高血压的分级、分期、分型管理-血管与心、脑、肾等器官结

高血压的分级、分期、分型管理 -血管与心、脑、肾等器官结构与功能检测-,上海交通大学医学院附属瑞金医院 上海市高血压研究所 王继光 ,0,30,60,90,120,150,1985,1990,1995,2000,2005,2010 (year),Stroke,CHD,Standardizedrate (1/100,000),Deaths attributed to stroke and CHD,China CVD report 2005,100,120,140,160,180,200,无血管或靶器官损害,有血管或靶器官损害,血管或靶器官并发症,分级 (stage or grade),高血压分级、分期、分型的基本理念,70,80,90,100,110,120,舒张压，mm Hg,收缩压，mm Hg,分型 (phenotyping or pathophysiology),分期 (stratification or severity),继发性高血压,有可测量异常的高血压,动脉硬化性高血压,高血压分级-准确测量血压，使用普遍有效的降压药物 高血压分期-测量血管与靶器官的结构与功能，选择强适应症药物 高血压分型-筛查病因以及影响血压的主要因素，采取病因治疗措施,坐位,袖带,血压计,24-h ambulatory BP monitoring,Hour of the day,BP (mm Hg),135,120,85,70,24-h mean Daytime mean Night-time mean,White coat hypertension,Masked hypertension,JingNing: Prevalence of white-coat, masked, and sustained hypertension,Prevalence (%),Normotension,46.4% (n=322),7.8% (n=54),10.8% (n=75),35.0% (n=243),White-coat HT,Masked HT,Sustained HT,Wang GL, et al. J Hypertens 2007; 25:23982405.,n=694,NICE 2011: Definitions,Stage 1 hypertension: Clinic BP is 140/90 mmHg or higher and ABPM or HBPM average is 135/85 mmHg or higher. Stage 2 hypertension: Clinic BP is 160/100 mmHg or higher and ABPM or HBPM daytime average is 150/95 mmHg or higher. Severe hypertension: Clinic systolic BP is 180 mmHg or higher or Clinic diastolic BP is 110 mmHg or higher.,Krause T, et al. BMJ 2011;343:d4891.,A：ACEI or ARB；B：-blockers；C：Dihydropyridine CCBs；D：Thiazides；：-blockers；F：Fixed dose combination,Chinese hypertension guidelines: Choice of antihypertensive drugs,Chin J Cardiol 2011;39:579-616.,Step 4,NICE 2011: Summary of antihypertensive drug treatment,Aged 55 y or black person of African or Caribbean family origin of any age,Aged under 55 years,C,A,A + C,A + C + D,Resistant hypertension A + C + D + consider further diuretic or alpha- or beta-blocker5 Consider seeking expert advice,Step 1,Step 2,Step 3,Key A ACE inhibitor or low-cost angiotensin II receptor blocker (ARB)1 C Calcium-channel blocker (CCB) D Thiazide-like diuretic,Krause T, et al. BMJ 2011;343:d4891.,ASCOT-BPLA: Primary and secondary endpoints,0.50,0.70,1.00,1.45,Primary endpoint Nonfatal MI (including silent MI)+fatal CHD Secondary endpoint Nonfatal MI(excluding silent MI)+ fatal CHD All coronary events All CV events and procedures Total mortality CV mortality Fatal and nonfatal stroke Fatal and nonfatal heart failure,2.00,Unadjusted Hazard ratio (95% CI) 0.90 (0.79-1.02)0.87 (0.76-1.00) 0.87 (0.79-0.96) 0.84 (0.78-0.90) 0.89 (0.81-0.99) 0.76 (0.65-0.90) 0.77 (0.66-0.89) 0.84 (0.66-1.05),Dahlf B et al. Lancet 2005:366;895-906.,Amlodipine Perindopril better,Atenolol Bendrofluathiazide better,ACCOMPLISH: Primary endpoint and components,Composite CV mortality/morbidity Cardiovascular mortality Non-fatal MI Non-fatal stroke Hospitalization for unstable angina Coronary revascularization procedure Resuscitated sudden death,Risk Ratio (95%),Favors CCB / ACEI,Favors ACEI / HCTZ,0.80 (0.720.90) 0.81 (0.62-1.06) 0.81 (0.63-1.05) 0.87 (0.67-1.13) 0.74 (0.49-1.11) 0.85 (0.74-0.99) 1.75 (0.73-4.17),Jamerson K et al. N Engl J Med 2008;359:2417-28.,高血压分级-准确测量血压，使用普遍有效的降压药物 高血压分期-测量血管与靶器官的结构与功能，选择强适应症药物 高血压分型-筛查病因以及影响血压的主要因素，采取病因治疗措施,Pulse diagnostics,中国高血压指南：危险分层,中华心血管病杂志 2011;39:579-616.,ART.LAB The Arterial Analyser,Blood vessel wall thicknessRFQIMT,Brightness mode scanning (B-mode),Frame rate 30 frames/s,Assessment of:,Zhang Y, et al. Submitted.,Concentric RemodelingN=107 (12.7%),Concentric HypertrophyN=16 (1.9%),Normal GeometryN=694 (82.6%),Eccentric HypertrophyN=26 (3.1%),0.42, 95 () 95 () 115 () 115 (),Left Ventricular Mass Index (gm/m2),Relative Wall Thickness,0.42,NingBo study: Echocardiographic LVH,非介入颅内动脉成像-MRA & CTA,Stages of chronic kidney disease,SBP (mm Hg),DBP (mm Hg),Men,Women,Men,Women,Microalbuminuria and BP,Sheng CS, et al. Diabetol 3:6.,中国高血压指南： 常用降压药物的适应证,中华心血管病杂志 2011;39:579-616.,高血压分级-准确测量血压，使用普遍有效的降压药物 高血压分期-测量血管与靶器官的结构与功能，选择强适应症药物 高血压分型-筛查病因以及影响血压的主要因素，采取病因治疗措施,高血压病因学分解,血管,血流,血压,自主神经,心脏,RAAS系统,肾脏,精神紧张,Na+, K+,酗酒,吸烟,体力活动,Hypertension Research 2011; 34(12):1255-1256.,继发性高血压或 具有典型临床特征的高血压,较早发现的继发性高血压（内分泌、大动脉狭窄、肾实质等） 新发现的继发性高血压（OSAS） 具有典型临床特征的高血压（高交感、代谢紊乱、动脉硬化等）,阻塞性睡眠呼吸暂停综合征,呼吸暂停,呼吸暂停,急性高血压,心动过速,SaO2,射频消融交感神经,尽管