在≥50岁就诊高血压患者中.ppt

北京大学人民医院王鲁雁,顽固性高血压与动脉病变,顽固性高血压定义,顽固性高血压是指尽管应用了3种的降压药物，患者的血压水平仍不能达到靶目标，3种降压药物中最好有一种为利尿剂，所有药物的剂量均已达到最佳。,需要注意，这里3种降压药物的规定并无理论依据，其目的是识别有可能存在继发性高血压,Hypertension，2008，51：1403141,顽固性高血压,常见临床问题，患病率不详，在一些大规模的临床试验中，有20一30的患者为顽固性高血压。老龄和肥胖是导致血压难以控制的两种主要因素,顽固性高血压,收缩压控制不满意在Framingham研究人群中，舒张压控制在90mmHg之内的患者能达到90，而收缩压140mmHg的患者仅有49。ALLHAT研究也发现有类似的问题，有92的患者舒张压能控制在90mmHg内，仅有67患者的收缩压能达到30kgm)。舒张压控制不满意的因素中，最重要的是肥胖，有13的肥胖患者不能满意控制舒张压,顽固性高血压,老龄,？,高血压,小动脉壁透明样变性包括大动脉在内的所有动脉,动脉,靶器官损害的根源,动脉,小动脉,主动脉的大分支，如无名动脉、锁骨下动脉、颈总动脉、髂动脉、肺动脉等,主动脉的其它分支，如冠状动脉、肾动脉和其它分配动脉(distributingarteries),大动脉（弹性动脉）,中动脉（肌性动脉）,直径2mm,动脉与血压形成,势能,外周阻力存在，搏出量2/3储存大A,使大A扩张，对管壁施加侧压力（收缩压）,动能推动搏出量的1/3在收缩期流向外周,心室收缩射血,150,100,50,150,100,50,150,100,50,(mmHg),(mmHg),(mmHg),Age68years,Age54years,Age24years,Renalartery,aorta,Thoracicaorta,Ascendingaorta,Abdominal,lliacartery,Femoralartery,动脉脉搏波分析(PWA),肱动脉血压,压力感受器,动脉,骨骼,140,70,70,140,函数转换,桡动脉压力波中心动脉压力波,16,AugmentationIndex(AIx)AIx=AP/PP,脉搏波传导速度（PWV）,动脉结构病变：粥样硬化,SchemeofAtheromatousPlaque,MacrophagesT-lymphocytes,Atheromatousplaque,Lumen,Fibrouscap,Endothelialcells,高血压患者临床特征及其与颈动脉粥样硬化之间的关系（n=224）,PrevalenceofPADincreaseswithage,FigureadaptedfromCreagerM,ed.ManagementofPeripheralArterialDisease.Medical,SurgicalandInterventionalAspects.2000.1MeijerWTetal.ArteriosclerThrombVascBiol1998;18:185-192.2.CriquiMHetal.Circulation1985;71:510-515.,PatientswithPAD(%),RotterdamStudy(ABITest0.9)1SanDiegoStudy(PADbynoninvasivetests)2,NewmanABetal.Circulation1993;88:837-845.TASCWorkingGroup.JVascSurg2000;31(1,pt2):S1-S288.DjoussePMetal.Circulation2000;102:3092-3097.,RiskfactorsforPAD,SmokingDiabetesHypertensionHypercholesterolemiaAlcohol,0.75123456,RelativeRisk,Reduced,Increased,MortalityisveryhighinpatientswithseverePAD,Relative5-yearmortality,1.CriquiMH.VascMed2001;6(suppl1):37.2.McKennaMetal.Atherosclerosis1991;87:11928.3.RiesLAGetal.(eds).SEERCancerStatisticsReview,19731997.US:NationalCancerInstitute;2000.,PREVENT:颈动脉内膜中层厚度(IMT),内膜中层厚度变化(mm),苯磺酸氨氯地平,Pittetal.Circulation2000;102:1503-10,P=0.007,安慰剂,0.033,0.013,CAMELOT/NORMALISE:阻遏和消退冠状动脉粥样硬化的进展,Nissenetal,fortheCAMELOTinvestigators.JAMA.2004;292:2217-2226.,安慰剂(n=49),依那普利(n=40),苯磺酸氨氯地平(n=47),P平均值患者N=136,P50%者，CTA和MRA的敏感度和特异度分别为8896%，7798%，和84100%，9099%；MRA判断RAS70%者较CTA准确，但MRA检查时间长，对急危重病人检查受限CTA和MRA检测RAS均有高估现象，有假阳性和偶有假阴性，且CTA诊断RAS70%者易误诊或过诊为闭塞，,肾动脉狭窄的治疗,包括介入治疗，外科治疗和药物治疗。药物治疗同高血压患者，双侧狭窄禁用ACEI和ARB介入治疗包括经皮腔内双肾动脉血管成形术(PTRA)和动脉内支架置入术。外科治疗包括肾血管旁路移植术、肾动脉内膜剥脱术、肾动脉再移植术、肾动脉狭窄段切除术、离体肾动脉成形术、自体肾移植术及肾切除术等。