教学课程-高血压PPT课件

-,1,Hypertension,Concept:systemicbloodpressureincreased,targetorgandamaged(brain,heart,eye,kidney,vessel),metabolismchangedEssentialhypertension(ET):unknowncause,95%，hypertensivedisease.Secondaryhypertension(ST):knowncause,1-5%,-,2,Epidemiology,Incidenceincreasingrapidly,11.26%in15yearsoldinChinain1999incidencedifferentamongrace,age,sex,area(城乡，南北，高原，发达地区等）知晓率，服药率，控制率lower,-,3,中国高血压的现状和流行趋势,1999年普查-患病率11.26%;10年上升25%-90年代初有高血压患者9500万-目前预计1亿1998年-脑血管病居城市居民死亡原因第二位，农村居首位，-脑卒中的主要危险因素为高血压伴随-糖尿病患病率；吸烟率；超重；冠心病,-,4,PathogenesisofHypertension,Hereditaryandgenehypothesis：20-40%populationhavehereditarytendencycandidatehypertensivegene5-8Environmentalfactors：hypoweight，overweight,highsaltdiet,drunk,-,5,PathophysiologyofHypertension,PsychologicalandpsychopathicfactorsReninangiotensinaldosteronesystem（RAAS）SodiumandhypertensionAbnormalityofvascularendothelium（ET，NO，AngII,PGI2,etc)Insulinresistancerevascularizationother（obesity，smoking，drinking，hypocalcium,hypomagnesium,hypopotassium）,-,6,PathophysiologyofHypertension,BP=COXSVRCO:bloodvolume，HR，myocardialcontractilitySVR：阻力小动脉结构改变血管壁顺应性降低血管的舒缩状态改变,-,7,ClinicalManifestation,Early:asymptom，greatBPvariationheadache，dizziness，palpitation，fatigueA2S4，aorticareaSMLate:manifestationofcomplicationsbrain,heart，eye,kidney,vesseldamage,-,8,ClinicalManifestationTargetorganrelatedtoacceleratedASrelatedtoBPlevelheartangina、MI，SDheartfailureBrainTIA，brainthrombosiscerebralhemorrhageencephalopathyKidneyrenalangiopathyrenalarteriolosclerosisrenalfailureArteryblockinglesionaorticdissection,-,9,ClinicalManifestation,Mostcommoncomplicationsarefrombrain，4-6timesofAMI。Include:TIA，brainthrombosis，braininfarction（包括腔隙性脑梗塞）,encephalopathy，cerebralhemorrhage。,-,10,HypertensionandStroke,BothSBP157:2413-2446.,-,30,降压治疗的实施过程,对高血压患者临床评估后，首先进行危险性水平分层（低危，中危，高危，极高危）所有患者都应采用非药物治疗措施制定降压治疗计划，确定血压控制目标值极高危高危患者：开始药物治疗中危：除改善生活方式，开始药物治疗低危：改善生活方式6M，BP仍高，开始药物治疗治疗随访，调整治疗方案,-,31,Non-medicationtreatment,减轻体重，BMI(Kg/m2)=24采用合理膳食：限制钠盐：每人每日3mg/dl,hyperkalimia,-,39,Anti-hypertensiveagents,angiotensionIIreceptorblocker,ARBSimilarindicationandcontraindicationwithACEI，Classification：科素亚（losartan)代文(valsartan)安博维(irbesartan),-,40,Anti-hypertensiveagents,ablockerIndication：Rapideffect,alltypehypertension,prostateproliferationClassification：non-selective