高血压与脑血管病pp件

1、14.85%14.85%85.15%85.15%strokestrokeothersothers要想身体安，耐得三分饥和寒。关于新的诊疗指南高血压血脂异常iadecola c, et al. stroke 2004;35:38donnan ga, et al. current opinion in neurology 2003;16:812938%goldstein lb, et al. stroke 2001;32:280barbro bj. clinical & experimental pharmacology & physiology 1999;26:563-565平均

2、降低百分率平均降低百分率脑血管病发生率 3540% 心肌梗死 2025% 心衰50% jnc 7rashid p, et al. stroke 2003;34:2741stroke 2004;35:1024-1033stroke 2004;35:1024-1033stroke 2004;35:1024-103320% 25% 30% 20%rarities 5%75%lumenlipidcorefibrous capshoulderintimamediaelasticlamininternalexternal* bogousslavsky et al. arch neurol 1986;223

3、-228thromboembolizedblood vessel withrecanalization (pica)posteriorinferiorcerebellararteryinternalcarotidarteryvertebralarteryathroscleroticplaquethrombusembolusocclusivethrombust2dwiadca. thick imt b. plaquec. remodelingd. stenosise. occlusion颈内动脉颈内动脉(ic)(ic)颈外动脉颈外动脉 (ec) (ec)皮肤皮肤近侧壁近侧壁远侧壁远侧壁1.0 c

4、m1.0 cm0.5-1.0 cm0.5-1.0 cm1.0 cm1.0 cm1.1.cbmcbmmaxmax : :双侧颈总动脉、动脉双侧颈总动脉、动脉分叉分叉8 8 条近侧和远侧壁最大条近侧和远侧壁最大imtimt的平均值的平均值2.2.m mmax:max:双侧颈总动脉、动脉分双侧颈总动脉、动脉分叉和颈内动脉共叉和颈内动脉共1212条近侧和条近侧和远侧壁最大远侧壁最大imtimt的平均值的平均值3.3.t tmaxmax: :双侧双侧1212近侧和远侧壁最近侧和远侧壁最大大imtimt4.4.ccccmaxmax: :双侧双侧4 4个颈总动脉远端个颈总动脉远端近侧和远侧壁平均最大近侧和远

5、侧壁平均最大imtimt5.5.cbcbmaxmax: :双侧颈动脉分叉处双侧颈动脉分叉处4 4个个近侧和远侧壁平均最大近侧和远侧壁平均最大imtimt6.6.icicmaxmax: :双侧颈内动脉近端双侧颈内动脉近端4 4个个近侧和远侧壁平均最大近侧和远侧壁平均最大imtimt7.7.fwfwmaxmax: :双侧颈内动脉近端、分双侧颈内动脉近端、分叉处、颈总动脉远端叉处、颈总动脉远端6 6个远侧个远侧壁平均最大壁平均最大imtimt8.8.nwnwmaxmax: :双侧颈内动脉近端、分双侧颈内动脉近端、分叉处、颈总动脉远端叉处、颈总动脉远端6 6个近侧个近侧壁平均最大壁平均最大imtimt

6、动脉分叉动脉分叉 (bif) (bif)颈总动脉颈总动脉(cc)(cc)男性，42岁，左肢麻木、无力入院 1. heart disease and stroke statistics 2004 update, american heart association 2. ouriel et al., j vasc surg 33:728-732, 2001血管内支架成型术020040060080010001200200020012002200320042005carotid stentingprotection deviceadoptioncea20ml/100g/min半暗带阈半暗带阈8ml/

7、100g/min梗死阈梗死阈anti-plateletprobucolstatinsmodifying the risk factors29%29%50%50%020406080100 血压正常者血压正常者 高血压患者高血压患者%i nternational n ifedipine once-daily s tudy: i ntervention as a goal in h ypertension t reatmentinsight实验英国荷兰法国西班牙挪威以色列瑞典丹麦意大利利尿剂联合用药组(双氢克尿噻+咪吡嗪)拜新同组31573164共入选9个国家的7434 名患者6321 名患者符合意

