【高血压精品英文课件】高心病 hypertensive heart disease

HypertensiveHeartDisease GeneBukhmanJanuary12th 2005 EpidemiologyI NumberofPatientswithHypertensionintheUnitedStates 50millionNumberofPatientswithHeartFailure 5millionPercentofHeartFailurePatientswithHypertension 75 JNC7 2004JessupandBrozena NEJM 2003 Mosterdetal NEJM 1997 MortalityinHypertension 50 fromischemicheartdiseaseorheartfailure33 fromcerebrovasculardisease10to15 fromrenalfailure KaplaninZipes Libby Bonow andBraunwald 2005 HypertensiveHeartDisease CoronaryArteryDiseaseHeartFailureDiastolicDysfunctionImpairedrelaxationLeftventricularmyocytehypertrophyInterstitialfibrosisSystolicDysfunctionIschemiccardiomyopathyLateconsequenceofafterloadArrhythmiasAtrialfibrillationLeftatrialenlargementVentricularArrythmias KaplaninZipes Libby Bonow andBraunwald 2005 LeftVentricularHypertrophyI ConcentricincreaseinLVmassCompensatoryresponsetoincreasedafterloadCollagenMyocytehypertrophy LorellandCarabello Circulation 2000 LeftVentricularHypertrophyII EffectofmechanicalloadingmostclearinrapidregressionfollowingaorticvalvereplacementInsystemichypertensionconfoundedbyroleofangiotensinIIandsympathetichormonesLVHoftendevelopsafterothersignsofdiastolicdysfunctioninHTNLVHalsoseentoprecededevelopmentofsystemicHTN LorellandCarabello Circulation 2000 JessupandBrozena NEJM 2003 ConsequencesofLVH Althoughinitiallycompensatory LVHultimatelyassociatedwithriskofcardiovasculareventssimilartohistoryofpriormyocardialinfarctionIschemiaDecreasedcoronaryreservewithincreasedLVmassanginaGreaterriskofdeathfollowingmyocardialinfarctionHeartFailureDepressedLVsystolicanddiastolicfunctionArrhythmiaAtrialfibrillationVentriculararrhythmiasNonuniformactionpotentialprolongationAlteredrepolarizationSpecificvulnerabilitytotorsadesIschemicventriculararrhythmia DunnandPfeffer NEJM 1999 EchocardiographyFindingsinSystemicHTN LeftatrialenlargementMitralannularcalcificationMildtomoderatemitralregurgitationAorticrootdilatationAorticvalvesclerosisMildaorticregurgitationDiastolicdysfunctionImpairedrelaxationRestrictivepatternReducedejectionfractionUsuallylateconsequencewithventriculardilatationSymmetricleftventricularhypertrophy Otto 2000 AurigemmaandGaasch NEJM 2004 DiastolicDysfunction AurigemmaandGaasch NEJM 2004Redfield NEJM 2004 PossibleRoleofLVHdeterminationinsystemicHTN SelectionofpatientsfortreatmentChoiceoftreatmentagentMonitoring EchocardiographicevaluationofLVH Framinghamaddsechocardiographyin1979ECGprobablyhas1 8ththesensitivityofechocardiographyProbably20percentprevalenceinthoseover40yearsoldPresentin20to30percentofotherwiselowriskpatientswithHTN LorellandCarabello Circulation 2000 Multiplemethodsofechocardiographicleftventricularmasscalculation LVM 0 8x 1 04x LVID LVPWT IVST 3 LVID3 Limitssetby2standarddeviationsoftheFraminghamcohortmeanPoorreproducibilityPossibleadvantageofcardiacMR Manning2004 LorellandCarabello Circulation 2000 TreatmentofHypertensionandAbsoluteCardiovascularRisk BenefitoftreatmentproportionaltooverallcardiovascularriskRiskincreaseswithlevelofbloodpressurewithoutclearthreshold MacMahon NEJM 2000 LVHandtreatmentofHTN