繼發(fā)性高血壓篩查意義及診斷策略課件

1、繼發(fā)性高血壓診斷意義及篩查策略繼發(fā)性高血壓篩查意義及診斷策略什么是高血壓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)繼發(fā)性高血壓篩查意義及診斷策略高血壓癥狀大多數(shù)高血壓沒有明顯癥狀部分高血壓患者會出現(xiàn)如下癥狀頭痛

2、、頭暈失眠耳鳴手腳麻木、頸背部肌肉酸痛、緊張繼發(fā)性高血壓篩查意義及診斷策略高血壓風(fēng)險等級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)繼發(fā)性高血壓篩查意義及診斷策略高血壓的危害繼發(fā)性高血壓篩查意義及診斷策略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.高血壓人群狀態(tài)中國中國繼發(fā)性高血壓篩查意義及診斷策略中國高血壓人群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.繼發(fā)性高血壓篩查意義及診斷策略繼發(fā)性高血壓篩查歷史繼發(fā)性高血壓篩查意義及診斷策略繼發(fā)性高血壓篩查現(xiàn)狀繼發(fā)性高血壓篩查意義及診斷策略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.繼發(fā)性高血壓篩查現(xiàn)狀繼發(fā)性高血壓的發(fā)病率為10.2%,包含腎血管性高血壓3.1%，原發(fā)性醛固酮增多癥1.4%，庫欣綜合征0.5%，嗜鉻細胞瘤0.3%，原發(fā)性甲狀腺功能減退3.0%；結(jié)論：年齡的增長及伴隨的動脈粥樣硬化疾病，與繼發(fā)性高血壓的發(fā)病率存在明顯的關(guān)系。繼發(fā)性高血壓篩查意義及診斷策略繼發(fā)性高血壓篩查意義繼發(fā)性高血壓診斷的意義在于，將有可能將不可治愈的疾病變成可以治愈的疾病。哪怕潛在疾病可能無法治愈，也可通過提供特異性的治療方案使血壓得到更好的控制，同時，潛在的疾病通常會造成比血壓升高更加嚴(yán)重的后果，因此需要對其進行治療。繼發(fā)性高血壓篩查意義及診斷策略

7、常見的內(nèi)分泌高血壓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原發(fā)性醛固酮增多癥庫欣綜合征嗜鉻細胞瘤肢端肥大癥繼發(fā)性高血壓篩查意義及診斷策略腎素-血管緊張素-醛固酮系統(tǒng)（RAAS）RAAS系統(tǒng)繼發(fā)性高血壓篩查意義及診斷策略原

8、發(fā)性醛固酮增多癥癥狀高血壓 原因未知的低血鉀特點癥狀無特異性與麻痹、肌無力臨床 癥狀相似篩查項目腎素活性PRA腎素濃度PRC醛固酮濃度ALD繼發(fā)性高血壓篩查意義及診斷策略藥物在原醛篩查中的影響藥物種類臨床常用藥物對ARR比值影響-受體阻斷劑美托洛爾、阿替洛爾及艾可洛爾等腎素ARRACE抑制劑、AT1受體拮抗劑依那普利、西拉普利、纈沙坦、氯沙坦等醛固酮腎素 ARR鈣通道阻斷劑硝苯地平、氨氯地平等無顯著影響利尿劑呋塞米、乙噻嗪等無顯著影響繼發(fā)性高血壓篩查意義及診斷策略原發(fā)性醛固酮增多癥篩查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. 針對原發(fā)性醛固酮增多癥，PAC/PRC的比值，相比于PAC/PRA的篩查方法更加有效和實用，目前的研究已經(jīng)提供了其可以作為一個有效篩查工具的初步證據(jù)。繼發(fā)性高血壓篩查意義及診斷策略原發(fā)性醛固酮增多癥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繼發(fā)性高血壓篩查意

11、義及診斷策略國外的研究進展及結(jié)論繼發(fā)性高血壓篩查意義及診斷策略ARR比值的應(yīng)用和現(xiàn)狀基層臨床機構(gòu)原醛癥的普及篩查高端醫(yī)療機構(gòu)的原醛癥的確認診斷標(biāo)準(zhǔn)化降壓藥物藥效研究和對AARR篩查的影響單一降壓藥物對AARR篩查比值的影響研究方法學(xué)一致性Cut-off無法實現(xiàn)互換性，PA篩查率差異很大繼發(fā)性高血壓篩查意義及診斷策略ARR與AARR的差異AARR-Aldosterone Active Renin Ratio醛固酮/活性腎素比值-PAC/PRCARR-Aldosterone Renin Ratio血液醛固酮/活性腎素-PAC/PRAARR單位ng/ml/hour 酶活力單位ARR參考范圍20-30

