内科学高血压(八年制英文)

EssentialHypertension

(EHT)

IntroductionWhatisbloodpressure?Bloodpressureisthepressureofblooduponthewallsofthebloodvessels.Bloodpressureismeasuredinmillimetersofmercury(mmHg).Yourbloodpressureisrecordedastwofigures.Forexample,150/95mmHg.Thisissaidas“150over95”.DefinationofHypertension:HypertensionisdefinedasaSBPof140mmHgorgreaterand/oraDBPof90mmHgorgreaterinsubjectswhoarenottakingantihypertensivemedication.IntroductionIntroduction

A"silent"killer

Cancause:ischaemicandhaemorrhagicstroke,myocardialinfarction,heartfailure,chronickidneydisease,cognitivedecline,prematuredeath.IntroductionClassification:Essentialhypertension:nospecificmedicalcausecanbefoundtoexplainapatient'scondition.>90%Secondaryhypertension:aresultofanothercondition,suchasrenal,vascular,andendocrinecauses.EpidemiologyOneofthemostcommondiseaseintheworld.InChina,morethan

200millionpeoplehaveestablishedorborderlineHP.IntheUS,65millionpeoplehavehypertension.患病率(%)所占比例(%)1.2005中国高血压指南2.中国高血压防治指南(2009年基层版)3.2010中国高血压指南EpidemiologyEpidemiologyIntheUS:70%ofthehypertensivesareawarethattheyhavehypertension59%arebeingtreatedOnly34%haveadequatelycontrolledBPEpidemiologyIntheChina:30.6%ofthehypertensivesareawarethattheyhavehypertension24.7%arebeingtreatedOnly6.1%haveadequatelycontrolledBP发病率(%)所占比例(%)1.2005中国高血压指南2.中国高血压防治指南(2009年基层版)3.2010中国高血压指南EpidemiologyEtiologyGenetic

:apredisposingfactor,buttheexactmechanismisunclear.Environmentalfactors:Dietary:SaltintakePsychosocialstressObesityAlcoholintakePathogenesisHighactivityoftheSNS(SympatheticNervousSystem)RAAS(Renin-AngiotensionAldosteroneSystem)RenalSodiumHandlingVascularRemodellingEndothelialCellDysfunctionOthers

PathologicalconsequencesNopathologicchangesoccurearlyinhypertension.Severeorprolongedhypertensiontargetorgans

damages(TOD)(primarilythecardiovascularsystem,brain,andkidney)

IncreasingriskofCAD,MI,stroke,andrenalfailure

Themechanism

developmentofgeneralizedarteriolosclerosisaccelerationofatherogenesis

ThepathologicalchangesofsmallarteryPathologicalchangeoftheBrainStroke:IschemicstrokeHemorrhagicstokeArterialAneurysmThepathologicalchangeoftheHeartLeftventricularhypertrophy(LVH)HeartfailureCoronaryarteryatherosclerosisMyocardialinfarctionPathologicalchangeofRenalHypertensioninducednephrosclerosis,atrophyofrenalcortexClinicalconsequences

