高血壓講課課件

1、高血壓1diseases of circulatory system hypertensionprof. shen-jiang hu高血壓2n掌握高血壓的診斷標準、危險分層和治療原則。n熟悉降壓藥物的種類及特點；降壓藥物的選擇和聯(lián)合用藥。n了解高血壓的患病率、病因、發(fā)病機制和并發(fā)癥；以及較常見的幾種繼發(fā)性高血壓。 講授目的和要求高血壓31、內(nèi)科學，王吉耀主編，人民衛(wèi)生出版社2、實用高血壓學余振球等主編，科學出版社3、現(xiàn)代內(nèi)科學英語精要王吉耀、劉文忠摘編，人民衛(wèi)生出版社 教材及參考書教材及參考書 高血壓4教學網(wǎng)站網(wǎng)址教學網(wǎng)站網(wǎng)址 n內(nèi)科學校級精品課程：n內(nèi)科學省級精品課程： 高血壓5blood

2、pressure has a unimodal distribution in the population高血壓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“高血壓可能是一個重要的代償機制，即使我們能夠控制它，也不應高血壓可能是一個重要的代償機制，即使我們能夠控制它，也不應該處理它。該處理它。”“the greatest dange

3、r 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高血壓7人類對高血壓認識的歷史framingham心臟研究：最早認識到高血壓與心臟病的關系1961年認識到高血壓與卒中的關系1970年世界衛(wèi)生組織首次提出高血壓階梯治療方案1978年jnc ii將舒張壓作為確診高血壓的和治療建議的基礎1980年jnc v收縮壓與舒張壓同等重要1992年jnc vii：降壓達標對減少各類患者的心血管事件至關重要200

4、3年中國高血壓治療指南更新：降壓藥物治療目標在于，降低血壓使其達到相應病人的目標水平2005年世界衛(wèi)生組織將“降壓要達標”作為高血壓日的宣傳口號2006年高血壓8atrial fibrillationaortic dissectiondementiachronic renal failureheart failurelv hypertrophymihypertensive encephalopathychdintracerebral hemorrhageischemiccerebralinfarctioncomplications of hypertension高血壓9the relation

5、ship between blood pressure and cardiovascular events高血壓10高血壓11definition of hypertensionnhypertension is a clinical syndrome, defined as systolic blood pressure 140 mmhg and/or diastolic blood pressure 90 mmhg. nhypertension should be considered a major risk factor for an array of cardiovascular an

6、d related disease as well as diseases leading to a marked increase in cardiovascular risk. 。hypertension in china(1991)死亡原因 死亡率占總死亡死亡原因 死亡率占總死亡 1/10萬%1/10萬 %循環(huán)系病226.138.5 內(nèi)分泌，代謝 - 腦血管病127.221.6 營養(yǎng)，免疫病16.92.9 - 心臟病98.916.8 泌尿生殖病 8.91.5惡性腫瘤40.523.9 精神病6.71.1呼吸系病81.713.9 神經(jīng)病5.30.9損傷，中毒36.96.3消化系病17.93.

7、0我國城市我國城市19991999年前年前1010位死亡原因位死亡原因我國農(nóng)村我國農(nóng)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(%)中國心血管健康多中心合作研究高血壓17etiologynthe pathogenesis of essential hypertension is multifactorial. ngenetic factors play an important r

8、ole. 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 essential hypertension. it alone is probably not sufficient to elevate blood pressure to abnormal le

9、vels; a combination of too much salt plus a genetic predisposition is required.高血壓18etiology高血壓19高血壓20pathogenesisnsympathetic nervous system hyperactivity. it is most apparent in younger hypertensives, who may exhibit tachycardia and an elevated cardiac output. however, correlations between plasma

10、catecholamines and blood pressure are poor. 高血壓21pathogenesisnrenin-angiotensin system. renin acts on angiotensinogen to cleave of the ten-amino-acid peptide angiotensin i. this peptide is then acted upon by angiotensin-converting enzyme to create the eight-amino-acid peptide angiotensin ii, a poten

