β受體阻滯劑在高血壓治療中的意義.ppt

1、受體阻滯劑在高血壓治療中的意義,北京協(xié)和醫(yī)院心內(nèi)科 嚴曉偉,血壓 = 心排血量 x 周圍血管阻力,高血壓 = 心排血量增加 和/或 周圍血管阻力增加,前負荷,體液容量,腎：鈉潴留,外源性鈉攝入,遺傳因素,心肌收縮力 心率,血管收縮,交感神經(jīng)系統(tǒng),腎素- 血管緊張素- 醛固酮系統(tǒng),Kaplan NM. Curr Opin Nephrol Hypertens 1994,血壓的控制,Schlaish MP Hypertension 2004;43:169-75,高血壓時交感活性增加,伴糖尿?。―M2）的高血壓患者 交感神經(jīng)興奮性顯著升高,110,100,90,80,70,60,50,40,30,20

2、,10,0,EHT+DM2,EHT,DM2,NT,P,0.001,P,0.01,P,0.001,P,0.001,交感活性(Impulses/100 beats,Huggett et al, Hypetens. 2004,合并代謝綜合征（MS）的高血壓患者交感神經(jīng)興奮性顯著升高,80,60,40,20,0,P0.01,P0.05,P0.01,P0.001,Huggett et al, Hypetens. 2004,交感活性(Impulses/100 beats,無MS和EHT,EHT,MS,MS+EHT,諾貝爾醫(yī)學獎 1988,James W. Black博士,200年來繼發(fā)現(xiàn)洋地黃以來最偉大的

3、發(fā)現(xiàn),阻滯劑在心血管領(lǐng)域的應(yīng)用,缺血性心臟病 穩(wěn)定性心絞痛 不穩(wěn)定性心絞痛 急性心肌梗塞 高血壓 心律不齊 非對稱性竇性心動過速 在心房纖顫或撲動中的心室率的控制 陣發(fā)性室上性心動過速 室性快速型心律失常/心室纖維性顫動(索 他洛爾) 先天性長 QT 綜合征,慢性心力衰竭 肥厚性梗阻性心肌病 主動脈疾病 Marfans -主動脈壁夾層形成 二尖瓣下垂 二尖瓣狹窄 法洛氏四聯(lián)癥 手術(shù)期間高危,阻滯劑其他方面的應(yīng)用,神經(jīng)學方面 焦慮 特發(fā)性震顫 偏頭痛預(yù)防 戒酒,內(nèi)分泌病癥 甲狀腺毒癥 嗜鉻細胞瘤 (使用 阻滯劑后,胃腸道病癥 食管血管曲張 門靜脈高血壓,眼科方面 青光眼 ( 局部,阻滯劑的作用機

4、制,抑制過度激活的交感神經(jīng) 兒茶酚胺對心肌的毒性作用 主要通過 1 受體通路介導 與RAS 間的相互作用 長期治療 延緩 、逆轉(zhuǎn)心肌重構(gòu)的生物學效應(yīng) 冠脈血流有利的重分配,阻滯劑的作用機制,減慢心率 即刻作用 改善心肌缺血 增加舒張期灌注 長期作用改善預(yù)后 心率是獨立的心血管危險因素 抗心律失常作用 自律性、折返激動、觸發(fā)激動 室顫閾 獨有的作用防止猝死,阻滯劑保護伴高血壓的2型糖尿病患者,受體阻滯劑/非糖尿病 受體阻滯劑/糖尿病 無受體阻滯劑/非糖尿病 無受體阻滯劑/糖尿病,生存率,時間（天數(shù),100,90,80,0,0,60,120,180,240,300,360,Kjekshus J E

5、ur Heart J 1990;11:43,2006年NICE高血壓指南新確診高血壓患者選擇藥物流程圖,2007 ESH/ESC 高血壓指南,NICE has advised the use of -blockers only as fourtth line antihypertensive agents. These conclusions must be considered with care but also with a critical mind . 2007 ESH/ESC高血壓指南,Reappraisal of European guidelines on hypertensi

6、on management,Box 5. Choice of antihypertensive drugs (1) Large-scale meta-analyses of available data confirm that major antihypertensive drug classes, that is,diuretics, ACE inhibitors, calcium antagonists, angiotensin receptor antagonists, and b-blockers do not differ significantly for their overa

7、ll ability to reduce BP in hypertension,Reappraisal of European guidelines on hypertension management,Box 5. Choice of antihypertensive drugs (2) There is also no undisputable evidence that major drug classes differ in their ability to protect against overall cardiovascular risk or cause-specific ca

8、rdiovascular events, such as stroke and myocardial infarction. The 2007 ESH/ESC guidelines conclusion that diuretics, ACE inhibitors, calcium antagonists, angiotensin receptor antagonists, and b-blockers can all be considered suitable for initiation of antihypertensive treatment, as well as for its

9、maintenance,Reappraisal of European guidelines on hypertension management,Box 5. Choice of antihypertensive drugs (4) Each drug class has contraindications as well favorable effects in specific clinical settings. The choice of drug(s) should be made according to this evidence. The traditional rankin

10、g of drugs into first, second, third, and subsequent choice, with an average patient as reference, has now little scientific and practical justification and should be avoided,Reappraisal of European guidelines on hypertension management,Box 6. Combination therapy (6)Despite trial evidence of outcome

11、 reduction, the -blocker/diuretic combination favors the development of diabetes and should thus be avoided, unless required for other reasons, in predisposed patients,Reappraisal of European guidelines on hypertension management,Box 7. Antihypertensive treatment in the elderly (2) Data from meta-an

12、alyses do not support the claim that antihypertensive drug classes significantly differ in their ability to lower BP and to exert cardiovascular protection, both in younger and in elderly patients. The choice of the drugs to employ should thus not be guided by age. Thiazide diuretics, ACE inhibitors

13、, calcium antagonists, angiotensin receptor antagonists, and -blockers can be considered for initiation and maintenance of treatment also in the elderly,Reappraisal of European guidelines on hypertension management,Box 8. Antihypertensive treatment in diabetic patients (3) Meta-analyses of available

14、 trials show that in diabetes all major antihypertensive drug classes protect against cardiovascular complications, probably because of the protective effect of BP lowering per se. They can thus all be considered for treatment,阻滯劑降壓的最佳人群,冠心?。?心絞痛 、 ACS 、 心肌梗死 、 CAD二級預(yù)防 ） 糖尿病 慢性穩(wěn)定性收縮性心力衰竭 室上性和室性心律失常（快速性） 高血壓伴冠心病危險因素者？ 高血壓伴心率增快者 社會心理應(yīng)激者 焦慮等精神壓力增加者 主動脈夾層 肥厚性心肌病 二尖瓣脫垂