對繼發(fā)高血壓的新認識

1、對繼發(fā)高血壓的新認識高血壓患者的評估明確血壓水平鑒別高血壓的原因查找其它危險因素靶器官損害及伴隨疾病或臨床情況評估總體心血管病危險繼發(fā)性高血壓的主要原因腎臟疾病心血管疾病內(nèi)分泌疾病自身免疫性疾病 高血壓是許多疾病病理生理過程的共同表現(xiàn)；不同的個體、家系和人群，血壓升高的機制可能不同；同一個高血壓個體可能同時并存有多個不同的升壓機制。神經(jīng)系統(tǒng)疾病睡眠呼吸疾病精神心理疾病藥源性的高血壓復雜疑難高血壓病因診斷平臺建設EH：essential hypertension RH：renal hypertension RVH：renovascular hypertension PA：primary aldo

2、steronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome 初步排查精確診斷?？茩z查病史體格檢查一般實驗室檢查臨床試驗?？茖嶒炇覚z查確定治療方案可疑患者 665(39.3%)424(33.9)210(22.4)202(21.3)130(18.3) 98(17.8) 95(16.9)繼發(fā)性高血壓a1027(60.7%)825(66.1)727(77.6)746(78.7)579(81.7)452(82.2)466(83.1)原發(fā)性高血壓a16921249937948709550

3、5612008200720062005200420032002病因n（%）Number Change of SH per year (1997.7 2008.7, add to 1523)Etiology of 7805 in-patients with hypertension in Peoples Hospital of Xinjiang from 1997.72008.7EHRHRVHPAPMCCSHyperthyHypothyOSASAdd toCase Number628211910430765512498627805Constituent ratio(%)80.491.521.33

4、3.930.830.070.150.6311.05100繼發(fā)性高血壓的篩查平臺腎性、腎血管性高血壓內(nèi)分泌性高血壓睡眠呼吸暫停相關性高血壓精神心理因素性高血壓EH：essential hypertension RH：renal hypertension RVH：renovascular hypertension PA：primary aldosteronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome Number Change of SH per year (1997.7 20

5、08.7, add to 1523)Etiology of 7805 in-patients with hypertension in Peoples Hospital of Xinjiang from 1997.72008.7EHRHRVHPAPMCCSHyperthyHypothyOSASAdd toCase Number628211910430765512498627805Constituent ratio(%)80.491.521.333.930.830.070.150.6311.05100EH：essential hypertension RH：renal hypertension

6、RVH：renovascular hypertension PA：primary aldosteronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome Number Change of SH per year (1997.7 2008.7, add to 1523)Etiology of 7805 in-patients with hypertension in Peoples Hospital of Xinjiang from 1997.72008.7EHRHRVHPAPMC

7、CSHyperthyHypothyOSASAdd toCase Number628211910430765512498627805Constituent ratio(%)80.491.521.333.930.830.070.150.6311.05100中華心血管病雜志OSAHS病理生理改變與臨床表現(xiàn)高血壓?？崎T診就診患者OSAHS檢出情況組別例數(shù)OSAHS檢出率PSG陽性率總體33916.7%81.72%男性170510.44%83.57%女性16862.97%75.76%高血壓?？崎T診就診的高血壓患者中OSAHS檢出率6.7%，其中以中年男性為主。2009年4月-2009年6月新疆自治區(qū)人民

8、醫(yī)院高血壓專科初次就診的3391例高血壓中疑似OSAHS患者279例行PSG監(jiān)測。張麗麗. 韓瑞梅.李南方等，中華高血壓雜志. 2011,19（7）：642-646正常組、超重組和肥胖組的OSAHS檢出率分別為6.6%（12/183）、22.22%（78/351）和36.75%（104/283） 正常腰圍組和中心性肥胖組的OSAHS檢出率分別是7.83%（9/115）和26.29% （184/700）,差異有顯著統(tǒng)計學意義不同體重高血壓患者中睡眠呼吸暫停綜合的檢出率張麗麗.李南方.嚴志濤等，中華心血管病雜志.2012,40（2）：120-124項目正常組N=154(31.9%)輕度OSAS組N