,药物治疗,AECICCBBBARB,BloodPressureOutcomeofAngioplastyinAtheroscleroticRenalArteryStenosisARandomizedTrial,atheroscleroticnatureoftheRASareductioninarterialdiameterofeither75%withoutthrombosisorof60%withapositivelateralizationtestastenosisaffectingthemainrenalartery,whichhadnotbeenpreviouslydilatedafunctionalkidneyontheoppositesideexhibitinganormalmainarteryoranarterialdiameterreduction50%.,Hypertension.1998;31:823-829,Trialprofile,antihypertensiveagentswereprescribedinthefollowingsequence:slow-releasenifedipine20mgBID;idemplusclonidine0.15mgBID;idemplusprazosin,2.5mgdaily.diastolicBPexceeded109mmHgonfirstoutpatientvisitor95mmHgontwosuccessivevisits,atenolol50mg/d,furosemide40mg/d,orenalapril10mg/dwasadded,DDD(defineddailydose):nifedipine30mg,clonidine0.45mg,prazosin5mg,furosemide40mg,enalapril10mg,andatenolol75mg,Differenceinbloodpressurereduction(meanand95%confidenceinterval)betweenpatientsallocatedtomedicaltreatmentandthoseallocatedtoangioplastybythemethodofbloodpressureassessment.,CONCLUSION,angioplastymadeBPcontroleasierintheshorttermbutwasmorefrequentlyassociatedwithcomplicationsthanconservativemanagementinpatientswithunilateralatheroscleroticRAS.Mostpatientsundergoingangioplastystillneededantihypertensiveagents6or12monthsaftertheprocedure.Thereductionintreatmentrequiredbypatientsundergoingangioplastyshouldthereforebeweighedagainsttherisksofcomplicationsandrestenosis.,StentPlacementinPatientsWithAtheroscleroticRenalArteryStenosisandImpairedRenalFunction,Design:RandomizedclinicaltrialSetting:10Europeanmedicalcenters.Participants:140patientswithcreatinineclearancelessthan80mL/minper1.73m2andARASof50%orgreater.Intervention:stentplacementandmedicaltreatment/medicaltreatmentonly(diuretics,calciumantagonists,-blockers,and-blockers,followedbyangiotensin-convertingenzymeinhibitors,angiotensinIIreceptorantagonists,andincreasingdosesofdiureticsiffirst-lineantihypertensivetreatmentfailed),astatin,andaspirin.Theprimaryendpoint:20%orgreaterdecreaseincreatinineclearance.Secondaryendpoints:safetyandcardiovascularmorbidityandmortality.,AnnInternMed,May4,2009,目的探讨动脉粥样硬化性肾动脉狭窄（ARAS）患者的临床特点，评价介入治疗和单纯药物治疗对肾功能预后的影响。方法分析本院经肾动脉造影确诊的ALIAS患者132例的临床资料。88例单侧ALIAS按年龄70岁和70岁分组及按基础GFR60mlmin和GFR60mlmin分组，比较介入治疗和药物治疗对GFR的影响。44例双侧ALIAS按行双侧、单侧、非介入治疗分组，比较3组差异。结果单侧ALIAS、年龄70岁者，介入治疗1年后GFR变化值优于药物治疗组（P005）；基础GFR60mlmin者，介入治疗1年后GFR变化值优于药物治疗组（P005）；年龄70岁，GFR60mlmin者，介入治疗与药物治疗相比，GFR变化值无显著性差异。双侧ALIAS者双侧介入治疗GFR变化值优于单侧介入，单侧介入优于非介入治疗组。Logistic回归分析示基础GFR60mlmin，进行介入治疗的单侧ALIAS者，肾功能（GFR）的预后较好。结论单侧ARAS年龄70岁，介入治疗前GFR60mlmin者，介入治疗后肾功能（