继发性高血压筛查意义及诊断策略课件

1、继发性高血压诊断意义及筛查策略继发性高血压筛查意义及诊断策略什么是高血压2013 ESH/ESC Guidelines for themanagement of arterial hypertension The Task Force for the management ofarterial hypertension of theEuropean Society ofHypertension (ESH) and of the European Society of Cardiology (ESC)继发性高血压筛查意义及诊断策略高血压症状大多数高血压没有明显症状部分高血压患者会出现如下症状头痛

2、、头晕失眠耳鸣手脚麻木、颈背部肌肉酸痛、紧张继发性高血压筛查意义及诊断策略高血压风险等级2013 ESH/ESC Guidelines for themanagement of arterial hypertension The Task Force for the management ofarterial hypertension of theEuropean Society ofHypertension (ESH) and of the European Society of Cardiology (ESC)继发性高血压筛查意义及诊断策略高血压的危害继发性高血压筛查意义及诊断策略Kear

3、ney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. Lancet.2005;365(9455):217-23.高血压人群状态中国中国继发性高血压筛查意义及诊断策略中国高血压人群Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide da

4、ta. Lancet.2005;365(9455):217-23.继发性高血压筛查意义及诊断策略继发性高血压筛查历史继发性高血压筛查意义及诊断策略继发性高血压筛查现状继发性高血压筛查意义及诊断策略The prevalence of secondary forms of hypertension was 10.2% , including renovascular hypertension (3.1%), primary aldosteronism (1.4%), Cushings syndrome (0.5%), pheochromocytoma (0.3%), primary hypothy

5、roidism (3.0%) Conclusions: Increasing age and coexisting atherosclerosis have significant effects on the prevalence of secondary forms of hypertension.The effect of age on prevalence of secondary forms of hypertension in 4429 consecutively referred patientsAnderson, Gunnar H. Jr; Blakeman, Nancy; S

6、treeten, David H.P.继发性高血压筛查现状继发性高血压的发病率为10.2%,包含肾血管性高血压3.1%，原发性醛固酮增多症1.4%，库欣综合征0.5%，嗜铬细胞瘤0.3%，原发性甲状腺功能减退3.0%；结论：年龄的增长及伴随的动脉粥样硬化疾病，与继发性高血压的发病率存在明显的关系。继发性高血压筛查意义及诊断策略继发性高血压筛查意义继发性高血压诊断的意义在于，将有可能将不可治愈的疾病变成可以治愈的疾病。哪怕潜在疾病可能无法治愈，也可通过提供特异性的治疗方案使血压得到更好的控制，同时，潜在的疾病通常会造成比血压升高更加严重的后果，因此需要对其进行治疗。继发性高血压筛查意义及诊断策略

7、常见的内分泌高血压Prospective Study on the Prevalence of Secondary Hypertension among Hypertensive PatientsVisiting a General Outpatient Clinic in Japan Masao OMURA, Jun SAITO, Kunio YAMAGUCHI, Yukio KAKUTA, and Tetsuo NISHIKAWA原发性醛固酮增多症库欣综合征嗜铬细胞瘤肢端肥大症继发性高血压筛查意义及诊断策略肾素-血管紧张素-醛固酮系统（RAAS）RAAS系统继发性高血压筛查意义及诊断策略原

8、发性醛固酮增多症症状高血压 原因未知的低血钾特点症状无特异性与麻痹、肌无力临床 症状相似筛查项目肾素活性PRA肾素浓度PRC醛固酮浓度ALD继发性高血压筛查意义及诊断策略药物在原醛筛查中的影响药物种类临床常用药物对ARR比值影响-受体阻断剂美托洛尔、阿替洛尔及艾可洛尔等肾素ARRACE抑制剂、AT1受体拮抗剂依那普利、西拉普利、缬沙坦、氯沙坦等醛固酮肾素 ARR钙通道阻断剂硝苯地平、氨氯地平等无显著影响利尿剂呋塞米、乙噻嗪等无显著影响继发性高血压筛查意义及诊断策略原发性醛固酮增多症筛查The PAC/PRC ratio offers several practical advantages c

9、ompared with the PAC/PRA screening method. The present study offers preliminary evidence that it may be a useful screening test for PHA. 针对原发性醛固酮增多症，PAC/PRC的比值，相比于PAC/PRA的筛查方法更加有效和实用，目前的研究已经提供了其可以作为一个有效筛查工具的初步证据。继发性高血压筛查意义及诊断策略原发性醛固酮增多症Rapid Screening Test for Primary Hyperaldosteronism: Ratio of Pl