targetorgans

hemorrhage

strokethrombosis

LVHHFHBPCHDAPMIarrhythmiaHF

progressiverenalnephrosclerosisprogressivescarringoftheglomerularenalfailure

stenosisthrombosisocclusiondilatationrapturehemorrhageClinicalFeatures1.VariationofBPThebloodpressurevarieswidelyovertime.Dependingonmanyvariables:SNSactivity,posture,skeletalmuscletone,stateofhydration,andcircumstance(whitecoatHP).ClinicalFeatures2.SymptomsofhypertensionUsuallyasymptomaticuntilcomplicationsdevelopintargetorgansDizziness,flushedfacies,headache,fatigue,epistaxis,andnervousnessHypertensiveemergenciescancauseseverecardiovascular,neurologic,renal,andretinalsymptomsClinicalFeatures3.ComplicationsofHypertensiona)brainandeyes:headache,vertigo,impairedvision,transientischemicattacks,sensoryormotordeficitb)heart:palpitation,chestpain,shortnessofbreath,swollenanklesc)kidney:thirst,polyuria,nocturia,haematuriad)peripheralarteries:coldextremities,intermittentclaudication4.familyandclinicalhistoryIndicationsofsecondaryhypertension:a)familyhistoryofrenaldiseasec)drug/substanceintake:oralcontraceptives,steroids…d)episodesofsweating,headache,anxiety,palpitatione)episodesofmuscleweakness(aldosteronism)Riskfactors:a)familyandpersonalhistoryofhypertensionandcardiovasculardiseaseb)familyandpersonalhistoryofdyslipidaemia,diabetesmellitusd)smokinghabits,dietaryhabitsf)obesity;amountofphysicalexerciseg)snoring;sleepapneah)personalityClinicalFeatures----BloodpressuremeasurementClinicBloodPressureHomeBloodPressureAmbulatorymonitoringPhysicalexamination1.ClinicBloodPressureBPmustbemeasuredtwice—firstwiththepatientsupineorseated,then≥2minafterthefirstmeasure.Patientsshouldsitwiththeirarmssupportedatheartlevel.Patientsshouldnotsmokeoringestcaffeinefor30minutespriortobloodpressuremeasurement.Patientsshouldsitdownforatleast5minutesbeforebloodpressureismeasured.Thebladderofthecuffshouldencircleatleast80%ofthearm.Alargecuffshouldbeusedforpatientswiththickarms.1.ClinicBloodPressure2.HomeBPSelf-measurementofBPisofclinicalvalue.Shouldbeencouragedinorderto:1.providemoreinformationontheBPloweringeffectoftreatmentattrough,andthusontherapeuticcoveragethroughoutthedose-to-dosetimeinterval2.improvepatient’sadherencetotreatmentregimens3.therearedoubtsontechnicalreliability/environmentalconditionsofambulatoryBPData

ambulatoryBPmayimprovepredictionofcardiovascularriskinuntreatedandtreatedpatients.Normalvalues:

24-hour:125–130/80mmHgDay:130–135/85mmHgNight:120/70mmHg3.AmbulatoryMeasurementAmbulatorymonitoringcanprovide:readingsthroughoutdayduringusualactivitiesreadingsduringsleeptoassessnocturnalchangesmeasuresofSBPandDBPloadExcludewhitecoatorofficehypertension3.AmbulatoryMeasurementAmbulatoryBPmonitoringshouldbeconsidered,whenconsiderablevariabilityofofficeBPoverthesameordifferentvisitshighofficeBPismeasuredinsubjectsotherwiseatlowCVriskamarkeddiscrepancybetweenBPvaluesmeasuredintheofficeandathomeresistancetodrugtreatmentissuspectedhypotensiveepisodesaresuspected,particularlyinelderly3.AmbulatoryMeasurementPhysicalExaminationSignssuggestingsecondaryhypertensionFeaturesofCushingsyndrome•Palpablekidneys(polycystickidney)•Diminishedanddelayedfemoralpulsesandreducedbloodpressureintheleg(aorticcoarctationoraortitis)•Precordialorchestmurmurs(aorticcoarctationoraortitis)•Abdominalbruit(renalarterystenosis).PhysicalExaminationSignssuggestingorgandamage

•vascularbruits•motororsensorydeficits•retinalchanges•abnormalapicalimpulse,cardiacarrhythmias,pulmonaryrales,dependentedema•absence,reduction,orasymmetryofperipheralpulses,ischemicskinlesionsTheKeith-WagnerCriteria

(changeinretina)

