn,筛查常用辅助筛查手段,Adrenal Vein Sampling-肾上腺静脉采血,On the basis of CT findings alone, 42 patients (21.7%) would have been incorrectly excluded as candidates for adrenalectomy, and 48 (24.7%) might have had unnecessary or inappropriate adrenalectomy. AVS is an essential diagnostic step in most patients to distinguish between unilateral and bilateral adrenal aldosterone hyper secretion. Surgery 2004;136:1227-35. 单独使用CT筛查，约有21.7%的病人被错误地取消肾上腺切除术，24.7%的病人接受到了不必要或不合适的肾上腺切除术。,肾上腺静脉采血国内外现状,肾上腺静脉F浓度与外周比值大于2提示插管成功 F校正后比值大于2有意义 确认醛固酮分泌腺瘤,肾上腺静脉采血,治疗策略,确诊的醛固酮腺瘤患者-肾上腺组织切除术 腹腔镜下肾上腺切除术的日益成熟，创伤和时间大大缩短 双侧肾上腺增生-醛固酮受体拮抗剂类药物治疗 副作用-男子女性型乳房征、性欲减退、月经不规律等问题 肾上腺肿瘤切除的患者，约有60%患者停药 纠正低血钾症得以治愈，血压改善,Medical Management of Aldosterone-Producing Adenomas Ranjan P. Ghose, MD; Phillip M. Hall, MD; and Emmanuel L. Bravo, MD,现状与未来,肾素/醛固酮比值的普及应用，原醛症的检出率日益提高 存在血钾水平正常的原醛症患者 筛查策略的运用，有助于提高血压控制率 醛固酮受体的分布与高醛固酮症的危害 原醛症筛查的成本有效性,库欣综合征（Cushings syndrome)的诊断,典型的库欣综合征患者，ATCH和皮质醇分泌丧失节律 地塞米松抑制试验呈现地塞米松无法抑制皮质醇水平的现象，导致高血压症状 影像学检测,库欣综合征,库欣综合征,临床症状明显，无需特殊诊断筛查 与非疾病特定人群性状类似-肥胖 擦伤、多血症、以及肌肉病变在库欣综合征中占有很高的比重 外源性与内源性库欣综合征 外源性-二十四肽促皮质刺激实验，合适的生理糖皮 质激素替代治疗 内源性-过夜地塞米松抑制实验、24小试尿排泄皮质醇实验,库欣症的筛查意义及诊断策略,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,库欣症的筛查策略,Urinary free cortisol versus 17-hydroxycorticosteroids: a comparative study of their diagnostic value in Cushings syndrome T. Mengden, P. Hubmann, J. Mfiller, P. Greminger, and W. Vetter Departement ffir Inhere Medizin, Universit/itsspital Z/irich,不同病因Cushing综合症鉴别,嗜铬细胞瘤,嗜铬细胞瘤的发病率在高血压人群中约占0.2% 间歇性或持续性高血压，剧烈头痛，全身大汗淋漓、心悸、心动过速等,嗜铬细胞瘤(pheochromocytoma),嗜铬细胞瘤,起源于肾上腺髓质，致死率高 因嗜铬细胞瘤致死患者，近1/3对患病一无所知 积极的诊断和治疗 误诊和不合适的治疗可能是致命的,嗜铬细胞瘤,嗜铬细胞瘤,持续或间断地释放大量儿茶酚胺，引起持续性或阵发性高血压和多个器官功能及代谢紊乱,The Laboratory Diagnosis of Adrenal Pheochromocytoma: The Mayo Clinic Experience YOGISH C. KUDVA, ANNA M. SAWKA, AND WILLIAM F. YOUNG, JR. Division of Endocrinology, Metabolism and Nutrition, and Internal Medicine (Y.C.K., W.F.Y.), Mayo Clinic, Rochester, Minnesota 55905; and Department of Internal Medicine, St. Josephs Healthcare and McMaster University (A.M.S.), Hamilton, Ontario, Canada L8N 4A6,嗜铬细胞瘤的筛查意义及诊断策略,FIG. 1. Plasma metanephrine (A) and normetanephrine (B) values in pheochromocytoma and those without pheochromocytoma. Dashed lin