高血压英文课

Hypertension,Longxian ChengDepartment of Cardiology, Union HospitalTongji Medical College, HUST, Wuhan,Introduction,Hypertension is a major public health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease.Approximately 100 million Chinese have elevated BP. Of these, 77% are aware of their diagnosis, 70% are receiving treatment, and only 33% are under control.,Definition,Hypertension is defined as a SBP of 140 mmHg or greater and/or a DBP of 90 mmHg or greater in subjects who are not taking antihypertensive medication. Essential or primary hypertension is a hypertension of unknown cause. Isolated systolic hypertension is defined as SBP of 140 mmHg or greater and diastolic BP less than 90 mmHg.,Classification of Blood Pressure Levels (mmHg),Category Systolic DiastolicOptimal 120 80Normal 130 85High-normal 130-139 85-89Grade 1 hypertension(mild) 140-159 90-99 Subgroup: borderline 140-149 90-94Grade 2 hypertension(moderate) 160-179 100-109Grade 3 hypertension(severe) 180 110 Isolated systolic hypertension 140 90 Subgroup: borderline 140-149 90,Notes,1. When a patients SBP and DBP fall into different categories, the higher category should apply. e.g.154/100 mmHg is defined as grade 2 hypertension.180/82 mmHg is defined as grade 3 isolated systolic hypertension.,Notes(Continue),2. BP is based on the average of two or more readings taken at each of two or more visits after an initial screening(筛查).e.g.12/2 first visit: 172/102 mmHg, 168/104 mmHg.13/2 second visit: 158/98 mmHg, 158/96mmHg.The average BP is 164/100 mmHg, which is defined as grade 2 hypertension.,Notes(continue),3. The patient should be clearly informed that a single elevated reading does not constitute a diagnosis of hypertension but is a sign that further observation is required.For instance:21/3 1st visit: 146/98mmHg, 150/98mmHg23/3 2nd visit: 128/84, 126/8027/3 3rd visit: 130/80, 130/82,Notes(continue),4. Optimal BP with respect to cardiovascular risk is less than 120/80 mmHg. However, unusually low readings should be evaluated for clinical significance.For example,70/50 mmHg is less than 120/80 mmHg, but it is not optimal.,Classification of Blood Pressure Levels (mmHg),Category Systolic DiastolicHypotension? 90 60Optimal 120 80Normal 130 85High-normal 130-139 85-89Grade 1 hypertension(mild) 140-159 90-99 Subgroup: borderline 140-149 90-94Grade 2 hypertension(moderate) 160-179 100-109Grade 3 hypertension(severe) 180 110 Isolated systolic hypertension 140 90 Subgroup: borderline 140-149 90,Epidemiology,Prevalence rate（患病率） of hypertension in China: In 1959, 5.11% In 1979, 7.73% In 1991, 11.88%The prevalence of high BP increases with age. Hypertension is more common in men than in women up to age 50, after that age, hypertension is more common in women. Hypertension is more common in northern China than in southern China.,Etiology and pathogenesis of EH,No cause can be establishedPossible mechanisms Genetic tendency Spontaneous hypertension rat EH tends to cluster in families High salt intake some hypertensives Vascular endothelium dysfunction nitric oxide endothelin,Pathogenesis of EH(Continue), Insulin resistance (胰岛素抵抗) sodium reabsorption, sympathetic nervous system activity, intracellular Na Ca Cigarette smoking by increasing plasma norepinephrine(去甲肾上腺素) Excessive use of alcohol perhaps by increasing plasma catecholamines儿茶酚胺So, the pathogenesis of EH is multifactorial.,Clinical findings,Symptoms: Mild to moderate EH is usually associated with normal health for many years. Some patients have headache, tinnitus（耳鸣）, palpitation, tiredness（疲劳）, and so on.Signs:BP is elevated.Some patients have a loud aortic second sound and an early systolic ejection click(收缩期喷射喀喇音).,Clinical findings(Continue),Complications :Hypertensive cardiovascular disease Hypertensive cerebrovascular disease Hypertension is the major predisposing cause of stroke. Hypertensive renal disease Chronic hypertension leads to nephrosclerosis(肾硬化症) Aortic dissection,Laboratory