11、t vasoconstrictor and a major stimulant of aldosterone release from the adrenal glands.高血壓22pathogenesisndefect of natriuresis. hypertensive patients exhibit a diminished ability to excrete a sodium load. this defect may result in increased plasma volume and hypertension.高血壓23pathogenesisnintracellu

12、lar 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 vascular smooth muscle tone. 高血壓24pathogenesisnexacerbating factors. the best-documented is obesity, which is asso

13、ciated 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 alcohol also raises blood pressure. cigarette smoking acutely raises blood pressure. 高血壓25pathologynheart. left v

14、entricular hypertrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death. 高血壓26pathologynbrain. hypertension is the major predisposing cause of stroke, especially intracerebral hemorr

15、hage but also ischemic cerebral infarction. 高血壓27pathologynkidney. chronic hypertension leads to nephrosclerosis, a common cause of renal insufficiency. 高血壓28clinical findingssymptoms:nelevations in pressure are often intermittent early. even in established case, the blood pressure fluctuates widely

16、 in response to emotional stress and physical activity.高血壓29clinical findingssymptoms:nmild to moderated essential hypertension is usually associated with normal health and well-being for many years. 高血壓30clinical findingssymptoms:nsuboccipital pulsating headaches, but any type of headache, may occu

17、r. accelerated hypertension is associated with somnolence, confusion, palpitation. 高血壓31signs：nhigh blood pressure.nphysical findings depend upon the duration and severity, and the degree of effect on target organs.na loud aortic second sound and an early systolic ejection click may occur. 高血壓32cate

18、goryjnc 7（usa） european chinaoptimal120 and 80normal120 and 80120-129 and/or 80-84120 and 80high-normal120-139 or 80-89130-139 and/or 85-89120-139 or 80-89hypertension 140 or 90grade i140-159 or 90-99140-159 and/or 90-99140-159 or 90-99grade ii 160 or 100160-179 and/or 100-109160-179 or 100-109grade

19、 iii 180 and/or 110 180 or 110isolated systolic hypertension 140 and 90 140 and 30% 20-30% 15-20% 8% 5-8% 4-5% 4%高血壓35factors influencing prognosis高血壓36factors influencing prognosis高血壓37management高血壓38goals of treatment高血壓39goals of treatment治療組間的血壓差異與卒中、治療組間的血壓差異與卒中、chd、主要、主要cvd事件、事件、cvd死亡及總死亡率風險的差

20、異直接相關死亡及總死亡率風險的差異直接相關lancet 2003;362:1527-450-5-10-15-20-25-30卒中chd心衰總死亡23%15%16%14% 4/3 mmhgn20 888主要cv事件15%高血壓41managementlifestyle modificationnweight lossnsodium restrictionncalcium and potassium supplementationnhigh-fiber, low-fat dietnalcohol moderationnexercise高血壓42when to initiate antihypert

21、ensive treatmentnbased on two criteria:nthe level of systolic and diastolic blood pressurenthe level of total cardiovascular risk高血壓43initiation of antihypertensive treatment高血壓44choice of antihypertensive drugsnfive major classes of antihypertensive agents thiazide diuretics, calcium antagonists, a

22、ce inhibitors, angiotensin receptor antagonists and -blockers are suitable for the initiation and maintenance of antihypertensive treatment, alone or in combination. 高血壓45choice of antihypertensive drugs高血壓46choice of antihypertensive drugs高血壓47choice of antihypertensive drugs高血壓48antihypertensive t

23、reatment: preferred drugs高血壓49antihypertensive treatment: preferred drugs高血壓50antihypertensive treatment: preferred drugs高血壓51compelling and possible contraindications to use of antihypertensive drugs高血壓52monotherapy versus combination therapynmonotherapy could be the initial treatment for a mild bp elevation with