8、向治疗的原则306060606025502550505050255050拜新同 (mg)阿替洛尔(mg)其他降压药物*拜新同拜新同组组1如病人禁忌使用阻滞剂,则用依那普利5mg; 2 如病人禁忌使用阻滞剂,则用依那普利10mg * 由施治医师决定利尿剂联合用药组利尿剂联合用药组双氢克尿噻 (mg)咪吡嗪 (mg)阿替洛尔 (mg)其他降压药物*2.55555122112345step12345step2250blood pressure (mmhg)180170160150140100908070ccb利尿剂利尿剂systolicdiastolicbaselineyear 1year 2yea

9、r 3year 4modified from brown m, et al. lancet 2000;356:36672.imt progression (mm/year)0.0080.0060.0040.00200.002year 2year 3year 4study endnifedipine（ccb)hydrochlorothiazide + amiloride(利尿剂）利尿剂） *p0.01*p0.001 vs zero within treatment groupsimon a, et al. circulation 2001;103:294954.单盲byington et al.

10、 am j cardiol. 1997;80:1087-1090.pitt et al. circulation. 2000. 双盲治疗随机苯磺酸氨氯地平 5 mg 10 mg安慰剂筛查/安慰剂导入剂量增加qca b-型超声-30612基线xxxxx18xxxx243036x0.050.040.030.020.010.00-0.01p= 0.0070122436内膜中层厚度变化(mm)安慰剂月-0.02-0.02-0.01-0.010 00.010.010.020.020.030.030.040.04内膜中层厚度变化内膜中层厚度变化(mm) 安慰剂安慰剂 0.033 0.013p=0.007前

11、瞻性随机对照试验前瞻性随机对照试验减慢颈动脉动脉粥样硬化的进展减慢颈动脉动脉粥样硬化的进展欧洲欧洲7个国家个国家(uk, sw, fr, de, it, sp, gr)的的2258例高血压患者例高血压患者治疗组：三代钙拮抗剂治疗组：三代钙拮抗剂 拉西地平拉西地平 对照组：对照组：-受体阻滞剂受体阻滞剂阿替洛尔阿替洛尔4-年年研究类型研究类型:目的目的:病人病人:治疗治疗:疗程疗程:-25-20-15-10-50阿替洛尔阿替洛尔拉西地平拉西地平n=959 n=972n=959 n=972sbpdbpmmhgcirculation.2002;19:2422-2427american journal

12、 of therapeutics 2003;10:429rothwell pm, et al. stroke 2003;34:2583rothwell pm, et al. stroke 2003;34:2583“the intrinsic capacity of cerebral blood vessels to maintain cerebral blood flow constant over a wide range of blood pressures”cbf=脑灌注压(cpp)脑血管阻力(cvr)平均动脉压(mabp)-平均静脉压(mvbp)脑血管阻力(cvr)平均动脉压(mabp

13、)-平均颅内压(micp)脑血管阻力(cvr)=r=k8lr220ml/100g/min半暗带阈半暗带阈8ml/100g/min梗死阈梗死阈健康人健康人背景背景健康人健康人ari=5ari=5术前 ari =3术后ari=6结果结果arch intern med 2003;163:10691818例原发性高血压患者服用蒙诺例原发性高血压患者服用蒙诺20mg qd20mg qd治疗治疗6 6周，治疗前、后周，治疗前、后2424小时动态血压趋势图小时动态血压趋势图cooper et al,1993.cooper et al,1993. 0 2 4 6 8 10 12 14 16 18 20 22 240 2 4 6 8 10 12 14 16 18 20 22 24180180160160140140120120100100808060 60 基线收缩压基线收缩压基线舒张压基线舒张压治疗后收缩压治疗后收缩压治疗后舒张压治疗后舒张压血压血压(mm hg)(mm hg)jama. 2003; 289: 2560-2572jama. 2003; 289: