高血压分级、分期、分型管理血管以及心、脑、肾等器官结.ppt

高血压的分级、分期、分型管理-血管与心、脑、肾等器官结构与功能检测-,上海交通大学医学院附属瑞金医院上海市高血压研究所王继光jiguangw,0,30,60,90,120,150,1985,1990,1995,2000,2005,2010(year),Stroke,CHD,Standardizedrate(1/100,000),DeathsattributedtostrokeandCHD,ChinaCVDreport2005,100,120,140,160,180,200,无血管或靶器官损害,有血管或靶器官损害,血管或靶器官并发症,分级(stageorgrade),高血压分级、分期、分型的基本理念,70,80,90,100,110,120,舒张压，mmHg,收缩压，mmHg,分型(phenotypingorpathophysiology),分期(stratificationorseverity),继发性高血压,有可测量异常的高血压,动脉硬化性高血压,高血压分级-准确测量血压，使用普遍有效的降压药物高血压分期-测量血管与靶器官的结构与功能，选择强适应症药物高血压分型-筛查病因以及影响血压的主要因素，采取病因治疗措施,坐位,袖带,血压计,24-hambulatoryBPmonitoring,Houroftheday,BP(mmHg),135,120,85,70,24-hmeanDaytimemeanNight-timemean,Whitecoathypertension,Maskedhypertension,JingNing:Prevalenceofwhite-coat,masked,andsustainedhypertension,Prevalence(%),Normotension,46.4%(n=322),7.8%(n=54),10.8%(n=75),35.0%(n=243),White-coatHT,MaskedHT,SustainedHT,WangGL,etal.JHypertens2007;25:23982405.,n=694,NICE2011:Definitions,Stage1hypertension:ClinicBPis140/90mmHgorhigherandABPMorHBPMaverageis135/85mmHgorhigher.Stage2hypertension:ClinicBPis160/100mmHgorhigherandABPMorHBPMdaytimeaverageis150/95mmHgorhigher.Severehypertension:ClinicsystolicBPis180mmHgorhigherorClinicdiastolicBPis110mmHgorhigher.,KrauseT,etal.BMJ2011;343:d4891.,A：ACEIorARB；B：-blockers；C：DihydropyridineCCBs；D：Thiazides；：-blockers；F：Fixeddosecombination,Chinesehypertensionguidelines:Choiceofantihypertensivedrugs,ChinJCardiol2011;39:579-616.,Step4,NICE2011:Summaryofantihypertensivedrugtreatment,Aged55yorblackpersonofAfricanorCaribbeanfamilyoriginofanyage,Agedunder55years,C,A,A+C,A+C+D,ResistanthypertensionA+C+D+considerfurtherdiureticoralpha-orbeta-blocker5Considerseekingexpertadvice,Step1,Step2,Step3,KeyAACEinhibitororlow-costangiotensinIIreceptorblocker(ARB)1CCalcium-channelblocker(CCB)DThiazide-likediuretic,KrauseT,etal.BMJ2011;343:d4891.,ASCOT-BPLA:Primaryandsecondaryendpoints,0.50,0.70,1.00,1.45,PrimaryendpointNonfatalMI(includingsilentMI)+fatalCHDSecondaryendpointNonfatalMI(excludingsilentMI)+fatalCHDAllcoronaryeventsAllCVeventsandproceduresTotalmortalityCVmortalityFatalandnonfatalstrokeFatalandnonfatalheartfailure,2.00,UnadjustedHazardratio(95%CI)0.90(0.79-1.02)0.87(0.76-1.00)0.87(0.79-0.96)0.84(0.78-0.90)0.89(0.81-0.99)0.76(0.65-0.90)0.77(0.66-0.89)0.84(0.66-1.05),DahlfBetal.Lancet2005:366;895-906.,AmlodipinePerindoprilbetter,AtenololBendrofluathiazidebetter,ACCOMPLISH:Primaryendpointandcomponents,CompositeCVmortality/morbidityCardiovascularmortalityNon-fatalMINon-fatalstrokeHospitalizationforunstableanginaCoronaryrevascularizationprocedureResuscitatedsuddendeath,RiskRatio(95%),FavorsCCB/ACEI,FavorsACEI/HCTZ,0.80(0.720.90)0.81(0.62-1.06)0.81(0.63-1.05)0.87(0.67-1.13)0.74(0.49-1.11)0.85(0.74-0.99)1.75(0.73-4.17),JamersonKetal.NEnglJMed2008;359:2417-28.,高血压分级-准确测量血压，使用普遍有效的降压药物高血压分期-测量血管与靶器官的结构与功能，选择强适应症药物高血压分型-筛查病因以及影响血压的主要因素，采取病因治疗措施,Pulsediagnostics,中国高血压指南：危险分层,中华心血管病杂志2011;39:579-616.,ART.LABTheArterialAnalyser,BloodvesselwallthicknessRFQIMT,Brightnessmodescanning(B-mode),Framerate30frames/s,Assessmentof:,ZhangY,etal.Submitted.,ConcentricRemodelingN=107(12.7%),ConcentricHypertrophyN=16(1.9%),NormalGeometryN=694(82.6%),EccentricHypertrophyN=26(3.1%),0.42,95()95()115()115(),LeftVentricularMassIndex(gm/m2),RelativeWallThickness,0.42,NingBostudy:EchocardiographicLVH,非介入颅内动脉成像-MRA39:579-616.,高血压分级-准确测量血压，使用普遍有效的降压药物高血压分期-测量血管与靶器官的结构与功能，选择强适应症药物高血压分型-筛查病因以及影响血压的主要因素，采取病因治疗措施,高血压病因学分解,血管,血流,血压,自主神经,心脏,RAAS系统,肾脏,精神紧张,Na+,K+,酗酒,吸烟,体力活动,HypertensionResearch2011;34(12):1255-1256.,继发性高血压或具有典型临床特征的高血压,较早发现的继发性高血压（内分泌、大动脉狭窄、肾实质等）新发现的继发性高血压（OSAS）具有典型临床特征的高血压（高交感、代谢紊乱、动脉硬化等）,阻塞性睡眠呼吸暂停综合征,呼吸暂停,呼吸暂停,急性高血压,心动过速,SaO2,射频消融交感神经,尽管有多种有效而且安全的降压药物，尽管经过数十年的