investigations,Routine investigationsHemoglobin, urinalysis & renal function studies, to detect hematuria, proteinuria, and casts, Serum potassium, since hypokalemia is typical of hyperaldosteronism（醛固酮增多症） Fasting glucose, since hyperglycemia is noted in diabetes and pheochromocytoma（嗜铬细胞瘤） Plasma cholesterol, as an indicator of atherosclerosis risk,Laboratory investigations(Continue),Serum uric acid(尿酸), since if elevated it is a contraindication to diuretic therapyElectrocardiography, to detect ventricular hypertrophyChest X-ray, to detect left ventricular enlargementFunduscopic examination: retina arteriolar narrowing arteriovenous nicking(动静脉交叉压迫) hemorrhage, exudate(渗出) papilledema(视神经乳头水肿),Laboratory investigations(Continue),Optional investigations Plasma renin(肾素) activity & aldosterone (醛固酮), urinary VMA（香草杏仁酸），to identify secondary hypertension Echocardiography, to detect ventricular hypertrophy Vascular ultrasonography should be performed if arterial disease is suspected. Renal ultrasonography should be performed if renal disease is suspected.,Clinic blood pressure measurement,With the patients sitting after 5 or more minutes of rest.Two or three measurements should be taken at each visit. The systolic reading is taken as the level of BP at which clear sounds are heard with each heartbeat. The diastolic reading is taken at the level when sounds disappear.,Ambulatory BP monitoring(动态血压监测),Noninvasive automatic device is available for ambulatory BP monitoring over periods of 24 h or more. ABPM offers the advantages of providing a more realistic setting for BP measurements. There are limited data available about the prognostic value of ABPM. ABPM is not a substitute for office measurement.,Normal reference of ABPM (mmHg）,24h Daytime Nighttime SBP DBP SBP DBP SBP DBPStaessen1 133 82 140 88 125 76JNC-VI2 135 85 120 75China3 130 80 135 85 125 75,1. J Hyperten. 1994; 12: (Suppl 7): S1;2. Arch Intern Med. 1997; 157: 2413;3. 中华心血管杂志，1995；23：325。,Situations in which ABPM should be considered,Unusual variability of blood pressure over the same or different visitsOffice or white coat hypertension(白大衣性高血压)Symptoms suggesting hypotensive episodesHypertension resistant to drug treatment,Diagnosis & differential diagnosis,To confirm a chronic elevation of blood pressure and determine its levelTo determine the presence of target-organ damage and to quantify its extentTo search for other cardiovascular risk factors & clinical conditions that may influence prognosis & treatmentTo identify secondary causes of hypertension,Classification of hypertension(mmHg),Category Systolic DiastolicGrade 1 hypertension(mild) 140-159 90-99 Subgroup: borderline 140-149 90-94Grade 2 hypertension(moderate) 160-179 100-109Grade 3 hypertension(severe) 180 110 Isolated systolic hypertension 140 90 Subgroup: borderline 140-149 55 yearsWomen65 yearsSmokingTC5.72mmol/L DiabetesFamily history of premature cardiovascular disease（早发心血管病家族史） （Men55 years，Women177mol/L）Vascular diseaseDissecting aneurysmAdvanced hypertensive retinopathyHemorrhage or exudatesPapilledema,Stratification of Risk to Quantify Prognosis,Blood Pressure（mmHg） Other Risk Factors Grade 1 Grade 2 Grade 3 & Disease History SBP140-159 SBP160-179 SBP180 or or DBP90-99 or DBP100-109 DBP110I no other risk factors Low Risk MED Risk High RiskII 1-2 risk factors MED Risk MED Risk Very-High-RiskIII 3 risk factors or TOD High Risk High Risk Very-High-Risk or DiabetesIV ACC Very-High-Risk Very-High-Risk Very-High-Risk,Treatment strategies & risk stratification,Low-risk group: monitor BP and other risk factors for 6 months，if goal BP is not attained, drug treatment should be initiated. Medium-risk group: begin drug treatment High-risk group & Very-high-risk group : should begin drug treatment Lifestyle modification should be used in all hypertensive patients,Example,A patient with diabetes（糖尿病） & BP of 140/94 mmHg plus left ventricular hypertrophy should be classified as having grade 1 