KWI:Minimalarteriolarnarrowing,irregularityofthelumen,andincreasedlightreflexKWII:Moremarkednarrowingandirregularitywitharteriovenousnicking(crossingdefects)KWIII:Flame-shapedhemorrhagesandexudatesinadditiontoabovearteriolarchangesKWIV:AnyoftheabovewithadditionofpapilledemaFlameshapedhemorrhagePapilledemaLaboratoryExaminationThetypeandextentofinvestigationswillvaryaccordingtotheavailabilityofresources.Theyoungerthepatient,orthehigherthepressure,orthefasterthedevelopmentofhypertension,themoredetailedthediagnosticexaminationshouldbe.Couldbeclassifiedinto:

recommendedtestsadditionaltestsextendedevaluationRecommendedtests:urineanalysisplasmaCreatinineand/orBUNplasmapotassium,sodiumrandombloodglucoseserumTC,TG,LDL-C,HDL-CLaboratoryExaminationhaematocritand/orHBelectrocardiogramplasmauricacidchestX-rayechocardiographyAdditionaltests:

CarotidultrasoundQuantitativeproteinuriaAnkle-brachialBPIndexGlucosetolerancetestHomeand24hambulatoryBPmonitoringPulsewavevelocitymeasurementLaboratoryExaminationextendedevaluationforsecondaryhypertension:measurementofrenin,aldosterone,corticosteroids,catecholaminesinplasmaand/orurine;arteriographies;renalandadrenalultrasound;CTandMRILaboratoryExaminationDiagnosis&

DifferentialDiagnosisClassificationofbloodpressureforadult

Category

SBP(mmHg)DBP(mmHg)

Normal<120<80Highnormal120-13980-89Hypertension

≥140≥90Stage1140-15990-99Stage2160-179100-109Stage3≥180≥110ISH

≥140<90

WhentheSBPandDBPfallintodifferentcategories,usethehighercategoryDiagnosticEvaluationToidentifycardiovascularriskfactors

ToassesspresenceorabsenceoftargetorgandamageToidentifyothercausesofhypertensionTheseevaluationmayusedinstratificationofthehypertensionpatientsFactorsinfluencingprognosis

----forriskstratificationRiskfactorsSubclinicalOrganDamageAssociatedclinicalcondition:DM,CV…CardiovascularRiskFactorsSystolicanddiastolicBPlevelsAge(M>55years;W>65years)SmokingDyslipidemia:TC>5.7mmol/l(220mg/dl),LDL-C>3.6mmol/l(140mg/dl),HDL-C:M<1.0mmol/l(40mg/dl)FamilyhistoryofprematureCVdisease(<50years)AbdominalobesityCRP≥10mg/L;orhs-CRP≥3mg/LHeartElectrocardiographyshouldberoutineassessmentofsubjectsinordertodetectLVHGeometricpatternscanbedefinedechocardiographically,ofwhichconcentrichypertrophycarriestheworseprognosis.Subclinicalorgandamage2.BloodvesselsUltrasoundscanningofcarotidarteriesisrecommendedwhendetectionofvascularhypertrophyorasymptomaticatherosclerosis(IMT>0.9mm)Largearterystiffeningcanbemeasuredbypulsewavevelocity;Alowankle-brachialBPindexsignalsadvancedperipheralarterydiseaseSubclinicalorgandamage3.Kidney

ReducedrenalfunctionorelevatedurinaryexcretionofalbuminEstimationfromserumcreatinineofglomerularfiltrationrateorcreatinineclearanceshouldberoutineprocedure.(M:Cr115-133μg/L,F107-124μg/L)Urinaryproteinbydipstick.Indipsticknegativepatientsmicroalbuminuriashouldbedetermined(30-300mg/hr,Alb/CrM>22mg/g,F≥31mg/g)SubclinicalorgandamageAssociatedclinicalcondition----DiabetesMellitusFastingplasmaglucose>7.0mmol/l(126mg/dl)onrepeatedmeasurements,orPostloadplasmaglucose>11.1mmol/l(200mg/dl)Cerebrovasculardisease:ischemicstroke;cerebralhaemorrhage;transientischemicattackHeartdisease:myocardialinfarction;angina;coronaryrevascularization;heartfailureAssociatedclinical

condition----EstablishedCV

Renaldisease:diabeticnephropathy;renalimpairment(serumcreatinineM>133,W>124mmol/l);proteinuria(>300mg/24h)Peripheralarterydisease

