对继发高血压的新认识

1、对继发高血压的新认识高血压患者的评估明确血压水平鉴别高血压的原因查找其它危险因素靶器官损害及伴随疾病或临床情况评估总体心血管病危险继发性高血压的主要原因肾脏疾病心血管疾病内分泌疾病自身免疫性疾病 高血压是许多疾病病理生理过程的共同表现；不同的个体、家系和人群，血压升高的机制可能不同；同一个高血压个体可能同时并存有多个不同的升压机制。神经系统疾病睡眠呼吸疾病精神心理疾病药源性的高血压复杂疑难高血压病因诊断平台建设EH：essential hypertension RH：renal hypertension RVH：renovascular hypertension PA：primary aldo

2、steronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome 初步排查精确诊断专科检查病史体格检查一般实验室检查临床试验专科实验室检查确定治疗方案可疑患者 665(39.3%)424(33.9)210(22.4)202(21.3)130(18.3) 98(17.8) 95(16.9)继发性高血压a1027(60.7%)825(66.1)727(77.6)746(78.7)579(81.7)452(82.2)466(83.1)原发性高血压a16921249937948709550

3、5612008200720062005200420032002病因n（%）Number Change of SH per year (1997.7 2008.7, add to 1523)Etiology of 7805 in-patients with hypertension in Peoples Hospital of Xinjiang from 1997.72008.7EHRHRVHPAPMCCSHyperthyHypothyOSASAdd toCase Number628211910430765512498627805Constituent ratio(%)80.491.521.33

4、3.930.830.070.150.6311.05100继发性高血压的筛查平台肾性、肾血管性高血压内分泌性高血压睡眠呼吸暂停相关性高血压精神心理因素性高血压EH：essential hypertension RH：renal hypertension RVH：renovascular hypertension PA：primary aldosteronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome Number Change of SH per year (1997.7 20

5、08.7, add to 1523)Etiology of 7805 in-patients with hypertension in Peoples Hospital of Xinjiang from 1997.72008.7EHRHRVHPAPMCCSHyperthyHypothyOSASAdd toCase Number628211910430765512498627805Constituent ratio(%)80.491.521.333.930.830.070.150.6311.05100EH：essential hypertension RH：renal hypertension

6、RVH：renovascular hypertension PA：primary aldosteronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome Number Change of SH per year (1997.7 2008.7, add to 1523)Etiology of 7805 in-patients with hypertension in Peoples Hospital of Xinjiang from 1997.72008.7EHRHRVHPAPMC

7、CSHyperthyHypothyOSASAdd toCase Number628211910430765512498627805Constituent ratio(%)80.491.521.333.930.830.070.150.6311.05100中华心血管病杂志OSAHS病理生理改变与临床表现高血压专科门诊就诊患者OSAHS检出情况组别例数OSAHS检出率PSG阳性率总体33916.7%81.72%男性170510.44%83.57%女性16862.97%75.76%高血压专科门诊就诊的高血压患者中OSAHS检出率6.7%，其中以中年男性为主。2009年4月-2009年6月新疆自治区人民

8、医院高血压专科初次就诊的3391例高血压中疑似OSAHS患者279例行PSG监测。张丽丽. 韩瑞梅.李南方等，中华高血压杂志. 2011,19（7）：642-646正常组、超重组和肥胖组的OSAHS检出率分别为6.6%（12/183）、22.22%（78/351）和36.75%（104/283） 正常腰围组和中心性肥胖组的OSAHS检出率分别是7.83%（9/115）和26.29% （184/700）,差异有显著统计学意义不同体重高血压患者中睡眠呼吸暂停综合的检出率张丽丽.李南方.严志涛等，中华心血管病杂志.2012,40（2）：120-124项目正常组N=154(31.9%)轻度OSAS组N

9、=112(23.2%) 中度OSAS组N=108(22.4%)重度OSAS组N=109(22.6%)P值 31.9% 68.1%年龄46.168.8949.0311.0350.6510.9949.6512.340.005 BMI指数27.182.9428.244.9928.283.7730.373.640.000 腹围95.4810.4198.1210.81100.2310.48103.6414.110.000 颈围39.076.1541.3511.4942.209.2342.457.310.034 收缩压132.8619.76133.5017.51135.8115.59140.1517.96

10、0.015 舒张压85.2613.2986.8111.8586.9413.0691.1315.890.013 OSAS与HBP N=483夜间打鼾，BMI24,BP140/90mmHG,n=483，没有停用降压药物OSAHS相关性高血压患者代谢特点高TG、低HDL、MS、IGR、高UA和高HCY随着OSAHS程度的加重,患病率上升，患病率在各组之间差异有统计学意义(P0.05) 住院高血压患者，疑似OSAS, 完成夜间睡眠呼吸监测的550例（男418例，女132例）程卫平，李南方等，中华高血压杂志，2009多器官损害患者中重度OSAHS的患病率OSAHS相关性高血压靶器官损害的患病率高于单纯高

11、血压患者主要发生在中重度组，常并发多器官损害。程维平.严志涛.李南方中华高血压杂志.2011,19（7）：642-646靶器官损害的定义及诊断：心肌肥厚：根据美国超声心动图联盟的标准：LVMI男50g/m2.7、女47g/m2.7定义为左室肥厚。冠心病：依据1979国际心脏病学会和协会及世界卫生组织(ISFC/ WHO) 临床命名标准化联合专题组的报告，确诊根据冠状动脉造影或冠状动脉CTA，冠脉主要的分支狭窄大于50%判断为有冠心病。脑血管病变：根据2007年中国缺血性脑血管病防治指南，有神经系统定位症状及体征，经头部影像学（CT或核磁）检查确诊。肾损害：根据诊断学（第七版，陈文彬，人民卫生出