hypertension with target organ disease and with another major risk factor. would be categorized as “grade 1 hypertension, high-risk ” would be recommended for immediate initiation of drug treatment and also lifestyle modification,Treatment,The goal of antihypertensive therapy is to reduce cardiovascular morbidity(发病率)& mortality(死亡率). The BP goal of antihypertensive therapy To achieve high normal BP (below 140/90 mmHg) in elderly patients To achieve normal BP (below 130/85mmHg) in young, middle-aged or diabetic subjects,Nonpharmacological treatments, Should be used in all hypertensive patients, either as definitive treatment or as an adjunct to drug therapy. Should be tailored to the individual characteristics of each patient, such as weight reduction for an overweight patient. Include: Weight reduction Complex dietary changes Increased physical activity Smoking cessation Others,Lifestyle modification (Continue), Weight reductionThrough a combination of dietary caloric restriction & increased physical activitySustained weight reduction is so difficult to achieve, so, more emphasis should be placed on prevention of weight gain.Patients should avoid appetite suppressant drug（食欲抑制药）and diet pill(减肥药丸),Lifestyle modification (Continue), Complex dietary changesReduction in salt intake 6g/d of sodium chloride (3*6*30=540) Reducing fat intakeIncreasing fruit and vegetableModeration of alcohol consumption for a heavy drinker,Lifestyle modification (Continue),Increased physical activity Regular aerobic physical activity can lower BP and is recommended for all hypertensive individuals. Patients with advanced cardiovascular disease may require medical evaluation before initiation of exerciseKeeping psychologic equilibriumSmoking cessation,Pharmacologic therapy,Principles of drug treatmentThe use of low doses of drugs to initiate therapyThe use of long-acting drugs providing 24h efficacy on a once-daily basisThe use of appropriate drug combinations to maximize hypotensive efficacy while minimizing side effects,Six main drug classes,Diuretics(利尿剂): DHCT, Furosemide(呋塞米)-blockers: Atenolol, Metoprolol Ca antagonists: Nifedipine, Amlodipine ACE inhibitors: Enalapril, Captopril AII antagonists: Losartan, Valsartan -blockers: Prazosin, Terazosin,Guidelines for selecting drug treatment of hypertension,Class of drug Indications(适应证) Possible indications ContraindicationsDiuretics Heart failure Diabetes Gout Systolic hypertension -Blockers Angina MI Asthma and COPD Tachyarrhythmias Pregnancy Heart block ACEI Heart failure Pregnancy Diabetic nephropathy Hyperkalemia After MI Renal artery stenosisCa antagonists Angina Systolic hypertension-blockers Prostatic hypertrophy Glucose intolerance （前列腺肥大） DyslipidemiaA antagonists ACEI cough same as ACEI,Antihypertensive drug therapy for patients with co-morbid conditions,Indication Drug treatment Diabetes with proteinuria ACE inhibitorsHeart failure ACE inhibitors, diureticsIsolated systolic hypertension Diuretics, Ca blockersMyocardial infarction -blocker, ACE inhibitorsAngina -blocker, Ca blockersBenign prostatic hyperplasia -blocker Dyslipidemia -blocker Tachyarrhythmias -blocker, Ca blockers,Secondary hypertension,It is a hypertension of known cause. The importance of identifying patients with SH is that they can sometimes be cured by surgery or by specific medical treatment. Secondary hypertension includes: Renal parenchymal diseases(肾实质病变) Renovascular hypertension Adrenal diseases（肾上腺疾病）,Renal parenchymal diseases,The most common causes of SHAny diseases of the renal parenchyma (肾实质): glomerulonephritis(肾小球肾炎) , diabetic nephropathy(肾病), polycystic kidneys(多囊肾).Most cases are related to increased intravascular volume or increased activity of the RAS,Renovascular hypertension,Diagnostic clues:The onset is below age 20 or after age 50 Upper abdominal bruit(杂音) Abrupt deterioration（恶化）in renal function after administration of ACEI The hypertension is difficult to control.Renal angiography（