：酚妥拉明Selective：哌唑嗪Contraindication：positionalhypotensiondrugresistance,-,41,Principaltopickuphypertensiveagents,HeartfailureACEI,diuretics，CCB?Systolichypertensiondiuretics，CCB(双氢吡啶类，长效）Diabetes,proteinuriaACEI,CCBRenalinsufficiency(mild)ACEI(非肾血管性）Myocardialinfarction-blocker（无内在拟交感）,ACEIStableangina-blocker，CCBDisorderoflipidablocker，ACEI,CCBpregnancymethyldopa，ablockerProstateproliferationablocker,-,42,Notrecommended,1asthma，depressivepatient-blocker2goutdiuretics3conductionblock-blocker,CCB（非二氢吡啶类）4renalvesseldiseaseACEI,ARB5peripheralvesseldisease-blocker6liverdisease甲基多巴，柳安苄心定7lipiddisorder-blocker，diuretics（highdose）8pregnancyACEI,ARB，diuretics,-,43,Recommendedprotocoltotreathypertension,Diuretics-blockerCalciumchannelblockerACEinhibitorDiureticsACEinhibitor（orARB)Calciumchannelblocker-blockerablocker-blocker,-,44,长期治疗随访实施过程,治疗个月后达到降压目标值,治疗个月后未达到降压目标值,有明显副作用,继续治疗血压控制一年以上可减少剂量,增加剂量改用另一类降压药联合用药,改用另一类降压药减少剂量,-,45,ClinicalTypeHypertensivecrisis(危象）：BPincreasedrapidlyinshorttime,DBP120or130mmHg,combinedwithseveresymptoms,maybeleadingtodeath.Including：hypertensiveurgencies（急症）w/otargetdamagehypertensiveemergencies（危症）w/targetdamagehypertensiveurgenciesw/grade3eyegroundiscalled急进型hypertensionhypertensiveurgenciesw/grade4eyegroundiscalled恶性hypertension,-,46,SBP升高为主，DBP也可升高血压突然急剧升高，周围血管阻力增加出现头痛，呕吐，心悸，气急，视力模糊靶器官病变，如心绞痛，肺水肿，高血压脑病等。Hypertensiveencephalopathy血压突然急剧升高致急性脑循环障碍引起脑水肿和颅内压增高而产生的临床症状。包括严重头痛，呕吐，神志改变（烦躁，意识模糊，抽搐，昏迷等）,-,47,Malignanthypertension以肾小动脉坏死为突出特征发病急骤，多见于中，青年血压显著升高，DBP130mmHg头痛，视力模糊，眼底III-IV级改变肾脏损害突出：持续性蛋白尿，血尿，肾衰进展迅速，不及时治疗，预后不良，多死于肾衰，脑卒中，心衰。,-,48,Treatmentofhypertensivecrisis,硝普钠Sodiumnitroprusside硝酸甘油Nitroglycerin尼卡地平Nicardipine乌拉地尔Urapidil,-,49,Senilehypertension,60岁MostlysystolicBpincrease由中年高血压延续者，多为混合型高血压易出现靶器官并发症易出现血压波动和体位性低血压，尤其服降压药后,-,50,Case1:56岁，男性，会计师。以发作性头晕一年，头疼伴耳鸣一周为主诉入院。一年前每于工作紧张或劳累时感觉头晕，经检查发现血压155-160/95-98mmHg，曾间断服用复方降压片。近一周来时有头痛、耳鸣，且睡眠不佳，血压170/100mmHg，为明确诊断来诊。病来饮食与二便均正常。既往无心肾疾病、脑血管病和糖尿病病史。吸烟28年，每天10-30支。母亲患高血压病，病故于脑溢血。,-,51,PhysicalexaminationBp168/97mmHg，P97次/分，体重68Kg，睑结膜无苍白，口唇无发绀，颈软，未闻及颈部血管杂音，双肺呼吸音清，心尖搏动位于胸骨左缘第5肋间锁中线内0.5cm处，范围2.5cm，心前区未触及震颤，叩诊心界不大，心率97次/分，心律规整，主动脉瓣区可闻及较柔和的2级收缩期杂音，伴第2心音亢进。腹软，肝脾肋下未触及，未闻及腹部血管杂音。颈动脉、桡动脉和足背动脉搏动良好。,-,52,Lab尿常规未见异常，Glu5.6mmol/L、K+4.8mmol/L、Cr76.6mol/L，BUN5.9mmol/L,cholesterol6.5mmol/L,TG0.9mm