12、ng/ml/hourAARR參考范圍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.繼發(fā)性高血壓篩查意義及診斷策略ARR篩查發(fā)展ARR比值20ng/dl，且PAC濃度15pg/ml原醛癥檢出率4.6%-Loh, 2000Mayo Clinic PA篩查率4.6%Stowasser M 調(diào)整對ARR篩查影響小的降壓藥物后，確認PA檢出率18%影響因素樣本人群藥物種類和干擾原醛癥篩查思路血鉀濃度檢測系統(tǒng)特異性繼發(fā)性高血壓篩查意義及診斷策略原醛癥的篩查思路繼發(fā)性高血壓篩查意義及診斷

14、策略原醛癥的篩查和診斷策略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繼

15、發(fā)性高血壓篩查意義及診斷策略原醛癥的確認診斷鹽抑制試驗鹽水負荷試驗氟氫可的松抑制試驗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繼發(fā)性高血壓篩查意義及診斷策略

16、原醛癥的確認診斷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操作簡單、實用性高可對門診病人進行操作可替代氟氫可的松抑制試驗，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繼發(fā)性高血壓篩查意義及診斷策略篩查常用輔助篩查手段CT影像學(xué)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繼發(fā)性高血壓篩查意義及診斷策略篩查常用輔助篩查手段Magnetic Resona

19、nce Imaging-磁共振成象磁共振成象在診斷醛固酮分泌腺瘤APA時具有高度的特異性。正如非功能性亢進腫瘤一樣，醛固酮分泌腺瘤APA和雙側(cè)腎上腺增生BAH，能夠通過磁共振成象顯示出細胞內(nèi)脂質(zhì)移動的圖象。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繼發(fā)性高血壓篩查意義及診斷策略篩查常用輔助篩查手段Adrenal Vein Sampling-腎上腺靜脈采血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.單獨使用CT篩查，約有21.7%的病人被錯誤地取消腎上腺切除術(shù)，24.7%的病人接受到了不必要或不合適的腎上腺切除術(shù)。繼發(fā)性高血壓篩查意義及診斷策略腎上腺靜脈采血國內(nèi)外現(xiàn)狀繼發(fā)性高血壓篩查意義及診斷策略腎上腺靜脈F濃度與外周比值大于2提示插管成功F校正后比值大于2有意義確認醛固酮分泌腺瘤腎上腺靜脈采血繼發(fā)性高血壓篩

22、查意義及診斷策略治療策略確診的醛固酮腺瘤患者-腎上腺組織切除術(shù)腹腔鏡下腎上腺切除術(shù)的日益成熟，創(chuàng)傷和時間大大縮短雙側(cè)腎上腺增生-醛固酮受體拮抗劑類藥物治療副作用-男子女性型乳房征、性欲減退、月經(jīng)不規(guī)律等問題腎上腺腫瘤切除的患者，約有60%患者停藥糾正低血鉀癥得以治愈，血壓改善Medical Management of Aldosterone-Producing AdenomasRanjan P. Ghose, MD; Phillip M. Hall, MD; and Emmanuel L. Bravo, MD繼發(fā)性高血壓篩查意義及診斷策略現(xiàn)狀與未來腎素/醛固酮比值的普及應(yīng)用，原醛癥的檢出率日益

23、提高存在血鉀水平正常的原醛癥患者篩查策略的運用，有助于提高血壓控制率醛固酮受體的分布與高醛固酮癥的危害原醛癥篩查的成本有效性繼發(fā)性高血壓篩查意義及診斷策略庫欣綜合征（Cushings syndrome)的診斷典型的庫欣綜合征患者，ATCH和皮質(zhì)醇分泌喪失節(jié)律地塞米松抑制試驗呈現(xiàn)地塞米松無法抑制皮質(zhì)醇水平的現(xiàn)象，導(dǎo)致高血壓癥狀影像學(xué)檢測庫欣綜合征繼發(fā)性高血壓篩查意義及診斷策略庫欣綜合征臨床癥狀明顯，無需特殊診斷篩查與非疾病特定人群性狀類似-肥胖擦傷、多血癥、以及肌肉病變在庫欣綜合征中占有很高的比重外源性與內(nèi)源性庫欣綜合征外源性-二十四肽促皮質(zhì)刺激實驗，合適的生理糖皮 質(zhì)激素替代治療內(nèi)源性-過夜地

24、塞米松抑制實驗、24小試尿排泄皮質(zhì)醇實驗繼發(fā)性高血壓篩查意義及診斷策略庫欣癥的篩查意義及診斷策略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繼發(fā)性高血壓篩查意義及診斷策略庫欣癥的篩查策略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繼發(fā)性高血壓篩查意義及診斷策略不同病因Cushing綜合癥鑒別Cushing病異位ACTH綜合征腎上腺皮質(zhì)癌腎上腺皮質(zhì)瘤大劑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升高明顯增高降低降低腎上腺CT雙側(cè)腎上腺增大雙側(cè)腎上腺增大腫瘤腫瘤垂體MRI微腺瘤、大腺瘤無無無繼發(fā)