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1、特 点,一 涉及面广 二 定义及诊治程序不规范 三 参考资料少 四 预后差,七个流程,理清思路,第一步 （Step one）定义是否准确,第二步（ Step Two） 排除假性难治性高血压,排除假性难治性高血压 Exclude Pseudoresistance,依从性：40%中断治疗（新诊断的第1年） 40%继续治疗（以后5-10年） 16% 白大衣效应：在难治性高血压中更常见约20%-30%,血压测量不准确,第三步（ Step Three） 鉴别和逆转生活方式,Franminghanm研究60-70%的高血压病人有肥胖，并随年龄增加。 在高血压肥胖病人中75%不限盐饮食，当体重减轻10kg血
2、压达正常。 肥胖高血压病人减肥比限盐更重要,肥胖,obesity is a common feature of patients with resistant hypertension. Mechanisms of obesity-induced hypertension are complex and not fully elucidated but include impaired sodium excretion, increased sympathetic nervous system activity, and activation of the renin-angiotensin-
3、aldosterone system.,体力活动与血压,1983年美国哈佛大学男性校友随访6-8年 的结果表明，体力活动指数及是否参加 剧烈运动项目（跑步、游泳、手球、网 球、平地滑雪等）与高血压发病率呈副 相关。每周参加运动项目的时数越多， 发生高血压的危险就越低。,Dietary Approaches Stop Hypertension 饮食控制终止高血压,U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES National Institutes of Health National Heart, Lung, and Blood Institute,N
4、IH Publication No. 06-4082 Originally Printed 1998 Revised April 2006,高盐 高胆固醇 高脂肪 低钾 低钙 低镁 低膳食纤维 低优质蛋白,高血压,第四步（ Step Four） 终止或最小化升高血压的药物,甘草长期服用可引起血压升高机制明确,第五步 Step Five（筛查继发性高血压）,OSAS与高血压关系,国外流行病学研究表明，OSAS与高血压具有很强的相关性 至少30%的高血压患者合并OSAS 50%以上的OSAS患者有高血压 OSAS是独立于年龄、体重、饮食、遗传等原因的高血压发病因素之一，是高血压发展的重要危险因素。
5、,原醛的筛查,一 筛查的必要性 二 疑惑 三 筛查步骤,原醛患病率高,原醛筛查必要性,患病率高 临床症状不典型预后差（but also because PA patients have higher cardiovascular morbidity and mortality than age- and sex-matched patients with essential hypertension and the same degree of blood pressure elevation ） 可治疗性或可治愈性疾病,原醛的疑惑,一 血压并不顽固 二 血钾不低 三 肾素不低 四 醛固酮不高
6、 五 影像学与临床不符 六 手术后血压仍然高,How frequent is hypokalemia in PA? In recent studies, only a minority of patients with PA (937%) had hypokalemia . Thus, normokalemic hypertension constitutes the most common presentation of the disease, with hypokalemia probably present in only the more severe cases. Half the
7、 patients with an APA and 17% of those with idiopathic hyperaldosteronism (IHA) had serum potassium concentrations less than 3.5 mmol/liter. Thus, the presence of hypokalemia has low sensitivity and specificity and a low positive predictive value for the diagnosis of PA.,Case Detection, Diagnosis, a
8、nd Treatment of Patients with Primary Aldosteronism: An Endocrine Society Clinical Practice Guideline,醛固酮可以不升高,Of 555 patients diagnosed with PAL at GHHU between 1993 and 1999, 414 (75%) had upright plasma aldosterone levels 30 ng/100 mL and 143 (26%) had levels 15 ng/100 mL.,The Endocrinologist 200
