肥胖与高血压

Obesity andHypertension,肥胖与高血压,成人肥胖如何定义？,图片来自/magazine/health-medicine/obese-americans-suffer-daily-pain/,根据体重指数（BMI）进行分级,Adapted from the World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO; 2000.WHO/IASO/IOTF. The Asia-Pacific perspective: redefining obesity and its treatment. Health Communications Australia: Melbourne. ISBN 0-9577082-1-1. 2000中国高血压指南 2010,中心性肥胖腹围测量,Han TS et al. Obes Res. 2002;10:923-931. Janssen I et al. Arch Intern Med. 2002;162:2074-2079.,Adapted from the World Health Organization. Obesity: Preventing and Managing the Global Epidemic. Geneva: WHO; 2000.WHO/IASO/IOTF. The Asia-Pacific perspective: redefining obesity and its treatment. Health Communications Australia: Melbourne. ISBN 0-9577082-1-1. 2000中国高血压指南 2010,中心性肥胖腹围标准,中国居民的超重和肥胖流行现状,利用2002年中国居民营养与健康状况调查209 849人的有效数据，计算全国的超重和肥胖患病率。18岁及以上成年人采用卫生部中国成人超重和肥胖症预防控制指南推荐的标准：18BMI24正常，24BMI28超重,BMI28肥胖,武阳丰，中华预防医学杂志，2005年5期,美国成人超重和肥胖流行现状更加严峻,CDC 2010 NCHS Health E-Stat, Cheryl D. Fryar,etc,Framingham Offspring Study.1987,75 and 65% of hypertension in menand women are attributable to obesity.Adiposity stands out as a majorcontrollable contributor to hypertension.,肥胖是引起高血压的重要因素,Waist circumference is more closelylinked to cardiovascular disease riskfactors than is BMI.Zhu et al. Am J Clin Nutr 2002A central distribution of body fat isassociated with increased BP,independently of body mass index. Siani et al. Am J Hypertens 2002,中心性肥胖与高血压更加相关,腹内脂肪累积（内脏型肥胖）与高血压更为相关,Close correlation of intra-abdominal fat accumulation to hypertension in obese womenHypertension. 1990 Nov;16(5):484-90,Scatterplots showing correlation between the intra-abdominal visceral fat area /subcutaneous fat area (V/S) ratio and systolic and diastolic blood pressures (BP) in obesesubjects not taking antihypertensive medication.,67 obese women (mean body mass index, 33.6 +/- 3.1; average age, 50 +/- 11 years)the ratio of the intra-abdominal visceral fat area to subcutaneous fat area was determined using a computed tomographic section at the level of the umbilicus.,我国门诊高血压患者肥胖/腹型肥胖比例接近50%,（n=16950）,（n=3584）,孙宁玲，王鸿懿，霍勇等，中华内科杂志，2013年8月第52卷第8期，654-658,2013ESH高血压指南加强了对肥胖危险因素评估,Journal of Hypertension 2013, 31:12811357,Factors Linking Obesity toHypertension,肥胖引起高血压的因素有哪些？,肥胖引起高血压的因素有哪些？,胰岛素抵抗与内皮功能障碍交感神经系统及RAS系统激活脂肪细胞因子刺激血流动力学改变肾脏对钠重吸收增加,肥胖与胰岛素抵抗/高胰岛素血症,FEBS Lett. 2008 January 9; 582(1): 97105.,高胰岛素血症引起肾脏钠重吸收增加,Horita S, Seki G, Yamada H, Suzuki M, Nakamura M, et al. (2011) Metabolic syndrome and insulin signaling in kidney. Endocrinol Metabol Syndrome S1:005,胰岛素刺激内皮素（endothelin-1）合成,J Biol Chem. 1991 Dec 5;266(34):23251-6,Dose response of the ET-1 mRNA levels to various concentrations of insulin.,胰岛素抵抗引起内皮功能障碍,Circulation. 