9、=112(23.2%) 中度OSAS組N=108(22.4%)重度OSAS組N=109(22.6%)P值 31.9% 68.1%年齡46.168.8949.0311.0350.6510.9949.6512.340.005 BMI指數(shù)27.182.9428.244.9928.283.7730.373.640.000 腹圍95.4810.4198.1210.81100.2310.48103.6414.110.000 頸圍39.076.1541.3511.4942.209.2342.457.310.034 收縮壓132.8619.76133.5017.51135.8115.59140.1517.96

10、0.015 舒張壓85.2613.2986.8111.8586.9413.0691.1315.890.013 OSAS與HBP N=483夜間打鼾，BMI24,BP140/90mmHG,n=483，沒有停用降壓藥物OSAHS相關性高血壓患者代謝特點高TG、低HDL、MS、IGR、高UA和高HCY隨著OSAHS程度的加重,患病率上升，患病率在各組之間差異有統(tǒng)計學意義(P0.05) 住院高血壓患者，疑似OSAS, 完成夜間睡眠呼吸監(jiān)測的550例（男418例，女132例）程衛(wèi)平，李南方等，中華高血壓雜志，2009多器官損害患者中重度OSAHS的患病率OSAHS相關性高血壓靶器官損害的患病率高于單純高

11、血壓患者主要發(fā)生在中重度組，常并發(fā)多器官損害。程維平.嚴志濤.李南方中華高血壓雜志.2011,19（7）：642-646靶器官損害的定義及診斷：心肌肥厚：根據(jù)美國超聲心動圖聯(lián)盟的標準：LVMI男50g/m2.7、女47g/m2.7定義為左室肥厚。冠心病：依據(jù)1979國際心臟病學會和協(xié)會及世界衛(wèi)生組織(ISFC/ WHO) 臨床命名標準化聯(lián)合專題組的報告，確診根據(jù)冠狀動脈造影或冠狀動脈CTA，冠脈主要的分支狹窄大于50%判斷為有冠心病。腦血管病變：根據(jù)2007年中國缺血性腦血管病防治指南，有神經(jīng)系統(tǒng)定位癥狀及體征，經(jīng)頭部影像學（CT或核磁）檢查確診。腎損害：根據(jù)診斷學（第七版，陳文彬，人民衛(wèi)生出

12、版社）提供的實驗室檢查標準，、慢性腎功能不全，血肌酐男106mol/L、女97mol/L和/或尿素氮7.1mmol/L；、Ccr80ml/min；、尿蛋白定性陽性或24小時尿蛋白定量80mg/24小時；、尿酸男416mol/L、女357mol/L。具有以上四項中的其中一項者定義為腎損害。頸動脈硬化：根據(jù)中國高血壓防治指南12定義，經(jīng)超聲檢測有斑塊形成，和/或頸動脈內(nèi)膜中層厚度0.9mm。眼底病變：根據(jù)中國高血壓防治指南12定義，按Wagener 和Backer高血壓眼底改變的診斷標準分為四級。EH：essential hypertension RH：renal hypertension RVH

13、：renovascular hypertension PA：primary aldosteronism PMC：pheochromocytoma CS：cushing syndrome OSAS： obstructive sleep apnea syndrome Number Change of SH per year (1997 2008, add to 1723)Etiology of 7809 in-patients with hypertension in Peoples Hospital of Xinjiang from 19972008中華心血管病雜志原發(fā)性醛固酮增多癥APAIHA

14、PAHACGSH 約占高血壓的1% 中重度高血壓 低血鉀，CO2CP升高 腎上腺的腫瘤或增大 低腎素和高醛固酮the prevalence of PA based on ARR and formal confirmation testing in hypertensive patientsthe Prevalence of PA Based on ARR and Formal Confirmation Testing in Moderate to Severe and Consecutive Hypertensive Patients Overview of Studies on the Pr