10、asma Aldosterone to Renin Concentration Determined by FullyAutomated Chemiluminescence Immunoassays Frank Holger Perschel,1* Rudolf Schemer,3 Lysann Seiler,4 Martin Reincke,4 Jaap Deinum,5 Christiane Maser-Gluth,6 David Mechelhoff,1 Rudolf Tauber,1 and Sven Diederich2Clinical Chemistry 2004继发性高血压筛查意

11、义及诊断策略国外的研究进展及结论继发性高血压筛查意义及诊断策略ARR比值的应用和现状基层临床机构原醛症的普及筛查高端医疗机构的原醛症的确认诊断标准化降压药物药效研究和对AARR筛查的影响单一降压药物对AARR筛查比值的影响研究方法学一致性Cut-off无法实现互换性，PA筛查率差异很大继发性高血压筛查意义及诊断策略ARR与AARR的差异AARR-Aldosterone Active Renin Ratio醛固酮/活性肾素比值-PAC/PRCARR-Aldosterone Renin Ratio血液醛固酮/活性肾素-PAC/PRAARR单位ng/ml/hour 酶活力单位ARR参考范围20-30

12、ng/ml/hourAARR参考范围32Recent studies using the ratio of plasma aldosterone concentration(PAC) to PRA as the screening test for primary aldosterondism inhypertensive populations suggested that the prevalence may be ashigh as 515%.-Prevalence of Primary Aldosterondism among Asian Hypertensive Patients i

13、n SingaporeKEH-CHUAN LOH, EVELYN S. KOAY, MIN-CHEH KHAW, SHANTA C. EMMANUEL, AND WILLIAM F. YOUNG, JR.继发性高血压筛查意义及诊断策略ARR筛查发展ARR比值20ng/dl，且PAC浓度15pg/ml原醛症检出率4.6%-Loh, 2000Mayo Clinic PA筛查率4.6%Stowasser M 调整对ARR筛查影响小的降压药物后，确认PA检出率18%影响因素样本人群药物种类和干扰原醛症筛查思路血钾浓度检测系统特异性继发性高血压筛查意义及诊断策略原醛症的筛查思路继发性高血压筛查意义及诊断

14、策略原醛症的筛查和诊断策略Minireview: Primary AldosteronismChanging Concepts in Diagnosis and Treatment WILLIAM F. YOUNG, JR.Professor of Medicine, Mayo Medical School; Consultant, Division of Endocrinology, Metabolism, Nutrition and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905继

15、发性高血压筛查意义及诊断策略原醛症的确认诊断盐抑制试验盐水负荷试验氟氢可的松抑制试验Comparison of Confirmatory Tests for the Diagnosis of Primary Aldosteronism Paolo Mulatero, Alberto Milan, Francesco Fallo, Giuseppe Regolisti, Francesca Pizzolo, Carlos Fardella, Lorena Mosso, Lisa Marafetti, Franco Veglio, and Mauro Maccario继发性高血压筛查意义及诊断策略

16、原醛症的确认诊断Salt Loading Test is a reasonably good alternative to the more expensive and complex FST for the diagnosis of PA after a positive screening test. J Clin Endocrinol Metab 91: 26182623, 2006操作简单、实用性高可对门诊病人进行操作可替代氟氢可的松抑制试验，可信度高Comparison of Confirmatory Tests for the Diagnosis of Primary Aldost

17、eronism Paolo Mulatero, Alberto Milan, Francesco Fallo, Giuseppe Regolisti, Francesca Pizzolo, Carlos Fardella, Lorena Mosso, Lisa Marafetti, Franco Veglio, and Mauro Maccario继发性高血压筛查意义及诊断策略筛查常用辅助筛查手段CT影像学的局限性CT Scanning, therefore clearly localizes adenomas in 50% of histologically proven cases, an

18、d can also produce misleading results.-Role for adrenal venous sampling in primary aldosteronismWilliam F. Young, Jr, MD, Anthony W. Stanson, MD, Geoffrey B. Thompson, MD, Clive S. Grant, MD,David R. Farley, MD, and Jon A. van Heerden, MB, ChB, Rochester, Minn继发性高血压筛查意义及诊断策略筛查常用辅助筛查手段Magnetic Resona

