高血压讲课课件

1、高血压1 Diseases of Circulatory System Hypertension Prof. Shen-Jiang Hu 高血压2 n掌握高血压的诊断标准、危险分层和治疗 原则。 n熟悉降压药物的种类及特点；降压药物的 选择和联合用药。 n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 教材及参考书教材及参考书 高血压4 教学网站网址教学网站网址 n内科学校级精品课程： n内科学

2、省级精品课程： 高血压5 Blood 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。该

3、处理它。” “The greatest danger to a man with high blood 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 认识到高血压与卒中的关系 1970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

4、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 Atrial Fibrillation Aortic Dissection Dementia Chronic Renal failure Heart Failure LV HypertrophyMI Hypertensive Encephalopathy CHD Intracerebral Hemorrhage Isc

5、hemic Cerebral Infarction Complications of Hypertension 高血压9 The Relationship between Blood Pressure and Cardiovascular Events 高血压10 高血压11 Definition of Hypertension nHypertension is a clinical syndrome, defined as systolic blood pressure 140 mmHg and/or diastolic blood pressure 90 mmHg. nHypertensi

6、on should be considered a major risk factor for an array of cardiovascular and related disease as well as diseases leading to a marked increase in cardiovascular risk. 。 Hypertension in China(1991) 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.

7、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 神经病5.30.9 损伤，中毒36.96.3 消化系病17.93.0 我国城市我国城市19991999年前年前1010位死亡原因位死亡原因 我国农村我国农村19991999年前年前1010位死亡原因位死亡原因 Trends in Awareness, Treatment, and Control of Hypertension in China Awareness(%) Treatment(%) Control(%) 中国心血管健康多中心合作研究 高血压17 Etiology nThe pat

8、hogenesis of essential hypertension is multifactorial. nGenetic factors play an important role. Children with one- or two-hypertensive parents have higher blood pressures. nEnvironmental factors also are significant. Increased salt intake has long been incriminated as a pathogenic factor in essentia

9、l hypertension. It alone is probably not sufficient to elevate blood pressure to abnormal levels; a combination of too much salt plus a genetic predisposition is required. 高血压18 Etiology 高血压19 高血压20 Pathogenesis nSympathetic nervous system hyperactivity. It is most apparent in younger hypertensives,

10、 who may exhibit tachycardia and an elevated cardiac output. However, correlations between plasma catecholamines and blood pressure are poor. 高血压21 Pathogenesis nRenin-angiotensin system. Renin acts on angiotensinogen to cleave of the ten- amino-acid peptide angiotensin I. This peptide is then acted

11、 upon by angiotensin-converting enzyme to create the eight-amino-acid peptide angiotensin II, a potent vasoconstrictor and a major stimulant of aldosterone release from the adrenal glands. 高血压22 Pathogenesis nDefect of natriuresis. Hypertensive patients exhibit a diminished ability to excrete a sodi

12、um load. This defect may result in increased plasma volume and hypertension. 高血压23 Pathogenesis nIntracellular sodium and calcium. An increase in intracellular Na+ may lead to increased intracellular Ca2 + concentrations as a result of facilitated exchange. This could explain the increase in vascula

13、r smooth muscle tone. 高血压24 Pathogenesis nExacerbating factors. The best-documented is obesity, which is associated with an increase in intravascular volume and an elevated cardiac output. Some hypertensives respond to high salt intake with substantial blood pressure increases. Excessive use of alco

14、hol also raises blood pressure. Cigarette smoking acutely raises blood pressure. 高血压25 Pathology nHeart. Left ventricular hypertrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death

15、. 高血压26 Pathology nBrain. Hypertension is the major predisposing cause of stroke, especially intracerebral hemorrhage but also ischemic cerebral infarction. 高血压27 Pathology nKidney. Chronic hypertension leads to nephrosclerosis, a common cause of renal insufficiency. 高血压28 Clinical Findings Symptoms

16、: nElevations in pressure are often intermittent early. Even in established case, the blood pressure fluctuates widely in response to emotional stress and physical activity. 高血压29 Clinical Findings Symptoms: nMild to moderated essential hypertension is usually associated with normal health and well-

17、being for many years. 高血压30 Clinical Findings Symptoms: nSuboccipital pulsating headaches, but any type of headache, may occur. Accelerated hypertension is associated with somnolence, confusion, palpitation. 高血压31 Signs： nHigh blood pressure. nPhysical findings depend upon the duration and severity,

18、 and the degree of effect on target organs. nA loud aortic second sound and an early systolic ejection click may occur. 高血压32 CategoryJNC 7（USA） European China Optimal120 and 80 Normal120 and 80120-129 and/or 80-84120 and 80 High-normal120-139 or 80-89130-139 and/or 85-89120-139 or 80-89 Hypertensio

19、n 140 or 90 Grade I140-159 or 90-99140-159 and/or 90-99140-159 or 90-99 Grade II 160 or 100160-179 and/or 100-109160-179 or 100-109 Grade III 180 and/or 110 180 or 110 Isolated Systolic Hypertension 140 and 90 140 and 30% 20-30% 15-20% 8% 5-8% 4-5% 4% 高血压35 Factors influencing prognosis 高血压36 Factor

20、s influencing prognosis 高血压37 Management 高血压38 Goals of treatment 高血压39 Goals of treatment 治疗组间的血压差异与卒中、治疗组间的血压差异与卒中、CHD、主要、主要CVD事件、事件、 CVD死亡及总死亡率风险的差异直接相关死亡及总死亡率风险的差异直接相关 Lancet 2003;362:1527-45 0 -5 -10 -15 -20 -25 -30 卒中CHD 心衰总死亡 23% 15% 16% 14% 4/3 mmHgN20 888 主要CV事件 15% 高血压41 Management Lifesty

21、le Modification nWeight Loss nSodium Restriction nCalcium and Potassium Supplementation nHigh-Fiber, Low-Fat Diet nAlcohol Moderation nExercise 高血压42 When to initiate antihypertensive treatment nBased on two criteria: nThe level of systolic and diastolic blood pressure nThe level of total cardiovasc

22、ular risk 高血压43 Initiation of antihypertensive treatment 高血压44 Choice of antihypertensive drugs nFive major classes of antihypertensive agents thiazide diuretics, calcium antagonists, ACE inhibitors, angiotensin receptor antagonists and -blockers are suitable for the initiation and maintenance of an

23、tihypertensive treatment, alone or in combination. 高血压45 Choice of antihypertensive 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 use of antihypertensive drugs 高血压52 Monotherapy versus combination therapy nMonotherapy could be the initial treatment for a mild BP elevation wit