RegressionofLVHwithtreatmentbyallclassesofagentsexceptdirectvasodilatorsPossiblesuperiorityofaceinhibitorsandangiotensinreceptorblockersNotclearifbenefittoLVHregressionindependentfromoverallbenefitofbloodpressurereduction LosartanInterventionforendpointreduction LIFE trial Dahlofetal Lancet 2002 ACC AHA ASE2003Guidelines EchocardiographyinHTNI ClassIIndications 1 WhenassessmentofrestingLVfunction hypertrophy orconcentricremodelingisimportantinclinicaldecisionmaking2 DetectionandassessmentoffunctionalsignificanceofconcomitantCADbystressechocardiography 3 Follow upassessmentofLVsizeandfunctioninpatientswithLVdysfunctionwhentherehasbeenadocumentedchangeinclinicalstatusortoguidemedicaltherapy Cheitlinetal ACC AHA ASE 2003 ACC AHA ASE2003Guidelines EchocardiographyinHTNII ClassIIaIndications 1 IdentificationofLVdiastolicfillingabnormalitieswithorwithoutsystolicabnormalities 2 AssessmentofLVhypertrophyinapatientwithborderlinehypertensionwithoutLVhypertrophyonECGtoguidedecisionmakingregardinginitiationoftherapy Alimitedgoal directedechocardiogrammaybeindicatedforthispurpose Cheitlinetal ACC AHA ASE 2003 ACC AHA ASE2003Guidelines EchocardiographyinHTNIII ClassIIbIndications 1 RiskstratificationforprognosisbydeterminationofLVperformance ClassIIIIndications 1 Re evaluationtoguideantihypertensivetherapybasedonLVmassregression 2 Re evaluationinasymptomaticpatientstoassessLVfunction Cheitlinetal ACC AHA ASE 2003 CommonindicationsforechocardiographyinHTN BorderlinehypertensionwithnootherriskfactorsAsmanyas30percentofpatientwithlowtomediumriskHTNwillhaveLVHPharmacologictreatmentpreferredPatientswithseverehypertensionintheoffice butnotoninitialambulatorymonitoringIfnoLVHsuggestseitherwhitecoathypertensionOrHTNofrecentonsetContinuedambulatorymonitoringHeartFailure RoleofLimitedechocardiography Cost 600forcompleteechocardiogram 150forlimitedstudyincludingm modeanddoppler 70forECG Worker sCompensation Hypertensionconsideredanoccupationalinjuryforselectedprofessionsinsomestatesifcanshowendorgandamage Forexample VirginiaCodeSection65 2 402 B hypertensionorheartdiseasecausingthedeathof oranyhealthconditionorimpairmentresultingintotalorpartialdisabilityof i salariedorvolunteerfirefighters ii membersoftheStatePoliceOfficers RetirementSystem iii membersofcounty cityortownpolicedepartments iv sheriffsanddeputysheriffs v DepartmentofEmergencyServiceshazardousmaterialsofficers and vi citysergeantsordeputycitysergeantsoftheCityofRichmondshallbepresumedtobeoccupationaldiseases sufferedinthelineofduty thatarecoveredbythistitleunlesssuchpresumptionisovercomebyapreponderanceofcompetentevidencetothecontrary FuturedirectionsforLVHassessmentinpatientswithHTN Ifabsoluteriskapproachadoptedmoreextensively questionofroleofLVHassessmentasanindependentriskfactorQuestionofsuperiorityofsomeanti hypertensiveagentsforpatientswithLVHImprovementsinaccuracyofLVmassassessmentwithcardiacMR References AurigemmaandGaasch ClinicalProblemSolving DiastolicHeartFailure NEJM 2004 Cheitlinetal ACC AHA ASE2003GuidelineUpdatefortheClinicalApplicationofEchocardiography 2003 Dahlofetal Cardiovascularmorbidityandmortal