12、版社）提供的实验室检查标准，、慢性肾功能不全，血肌酐男106mol/L、女97mol/L和/或尿素氮7.1mmol/L；、Ccr80ml/min；、尿蛋白定性阳性或24小时尿蛋白定量80mg/24小时；、尿酸男416mol/L、女357mol/L。具有以上四项中的其中一项者定义为肾损害。颈动脉硬化：根据中国高血压防治指南12定义，经超声检测有斑块形成，和/或颈动脉内膜中层厚度0.9mm。眼底病变：根据中国高血压防治指南12定义，按Wagener 和Backer高血压眼底改变的诊断标准分为四级。EH：essential hypertension RH：renal hypertension RVH

13、：renovascular hypertension PA：primary aldosteronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome Number Change of SH per year (1997 2008, add to 1723)Etiology of 7809 in-patients with hypertension in Peoples Hospital of Xinjiang from 19972008中华心血管病杂志原发性醛固酮增多症APAIHA

14、PAHACGSH 约占高血压的1% 中重度高血压 低血钾，CO2CP升高 肾上腺的肿瘤或增大 低肾素和高醛固酮the prevalence of PA based on ARR and formal confirmation testing in hypertensive patientsthe Prevalence of PA Based on ARR and Formal Confirmation Testing in Moderate to Severe and Consecutive Hypertensive Patients Overview of Studies on the Pr

15、evalence of Hypokalemia in PAAPAs-Mass on CT (Jan 1992August 1999)-stowarss M. AustraliaAPA sizeNo APAsMass on CT(%)1 cm5242 (81%)1cm5914 (24%)Total11156 (50%)AP macroAAP microAUMNUAHIHAPrevalence（%）38365219Radiological manifestationlateral adenoma normalnormalnormal or nodenormal or nodeValue of CT

16、 scan for the diagnosis of PATarget organ damage caused by PAInvestigatorCountry Subjects ResultsJ D. Blumenfeld et alNew York82 microalbuminuria and increased urinary protein excretion40%; cardiovascular events( angina and myocardial infarction) 7.3%, cerebrovascular events (transient ischemic atta

17、ck or stroke) 6.1%.Paul Milliez et alFrance124 a history of stroke 12.9%;Non-fatal myocardial infarction 4.0%;A history of atrial fibrillation 7.3% , LVH 32%.Francesco Fallo et alItaly85metabolic syndrome 41.1%;Hyperglycemia in Metabolic Syndrome 27.0%;diabetes mellitus 8.2%.Rossi GP et alItaly17 LV

18、H 30%; LV concentric remodeling 17%.Cristiana Catena et alItaly54 cardiovascular events 35%, odds ratios of 4.61, with odds ratios of 4.93, 4.36, and 2.80 for sustained arrhythmias, cerebrovascular events, and coronary heart disease , respectively. Then patients with PH.Yuji ShigematsuJapan23eccentr

19、ic LVH 57%;concentric LVH 9%.*Subjects: patients with Primary AldosteronismCardiovascular impairment caused by aldosteronethrombosisblood pressure elevationsympathetic excitationoxidative stress Na+ retention, excretion of K+ and Mg+ arrhythmiavascular injury myocardium fibrosisvascular endothelial

20、injuryinflammationaldosterone诊断原发性醛固酮增多症的新挑战原醛在高血压的人群中不一定只有1%原醛不一定都合并低血钾原醛不一定都有肾上腺影像学改变原醛不一定是温良的高血压原醛的诊断需要建立筛查方案和筛查体系。Condition that in a hypertensive make the search for PA Unexplained hypokalemia (spontaneous or diuretic induced)Resistant hypertension and grade 2 to3 hypertensionEarly onset hypert

21、ension and/or stroke(50 years)Incidentally discovered apparently non functioning adrenal mass (incidentaloncoma)Evidence of organ damage (LVH, diastolic dysfunction, AV block, carotid atherosclerosis, microalbuminuria, endothelia dysfunction) particularly if disproportionate for the severity of hype

22、rtensionMetabolic syndromeObstructive sleep apnea syndrome (this is still contentious)The diagnosis of PAScreening: PAC, PRA and ARRConfirming: OSLT, SLT. FST and Captopril STLateralizing: CTAVSAdrenal vein sling (AVS) is currently the most reliable available means of differentiating unilateral from

23、 bilateral PA and lateralizing micro aldosterone-producing adenomas preoperatively, although which is invasive, technically challenging, difficult to interpret, and commonly held to be risky.Paolo Mulatero et al. Hypertension, 2010项目参数性别（男/女）195/135年龄（岁）47.378.84体重指数（kg/m2）27.013.42病程（年）5（1天-30年）确诊PA前服用抗高血压药者2种（%）80.3%（265/330）入院收缩压（mmHg）145.0319.14入院舒张压（mmHg）95.0312.64最高收缩压（mmHg）176.422.77最高收缩压（mmHg）112.4114.36新疆高血压研究所对330例PA的临床资料分析血钾3.5mmol/L(%)37.27%(123/330)血钾（mmol/L）3.670.43尿钾（mmol/L）40.85(10.7-167.8)尿pH6(5-8)坐位肾素活性（ng/ml/h）0.34（0.001-2.15）坐位醛固酮(ng/dl)17.58（4.81-