Advancedretinopathy:haemorrhagesorexudates,papilloedemaAssociatedclinicalconditionHigh/Veryhigh

risksubjectsSystolicBP>180mmHgand/ordiastolicBP>110mmHgSystolicBP>160mmHgwithlowdiastolicBP(<70mmHg)DiabetesmellitusThreecardiovascularriskfactorsOneormoreofthefollowingsubclinicalorgandamagesEstablishedcardiovascularorrenaldiseaseStratificationofHypertensionpatientsBloodPressureriskfactors&DiseaseHistoryGradeIGradeIIGradeIIII.NoriskfactorsLowriskMedriskHighriskII.1-2riskfactorsMedriskMedriskVeryhighriskIII.3ormoreriskfactorsorTODordiabetesHighriskHighriskVeryhighriskIV.ACCVeryhighriskVeryhighriskVeryhighriskTOD-TargetOrganDamage;ACC-AssociatedClinicalConditionsDifferentialDiagnosisShouldexcludeSecondaryHypertensionSecondaryHypertension

CommonCausesRenal

GlomerulonephritisPyelonephritisObstructivenephropathyCollagendiseases,CongenitaldiseasesDiabetesnephropathyRenaltumor----reninsecretingtumorPheochromocytomaPrimaryaldosteronism

PheochromocytomaGanglion-neurotomasandneuroblastomasExcretionoflargeamountsofcatecholamines90%ariseintheadrenalmedulla10%aremalignant.ParoxysmalorpersistHTClinicfeatures:Headache,sweating,palpitations,nervousness,weightloss,hypermetabolism,orthostatichypotension.PrimaryAldosteronismMildormoderatehypertensionHypokalemia,muscleweakness,paralysisPolyuria,nocturiaandpolydipsia,HypochloremicalkalosisUrinealdosteroneelevationPlasmareninactivedecreaseObstructiveSleepApnea(OSA)RenalarterystenosisCushing’ssyndromeCoarctationoftheaortaDrug-induced:

NSAIDs;Sympathomimeticmedications;Prophylactic;Monoamineoxidaseinhibitors;Mineralocorticoids;Immuno-inhibitors.

SecondaryHypertension

OtherCausesTherapyGoalofHypertensionManagement<140/90mmHgWithDiabetesorkidneydysfunction:<130/80mmHgToreducemorbidityandmortalityofcerebralandcardiovascularcomplications.Controllingothercardiovascularriskfactors1.LifestyleModificationsShouldbeinstitutedinallpatients,includingthosewhorequiredrugtreatment.ThepurposeistolowerBP,tocontrolotherriskfactorsandtoreducethenumberofdosesofantihypertensivedrugs.AlsoadvisableinsubjectswithhighnormalBPandadditionalriskfactorstoreducetheriskofdevelopinghypertension.-smokingcessation-weightreduction(andweightstabilization)-reductionofexcessivealcoholintake-physicalexercisereductionofsaltintakeincreaseinfruitandvegetableintakeanddecreaseinsaturatedandtotalfatintake1.LifestyleModifications2.DrugTherapyPriciples:DrugtherapyshouldbeindividuallyAlowdoseofinitialdrugtherapyCombinationtherapiesmayprovideadditionalefficacywithfeweradverseeffects.Optimalformulationshouldprovide24-hourefficacywithonce-dailydose.Thechoiceofaspecificdrugoradrugcombination1.Thepreviousfavourableorunfavourableexperienceoftheindividualpatientwithagivenclassofcompounds2.Theeffectofdrugsoncardiovascularriskfactorsinrelationtothecardiovascularriskprofileoftheindividualpatient3.Thepresenceofsubclinicalorgandamage,clinicalcardiovasculardisease,renaldiseaseordiabetesThechoiceofaspecificdrugoradrugcombination4.Thepresenceofotherdisordersthatmaylimittheuseofparticularclassesofantihypertensivedrugs5.Thepossibilitiesofinteractionswithdrugsusedforotherconditions6.Thecostofdrugs,eithertotheindividualpatientortothehealthproviderAntihypertensiveDrugsDiureticsß-Adrenergicreceptorblockers(BB)Calciumchannelblockers(CCB)ACEinhibitors(ACEI)AngiotensinIIreceptorblockers(ARB)Antihypertensivetreatment:

