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1、高血压,1,Diseases of Circulatory System,Hypertension,Prof. Shen-Jiang Hu,高血压,2,掌握高血压的诊断标准、危险分层和治疗原则。 熟悉降压药物的种类及特点；降压药物的选择和联合用药。 了解高血压的患病率、病因、发病机制和并发症；以及较常见的几种继发性高血压。,讲授目的和要求,高血压,3,1、内科学，王吉耀主编，人民卫生出版社 2、实用高血压学余振球等主编，科学出版社 3、现代内科学英语精要王吉耀、刘文忠摘编，人民卫生出版社,教材及参考书,高血压,4,教学网站网址,内科学校级精品课程： 内科学省级精品课程：,高血压,5,Blood
2、 Pressure has a unimodal distribution in the Population,高血压,6,“Hypertension may be an important compensatory mechanism which should not be tampered with, even were it certain that we could control it.” White PD, 1931 “高血压可能是一个重要的代偿机制，即使我们能够控制它，也不应该处理它。” “The greatest danger to a man with high blood
3、pressure lies in its discovery, because then some fool is certain to try to reduce it.” Hay J, 1931,高血压,7,人类对高血压认识的历史,Framingham心脏研究：最早认识到高血压与心脏病的关系,1961年,世界卫生组织首次提出高血压阶梯治疗方案,1978年,JNC II将舒张压作为确诊高血压的和治疗建议的基础,1980年,JNC V收缩压与舒张压同等重要,1992年,JNC VII：降压达标对减少各类患者的心血管事件至关重要,2003年,中国高血压治疗指南更新：降压药物治疗目标在于，降低血压
4、使其达到相应病人的目标水平,2005年,世界卫生组织将“降压要达标”作为高血压日的宣传口号,2006年,高血压,8,Hypertension,Atrial Fibrillation,Aortic Dissection,Dementia,Chronic Renal failure,Heart Failure,LV Hypertrophy,MI,Hypertensive Encephalopathy,CHD,Intracerebral Hemorrhage,Ischemic Cerebral Infarction,Complications of Hypertension,高血压,9,The Re
5、lationship between Blood Pressure and Cardiovascular Events,高血压,10,高血压,11,Definition of Hypertension,Hypertension is a clinical syndrome, defined as systolic blood pressure 140 mmHg and/or diastolic blood pressure 90 mmHg. Hypertension should be considered a major risk factor for an array of cardiov
6、ascular and related disease as well as diseases leading to a marked increase in cardiovascular risk. 。,Hypertension in China(1991),15% 10%14.9% 10%,死亡原因 死亡率占总死亡死亡原因 死亡率占总死亡 1/10万%1/10万 % 循环系病226.138.5 内分泌，代谢 - 脑血管病127.221.6 营养，免疫病16.92.9 - 心脏病98.916.8 泌尿生殖病 8.91.5 恶性肿瘤40.523.9 精神病6.71.1 呼吸系病81.713.9
7、 神经病5.30.9 损伤，中毒36.96.3 消化系病17.93.0,我国城市1999年前10位死亡原因,中国1999年卫生统计,死亡原因死亡专率占总死亡死亡原因死亡率占总死亡 1/10万%1/10万% 循环系病186.630.8泌尿生殖病9.21.5 - 脑血管病 111.618.4* 新生儿病810.31.3 - 心脏病 75.012.4(每10万出生） 呼吸系病133.722.0肺结核7.91.3 恶性肿瘤111.618.4内分泌，代谢 损伤，中毒67.011.0营养，免疫病6.41.0 消化系病24.24.0,我国农村1999年前10位死亡原因,中国1999年卫生统计,Trends
8、in Awareness, Treatment, and Control of Hypertension in China,Awareness(%) Treatment(%) Control(%) 1991 26.6 12.2 2.9 2002 30.2 24.7 6.1,中国心血管健康多中心合作研究,高血压,17,Etiology,The pathogenesis of essential hypertension is multifactorial. Genetic factors play an important role. Children with one- or two-hype
9、rtensive parents have higher blood pressures. Environmental factors also are significant. Increased salt intake has long been incriminated as a pathogenic factor in essential hypertension. It alone is probably not sufficient to elevate blood pressure to abnormal levels; a combination of too much sal
10、t plus a genetic predisposition is required.,高血压,18,Etiology,高血压,19,高血压,20,Pathogenesis,Sympathetic nervous system hyperactivity. It is most apparent in younger hypertensives, who may exhibit tachycardia and an elevated cardiac output. However, correlations between plasma catecholamines and blood pr
11、essure are poor.,高血压,21,Pathogenesis,Renin-angiotensin system. Renin acts on angiotensinogen to cleave of the ten-amino-acid peptide angiotensin I. This peptide is then acted upon by angiotensin-converting enzyme to create the eight-amino-acid peptide angiotensin II, a potent vasoconstrictor and a m
12、ajor stimulant of aldosterone release from the adrenal glands.,高血压,22,Pathogenesis,Defect of natriuresis. Hypertensive patients exhibit a diminished ability to excrete a sodium load. This defect may result in increased plasma volume and hypertension.,高血压,23,Pathogenesis,Intracellular sodium and calc
13、ium. An increase in intracellular Na+ may lead to increased intracellular Ca2 + concentrations as a result of facilitated exchange. This could explain the increase in vascular smooth muscle tone.,高血压,24,Pathogenesis,Exacerbating factors. The best-documented is obesity, which is associated with an in
14、crease in intravascular volume and an elevated cardiac output. Some hypertensives respond to high salt intake with substantial blood pressure increases. Excessive use of alcohol also raises blood pressure. Cigarette smoking acutely raises blood pressure.,高血压,25,Pathology,Heart. Left ventricular hype