9、4;14: 267276The AldosteroneRenin Ratio in Screening for Primary Aldosteronism Michael Stowasser, FRACP, PhD* and Richard D . Gordon, FRACP, PhD, MD,影响肾素因素较多,低盐饮食 降压药物的影响 血钾水平 钠的摄入量 年龄 肾功能情况 肾血管性高血压,ARR比值,是筛查原发性醛固酮增多症的第一步（严格控制药物及其他条件） 欧洲高血压指南2003版ARR50建议继续筛查 (肾素单位：ng/ml小时 , ALD pg/ml）,肾上腺囊肿,在筛查继发性高血压
10、中肾上腺功能比形态更重要,原发性醛固酮增多症,04年CT,2011年CT,手术效果差与术前未确 定性质直接相关,肾动脉狭窄,在高血压科住院患者中继发性高血压病因第一位 老年患者动脉粥样硬化为主 青年病因大动脉炎为主 儿童病因大动脉炎为主,肾动脉狭窄临床诊断方法,超声检查,漏诊率高,磁共振,假阳性率高,放射性核素,假阳性率高、且不能清楚的显 示狭窄的部位和程度,DSA,可清楚的显示狭窄的程度和部位，但费用高不 能普及,血管三维成像技术,阳性率高，与DSA符合率98% 以上（分支和肾内狭窄显示不 清），费用适中。,The best screening test for pheochromocyto
11、ma is plasma free metanephrines (normetanephrine and metanephrine), which carries a 99% sensitivity and an 89% specificity.,Lenders JW, Eisenhofer G, Mannelli M, Pacak K. Phaeochromocytoma.Lancet. 2005;366:665 675,嗜铬细胞瘤,Right cerebellar cerebral hemorrhage,plasma MN:39.76(090 pg/ml） plasma NMN:4415.
12、84(0200 pg/ml),neck paraganglioma,骶骨嗜铬细胞瘤,神经精神因素,焦虑与抑郁可导致血压不易控制 发作性高血压已经引起高血压学界的关注,血压发作性升高,一 首先排除嗜铬细胞瘤（2%，虽然占发作性 比例并不高） 二 敏感性和特异性均高的方法是血浆FMN、FNMN测定 三 一定做ABPM 四 应建立发作性高血压概念 五 应重视这一特殊类型高血压 六 发病机制需要探讨,继发性检查,肾上腺、肾动脉、肾脏 薄层CT扫描,血浆游离3甲氧基肾上腺素 及3甲氧基去甲肾上腺素测定,血浆肾素活性、醛固酮浓度测定,血电解质（血钾、钠、氯、钙）,血常规、尿常规,各种激素的检测,第六步（
13、Step Six）药物疗法,利尿剂的使用,investigators at Mayo Clinic found that patients referred for resistant hypertension often had occult volume expansion underlying their treatment resistance,Resistant hypertension: comparing hemodynamic management to specialist care. Hypertension. 2002;39: 982988.,增加利尿剂的剂量或据肾功能改
14、变利尿剂的类型 In patients with underlying CKD (creatinine clearance 30 mL/min), loop diuretics may be necessary for effective volume and blood pressure control.,两种药物的联合,The combinations that included a thiazide diuretic were consistently more effective than combinations that did not include the diuretic.,
15、Results of combination anti-hypertensive Therapy after failure of each of the components J Hum Hypertens. 1995;9:791796.,三种药物的联合,must be tailored on an individual basis taking into consideration prior benefit, history of adverse events, contributing factors, including concomitant disease processes s
16、uch as CKD or diabetes, patient financial limitations.,三种药物的联合,a triple drug regimen of an ACE inhibitor or ARB, calcium channel blocker, and a thiazide diuretic is effective and generally well tolerated.,第七步 （Step Seven）,有回顾性研究资料显示： 顽固性高血压转至高血压专科随访一年血压下降18/9mmHg,血压控制率由18%提高至52%,Mansoor GA. Blood pressure control in the hypertension clinic. Am J Hypertens. 2003;16:878880.,In a separate retrospective analysis, hypertension specialists at the Rush University Hypertension Center were able to control blood pressure to 140/90 mm Hg in 53% of patients referred for resistant hypertension,谢 谢,