PreferreddrugsSubclinicalorgandamage

LVH:ACEI,CA,ARBAtherosclerosis:CA,ACEIMicroalbuminuria:ACEI,ARBRenaldysfunction:ACEI,ARBAntihypertensivetreatment:

PreferreddrugsClinicaleventPreviousMI:BB,ACEI,ARBAnginapectoris:BB,CAHeartfailure:diureticsBB,ACEI,ARB,anti-aldosteroneagentsAtrialfibrillationRecurrent:ARB,ACEIPermanent:BB,non-dihydropiridineCAESRD/proteinuria:ACEI,ARB,loopdiureticsPeripheralarterydisease:CAAntihypertensivetreatment:

PreferreddrugsConditionISH(elderly):diuretics,CAMetabolicsyndrome:ACEI,ARB,CADiabetesmellitus:ACEI,ARBPregnancy:CA,methyldopa,BBBlacks:diuretics,CAConditionsfavouringuseofsomeantihypertensivedrugsversusothersThiazidediuretics:Isolatedsystolichypertension(elderly)HeartfailureHypertensioninblacksConditionsfavouringuseofsomeantihypertensivedrugsversusothersBeta-blockersAnginapectorisPost-myocardialinfarctionHeartfailureTachyarrhythmiasPregnancyConditionsfavouringuseofsomeantihypertensivedrugsversusothersCalciumantagonists(dihydropyridines)Isolatedsystolichypertension(elderly)AnginapectorisLVhypertrophyCarotid/CoronaryAtherosclerosisPregnancyHypertensioninblacksConditionsfavouringuseofsomeantihypertensivedrugsversusothersCalciumantagonists(verapamil/diltiazem)AnginapectorisCarotidatherosclerosisSupraventriculartachycardiaConditionsfavouringuseofsomeantihypertensivedrugsversusothersACEinhibitorsHeartfailureLVdysfunctionPost-myocardialinfarctionDiabeticnephropathyNon-diabeticnephropathyLVhypertrophyCarotidatherosclerosisProteinuria/MicroalbuminuriaAtrialfibrillationMetabolicsyndromeConditionsfavouringuseofsomeantihypertensivedrugsversusothersAngiotensinreceptorantagonistsHeartfailurePost-myocardialinfarctionDiabeticnephropathyProteinuria/MicroalbuminuriaLVhypertrophyAtrialfibrillationMetabolicsyndromeACEI-inducedcoughConditionsfavouringuseofsomeantihypertensivedrugsversusothersantialdosteroneHeartfailurePost-myocardialinfarctionLoopdiureticsEndstagerenaldiseaseHeartfailureCombinationTherapiesMayprovideadditionalefficacywithfeweradverseeffects.

Diureticsasthebasementdrugincombinationtherapy.

Diuretics----ACEI/ARBDiuretics----CCBDiuretics----BBCCBasthebasementdrugincombinationtherapy

CCB----ACEI/ARBCCB----BBOthers:ThreedrugscombinationCompellingandpossiblecontraindicationstouseofantihypertensivedrugsCausesforInadequate

ResponsetoDrugTherapyIncorrectmeasurementoftheBPVolumeoverloadorPseudo-resistanceDrug-relatedcausesAssociatedconditionsHypertensivecrisisHypertensiveEmergenciesandUrgenciesEmergencies:Thebloodpressureiselevatedseverelyandassociatedwith