15、rtrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death.,高血压,26,Pathology,Brain. Hypertension is the major predisposing cause of stroke, especially intracerebral hemorrhage but also
16、 ischemic cerebral infarction.,高血压,27,Pathology,Kidney. Chronic hypertension leads to nephrosclerosis, a common cause of renal insufficiency.,高血压,28,Clinical Findings,Symptoms: Elevations in pressure are often intermittent early. Even in established case, the blood pressure fluctuates widely in resp
17、onse to emotional stress and physical activity.,高血压,29,Clinical Findings,Symptoms: Mild to moderated essential hypertension is usually associated with normal health and well-being for many years.,高血压,30,Clinical Findings,Symptoms: Suboccipital pulsating headaches, but any type of headache, may occur
18、. Accelerated hypertension is associated with somnolence, confusion, palpitation.,高血压,31,Signs： High blood pressure. Physical findings depend upon the duration and severity, and the degree of effect on target organs. A loud aortic second sound and an early systolic ejection click may occur.,高血压,32,D
19、efinition and Classification of Blood Pressure Levels in different Country,高血压,33,Stratification of CV Risk,Stratification of CV Risk in four categories. SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: Cardiovascular events; HT: hypertension. Low, moderate, high and very high risk r
20、efer to 10 year risk of a CV fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome. The dashed line indicates how definition of hypertension may be variable, depending on the level of total CV ri
21、sk.,Estimate total cardiovascular risk,Framingham Study：Risk for cardiovascular events over 10 years Very high High Moderate Low 30% 20-30% 15-20% 15%,SCORE charts：the risk of dying from cardiovascular disease over 10 years Very high High Moderate Low 8% 5-8% 4-5% 4%,高血压,35,Factors influencing progn
22、osis,高血压,36,Factors influencing prognosis,高血压,37,Management,高血压,38,Goals of treatment,高血压,39,Goals of treatment,降压是硬道理！微小的血压差异，显著的心血管收益,治疗组间的血压差异与卒中、CHD、主要CVD事件、CVD死亡及总死亡率风险的差异直接相关,Lancet 2003;362:1527-45,高血压,41,Management,Lifestyle Modification Weight Loss Sodium Restriction Calcium and Potassium S
23、upplementation High-Fiber, Low-Fat Diet Alcohol Moderation Exercise,高血压,42,When to initiate antihypertensive treatment,Based on two criteria: The level of systolic and diastolic blood pressure The level of total cardiovascular risk,高血压,43,Initiation of antihypertensive treatment,高血压,44,Choice of ant
24、ihypertensive drugs,Five major classes of antihypertensive agents thiazide diuretics, calcium antagonists, ACE inhibitors, angiotensin receptor antagonists and -blockers are suitable for the initiation and maintenance of antihypertensive treatment, alone or in combination.,高血压,45,Choice of antihyper
25、tensive drugs,高血压,46,Choice of antihypertensive drugs,高血压,47,Choice of antihypertensive drugs,高血压,48,Antihypertensive treatment: Preferred drugs,高血压,49,Antihypertensive treatment: Preferred drugs,高血压,50,Antihypertensive treatment: Preferred drugs,高血压,51,Compelling and possible contraindications to u
26、se of antihypertensive drugs,高血压,52,Monotherapy versus combination therapy,Monotherapy could be the initial treatment for a mild BP elevation with a low or moderate total cardiovascular risk.,高血压,53,Monotherapy versus combination therapy,A combination of two drugs at low doses should be preferred as
27、 first step treatment when initial BP is in the grade 2 or 3 range or total cardiovascular risk is high or very high.,高血压,54,Monotherapy versus combination therapy,In several patients BP control is not achieved by two drugs, and a combination of three of more drugs is required.,高血压,55,Monotherapy ve
28、rsus combination therapy strategies,高血压,56,Possible combinations between some classes of antihypertensive drugs,-blockers,Calcium antagonists,Diuretics,Angiotesin II antagonists,-blockers,ACE inhibitors,Journal of Hypertension 2007, 25:11051187.,高血压,57,复习思考题,1、中国血压水平的定义和分级？ 2、如何进行高血压的危险分层？ 3、高血压的治疗原则是什么？,高血压,58,Thanks for your attention!,