改善血压控制的质量和内涵.ppt

改善血压控制的质量和内涵,降低和控制清晨高血压张维忠,以长期高质量血压控制和预防或逆转靶器官损害为目标的优化治疗，更有利于指导降压治疗，并获得更大程度的益处。优化治疗策略需要优选降压治疗的基本元素、剂量以及联合治疗方案与路径，2009年ESH治疗指南再评价提出Preferreddrugs，Preferredcombinations。,降压治疗策略的新理念,ClinicBPcanrepresentthewholebloodpressurestatus?,-20,-15,-10,-5,0,DrugA（highT/Pratio）,DrugB（lowT/Pratio）,ClinicBPRoutinetimeofmeasurement,ABPM,Drugdelivery,NeutelJM,BloodPressureMonitoring2019,6:9-16,AverageBPchange(mmHg),Dolan,E.etal.Hypertension2019;46:15661,SuperiorpredictivevalueofABPonCVmortality,TheFinn-HomeStudy,TheFinn-HomeStudy.Hypertension2019,59:212-218,PrognosticValueoftheVariabilityinHome-MeasuredBloodPressureandHeartRate,24-hBloodPressureProfile,Timeofday,Bloodpressure(mmHg),18:0022:0002:0006:0010:0014:0018:00,Timeofawakening,Sleep,180,160,140,120,100,80,Millar-Craigetal,1978;Manciaetal,1983,清晨高血压MorningHypertension,清晨高血压:清晨时段血压升高(135/85mmHg)清晨高血压是隐蔽性高血压(MaskedHypertension)的一种主要表现清晨高血压与血压晨峰或血压昼夜节律异常有密切关系,Cohen,MC,etal.AmJCardiol2019;79:1512-1516EllioltWJStroke2019;29:992-996,CVEventisHighestIntheMorning,*Relativerisk(95%Cl)basedonproportionofactualnumberofincidenceversusexpectednumberofincidence(ifnocircadianvariationsexisted),50,40,30,20,10,0,AcuteMl,Stroke,Increaseinrelativerisk(%)*,38%,49%,BrJCardiol2019;15:31-34,HighincidentofStroke25:2218-2223.,MorninghypertensionandcomplicationsinPatientswithtype2diabetes,70,60,50,40,30,20,10,0,Morningnormotensives(n=73)Morninghypertensives(n=97),p0.01,Prevalenceofcomplications(%),Neuropathy,Retinopathy,CoronaryArterydisease,Cerebrovasculardisease,Hypertensionstatusanddiabetesonsilentcerebralinfarct,EguchiK,etal.Stroke2019;34:2471-2474.,MorninghypertensionandleftventricularhypertrophyInmedicatedpatientswithhypertensive,Datapresentedatthe2019AnnualScientificMeetingofJapaneseSocietyofHypertension,Miyazaki,Japan.,White-coathypertension(n=59),White-coathypertension(morningsurge),Sustainedhypertension(n=44),Morninghypertension(n=27),P=0.001,P=0.01,P=0.01,200,100,0,LeftventricularMassindex(g/m2),MEaverage(mmHg)127.3127.1142.4143.5MEsurge(mmHg)8.4247.325,CaramoriML,etal.NEnglJMed2019;348:260-264,160,140,120,100,80,40,60,80,100,120,DiastolicPressure(mmHg),SystolicPressure(mmHg),P=0.005,P=0.003,Morning,Daytime,Night-time,Morning,Daytime,Night-time,Microalbuminuria(n=14)Nonmoaibuminuria(n=17),NS,NS,NS,NS,MorningbloodpressureandmicroalbuminuriaInnewlydiagnoseddiabeticpatients,改善血压控制的质量和内涵,有效控制24小时血压水平控制夜间高血压控制清晨高血压减轻长时血压变异,Bloodpressurecontrolintheriskyearly-morninghours,RedonJetal.BloodPressMonit2019;7:111-118KarioKetal.Circulation2019;108:72e-73e,70,60,50,40,30,20,10,0,Controlled(morningSBP/DBP135/85mmHg),Notcontrolled,Patients(%),ACAMPA(ABPM),J-MORE(HBPM),TwostudiesinpatientswithcontrolledofficeBPhaveshownpoorcontrolofmeanmorningBP,控制清晨高血压的治疗方法,使用超长效降压药物将给药时间改为临睡前使用长效1阻滞剂多沙唑嗪控释片,苯磺酸氨氯地平长效的药理学机制,氨氯地平的血浆半衰期长达35-50小时。氨氯地平的分子侧链带正电荷，与带负电荷的细胞膜结合，能持久地发挥阻滞血管平滑肌细胞L型钙通道作用。,苯磺酸氨氯地平的化学结构和作用机制,苯磺酸氨氯地平的化学结构,氨氯地平与细胞膜的作用受电荷平衡影响,MorningdosingofamlodipineonmorningBPinhypertensivepatients,40,20,0,-20,-40,-60,-80,120,140,160,180,200,220,BaselinemorningsystolicBP(mmHg),4/35=11%,AmlodipinegroupReductionofmorningsystolicBP(mmHg),r=-0.73P0.001n=38,Nonresponders,EguchiK,etal.AmJHypertens2019;17:112-117,MorningdosingofvalsartanonmorningBPinhypertensivepatients,40,20,0,-20,-40,-60,-80,120,140,160,180,200,220,BaselinemorningsystolicBP(mmHg),15/33=45%,ValsartangroupReductionofmorningsystolicBP(mmHg),r=-0.53p=0.001n=38,EguchiK,etal.AmJHypertens2019;17:112-117,Nonresponders,络活喜有效控制24h和清晨血压,Clin.Dru