15、evalence of Hypokalemia in PAAPAs-Mass on CT (Jan 1992August 1999)-stowarss M. AustraliaAPA sizeNo APAsMass on CT(%)1 cm5242 (81%)1cm5914 (24%)Total11156 (50%)AP macroAAP microAUMNUAHIHAPrevalence（%）38365219Radiological manifestationlateral adenoma normalnormalnormal or nodenormal or nodeValue of CT

16、 scan for the diagnosis of PATarget organ damage caused by PAInvestigatorCountry Subjects ResultsJ D. Blumenfeld et alNew York82 microalbuminuria and increased urinary protein excretion40%; cardiovascular events( angina and myocardial infarction) 7.3%, cerebrovascular events (transient ischemic atta

17、ck or stroke) 6.1%.Paul Milliez et alFrance124 a history of stroke 12.9%;Non-fatal myocardial infarction 4.0%;A history of atrial fibrillation 7.3% , LVH 32%.Francesco Fallo et alItaly85metabolic syndrome 41.1%;Hyperglycemia in Metabolic Syndrome 27.0%;diabetes mellitus 8.2%.Rossi GP et alItaly17 LV

18、H 30%; LV concentric remodeling 17%.Cristiana Catena et alItaly54 cardiovascular events 35%, odds ratios of 4.61, with odds ratios of 4.93, 4.36, and 2.80 for sustained arrhythmias, cerebrovascular events, and coronary heart disease , respectively. Then patients with PH.Yuji ShigematsuJapan23eccentr

19、ic LVH 57%;concentric LVH 9%.*Subjects: patients with Primary AldosteronismCardiovascular impairment caused by aldosteronethrombosisblood pressure elevationsympathetic excitationoxidative stress Na+ retention, excretion of K+ and Mg+ arrhythmiavascular injury myocardium fibrosisvascular endothelial

20、injuryinflammationaldosterone診斷原發(fā)性醛固酮增多癥的新挑戰(zhàn)原醛在高血壓的人群中不一定只有1%原醛不一定都合并低血鉀原醛不一定都有腎上腺影像學改變原醛不一定是溫良的高血壓原醛的診斷需要建立篩查方案和篩查體系。Condition that in a hypertensive make the search for PA Unexplained hypokalemia (spontaneous or diuretic induced)Resistant hypertension and grade 2 to3 hypertensionEarly onset hypert

21、ension and/or stroke(50 years)Incidentally discovered apparently non functioning adrenal mass (incidentaloncoma)Evidence of organ damage (LVH, diastolic dysfunction, AV block, carotid atherosclerosis, microalbuminuria, endothelia dysfunction) particularly if disproportionate for the severity of hype

22、rtensionMetabolic syndromeObstructive sleep apnea syndrome (this is still contentious)The diagnosis of PAScreening: PAC, PRA and ARRConfirming: OSLT, SLT. FST and Captopril STLateralizing: CTAVSAdrenal vein sling (AVS) is currently the most reliable available means of differentiating unilateral from

23、 bilateral PA and lateralizing micro aldosterone-producing adenomas preoperatively, although which is invasive, technically challenging, difficult to interpret, and commonly held to be risky.Paolo Mulatero et al. Hypertension, 2010項目參數(shù)性別（男/女）195/135年齡（歲）47.378.84體重指數(shù)（kg/m2）27.013.42病程（年）5（1天-30年）確診PA前服用抗高血壓藥者2種（%）80.3%（265/330）入院收縮壓（mmHg）145.0319.14入院舒張壓（mmHg）95.0312.64最高收縮壓（mmHg）176.422.77最高收縮壓（mmHg）112.4114.36新疆高血壓研究所對330例PA的臨床資料分析血鉀3.5mmol/L(%)37.27%(123/330)血鉀（mmol/L）3.670.43尿鉀（mmol/L）40.85(10.7-167.8)尿pH6(5-8)坐位腎素活性（ng/ml/h）0.34（0.001-2.15）坐位醛固酮(ng/dl)17.58（4.81-