19、nce Imaging-磁共振成象磁共振成象在诊断醛固酮分泌腺瘤APA时具有高度的特异性。正如非功能性亢进肿瘤一样，醛固酮分泌腺瘤APA和双侧肾上腺增生BAH，能够通过磁共振成象显示出细胞内脂质移动的图象。Role for adrenal venous sampling in primary aldosteronism William F. Young, Jr, MD, Anthony W. Stanson, MD, Geoffrey B. Thompson, MD, Clive S. Grant, MD, David R. Farley, MD, and Jon A. van Heerden

20、, MB, ChB, Rochester, Minn继发性高血压筛查意义及诊断策略筛查常用辅助筛查手段Adrenal Vein Sampling-肾上腺静脉采血On the basis of CT findings alone, 42 patients (21.7%) would have been incorrectly excluded as candidates for adrenalectomy, and 48 (24.7%) might have had unnecessary or inappropriate adrenalectomy. AVS is an essential d

21、iagnostic step in most patients to distinguish between unilateral and bilateral adrenal aldosterone hyper secretion. Surgery 2004;136:1227-35.单独使用CT筛查，约有21.7%的病人被错误地取消肾上腺切除术，24.7%的病人接受到了不必要或不合适的肾上腺切除术。继发性高血压筛查意义及诊断策略肾上腺静脉采血国内外现状继发性高血压筛查意义及诊断策略肾上腺静脉F浓度与外周比值大于2提示插管成功F校正后比值大于2有意义确认醛固酮分泌腺瘤肾上腺静脉采血继发性高血压筛

22、查意义及诊断策略治疗策略确诊的醛固酮腺瘤患者-肾上腺组织切除术腹腔镜下肾上腺切除术的日益成熟，创伤和时间大大缩短双侧肾上腺增生-醛固酮受体拮抗剂类药物治疗副作用-男子女性型乳房征、性欲减退、月经不规律等问题肾上腺肿瘤切除的患者，约有60%患者停药纠正低血钾症得以治愈，血压改善Medical Management of Aldosterone-Producing AdenomasRanjan P. Ghose, MD; Phillip M. Hall, MD; and Emmanuel L. Bravo, MD继发性高血压筛查意义及诊断策略现状与未来肾素/醛固酮比值的普及应用，原醛症的检出率日益

23、提高存在血钾水平正常的原醛症患者筛查策略的运用，有助于提高血压控制率醛固酮受体的分布与高醛固酮症的危害原醛症筛查的成本有效性继发性高血压筛查意义及诊断策略库欣综合征（Cushings syndrome)的诊断典型的库欣综合征患者，ATCH和皮质醇分泌丧失节律地塞米松抑制试验呈现地塞米松无法抑制皮质醇水平的现象，导致高血压症状影像学检测库欣综合征继发性高血压筛查意义及诊断策略库欣综合征临床症状明显，无需特殊诊断筛查与非疾病特定人群性状类似-肥胖擦伤、多血症、以及肌肉病变在库欣综合征中占有很高的比重外源性与内源性库欣综合征外源性-二十四肽促皮质刺激实验，合适的生理糖皮 质激素替代治疗内源性-过夜地

24、塞米松抑制实验、24小试尿排泄皮质醇实验继发性高血压筛查意义及诊断策略库欣症的筛查意义及诊断策略Prospective Study on the Prevalence of Secondary Hypertension among Hypertensive Patients Visiting a General Outpatient Clinic in JapanMasao OMURA, Jun SAITO, Kunio YAMAGUCHI, Yukio KAKUTA, and Tetsuo NISHIKAWA继发性高血压筛查意义及诊断策略库欣症的筛查策略Urinary free cortis

25、ol versus 17-hydroxycorticosteroids: a comparative study of their diagnostic value in Cushings syndromeT. Mengden, P. Hubmann, J. Mfiller, P. Greminger, and W. VetterDepartement ffir Inhere Medizin, Universit/itsspital Z/irich继发性高血压筛查意义及诊断策略不同病因Cushing综合症鉴别Cushing病异位ACTH综合征肾上腺皮质癌肾上腺皮质瘤大剂量地米刺激能被抑制不能被抑制不能被抑制不能被抑制血ACTH升高明显增高降低降低肾上腺CT双侧肾上腺增大双侧肾上腺增大肿瘤肿瘤垂体MRI微腺瘤、大腺瘤无无无继发