2006 Apr 18;113(15):1888-904,健康状态,胰岛素抵抗及高胰岛素血症,ETA, Endothelin type A receptors ETB, Endothelin type B receptors,胰岛素抵抗与高血压,中心肥胖引起交感神经系统激活,Relations between basal muscle sympathetic nerve activity and total fat mass (A) , abdominal visceral fat (B) and abdominal subcutaneous fat (C).,Circulation. 2002;106:2533-2536;,A B C,肥胖激活RAS系统,Hypertension. 2005;45:356-362,降低体重可降低系统RAS水平,Hypertension. 2005;45:356-362,肥胖可导致炎症状态,肥胖对心血管结构影响,肥胖对血流动力学的改变,Circulation. 2006;113:898-918,肥胖引起肾脏对钠重吸收增加,Hypertension Research (2009) 32, 649657,Treatment of ObeseHypertensive Patients,如何对肥胖型高血压进行治疗？,生活方式干预减少体重可降低血压,Dotted lines represent the weight loss group; solid lines represent the usual care group. Error bars represent 95% CIs.,Long-Term Weight Loss and Changes in Blood Pressure: Results of the Trials of Hypertension Prevention, Phase II,Ann Intern Med. 2001;134:1-11,减肥药物在肥胖型高血压中的应用,进一步回顾奥利司他和利拉鲁肽的研究结果：与安慰剂相比，奥利司他可降低体重2.7 kg和舒张压2.2 mm Hg；GLP-1激动剂（利拉鲁肽）在非糖尿病患者中也显示出良好的减重和降压效应，但却因轻度心率增快（3次/分）受到心血管安全性方面的关注。二甲双胍作为传统的降糖药物，在非糖尿病患者中显示出良好的安全性和减轻体重、降低血压的作用，但能否在肥胖型高血压中广泛使用尚需进一步的大规模临床试验证实。,2012年欧洲高血压学会肥胖工作组共识,共识未就减肥药物在肥胖型高血压治疗中的地位进行评价,Joint statement of the European Association for the Study ofObesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension Journal of Hypertension 2012, 30:10471055,减肥手术在肥胖型高血压中的应用,目前，减肥手术应当仅仅作为一种保留手段，对严重肥胖患者且在其他常规医疗手段均已失效的情况下应用。,2011年美国心脏病学会（AHA）声明,2012年欧洲高血压学会肥胖工作组共识,减肥手术是目前对于病理性肥胖患者长期减重效果最强的治疗方式，同时也显示出良好的降糖、降压和一定的降低心血管病风险的疗效。本共识对于这一治疗方式只是汇总了目前的循证医学证据，并未对其价值进行评价。,Journal of Hypertension 2012, 30:10471055Circulation, 2011, 123(15):1683-1701.,降压药物的选择,血容量扩张和神经内分泌激活是肥胖型高血压的主要病理生理改变RAS抑制剂可作为一线降压药物如血压控制不佳，考虑到肥胖患者多合并水钠潴留，可使用小剂量噻嗪类利尿剂联合RAS抑制剂使用,Joint statement of the European Association for the Study ofObesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension Journal of Hypertension 2012, 30:10471055,ARB单用或联用氢氯噻嗪治疗伴有代谢综合征的高血压患者的疗效,一项为期52周的评价氯沙坦单用或联用氢氯噻嗪（HCTZ）治疗伴有代谢综合征的高血压患者的疗效的前瞻性队列研究,J Human Hypertension 2010; 24, 739748.,研究设计,为期52周的多中心、前瞻性、开放、队列研究纳入1738名轻中度高血压伴代谢综合征患者给予氯沙坦50mg起始治疗，对于未达标患者（BP140/90mmHg）逐渐滴定至氯沙坦100mg、氯沙坦100mg+HCTZ12.5mg或氯沙坦100mg+HCTZ25mg+CCB（根据病情需要）评估指标：降压疗效指标：第4、8、12、32和52周时，收缩压（SBP）和舒张压（DBP）的变化探索性指标：治疗52周，TG、LDL-C、HDL-C、尿酸、hs-CRP较基线的变化,J Human Hypertension 2010; 24, 739748.,氯沙坦显著降低高血压伴代谢综合征患者血压,治疗52周后，SBP平均下16.95mmHg(P=0.001)；DBP下降9.84mmHg(P=0.001)。治疗52周后，ITT分析显示，血压控制率（BP140/90mmHg）为70.0%；而在所有完成随访的患者中，血压控制率为79.4%,J Human Hypertension 2010; 24, 739748.,氯沙坦显著改善腰围、BMI、总胆固醇、尿酸等代谢指