繼發(fā)性高血壓篩查的意義及診斷策略演示文稿

繼發(fā)性高血壓篩查的意義及診斷策略演示文稿當(dāng)前第1頁\共有41頁\編于星期五\11點(diǎn)（優(yōu)選）繼發(fā)性高血壓篩查的意義及診斷策略當(dāng)前第2頁\共有41頁\編于星期五\11點(diǎn)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、頭暈失眠耳鳴手腳麻木、頸背部肌肉酸痛、緊張當(dāng)前第3頁\共有41頁\編于星期五\11點(diǎn)高血壓風(fēng)險等級2013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTheTaskForceforthemanagementofarterialhypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC)當(dāng)前第4頁\共有41頁\編于星期五\11點(diǎn)高血壓的危害當(dāng)前第5頁\共有41頁\編于星期五\11點(diǎn)KearneyPM,WheltonM,ReynoldsK,MuntnerP,WheltonPK,HeJ.Globalburdenofhypertension:analysisofworldwidedata.Lancet.2005;365(9455):217-23.高血壓人群狀態(tài)中國中國當(dāng)前第6頁\共有41頁\編于星期五\11點(diǎn)中國高血壓人群KearneyPM,WheltonM,ReynoldsK,MuntnerP,WheltonPK,HeJ.Globalburdenofhypertension:analysisofworldwidedata.Lancet.2005;365(9455):217-23.當(dāng)前第7頁\共有41頁\編于星期五\11點(diǎn)繼發(fā)性高血壓篩查歷史當(dāng)前第8頁\共有41頁\編于星期五\11點(diǎn)繼發(fā)性高血壓篩查現(xiàn)狀當(dāng)前第9頁\共有41頁\編于星期五\11點(diǎn)Theprevalenceofsecondaryformsofhypertensionwas10.2%,includingrenovascularhypertension(3.1%),primaryaldosteronism(1.4%),Cushing'ssyndrome(0.5%),pheochromocytoma(0.3%),primaryhypothyroidism(3.0%)Conclusions:Increasingageandcoexistingatherosclerosishavesignificanteffectsontheprevalenceofsecondaryformsofhypertension.Theeffectofageonprevalenceofsecondaryformsofhypertensionin4429consecutivelyreferredpatientsAnderson,GunnarH.Jr;Blakeman,Nancy;Streeten,DavidH.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(xì)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。當(dāng)前第10頁\共有41頁\編于星期五\11點(diǎn)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(jìn)行治療。當(dāng)前第11頁\共有41頁\編于星期五\11點(diǎn)常見的內(nèi)分泌高血壓ProspectiveStudyonthePrevalenceofSecondaryHypertensionamongHypertensivePatientsVisitingaGeneralOutpatientClinicinJapanMasaoOMURA,JunSAITO,KunioYAMAGUCHI,YukioKAKUTA,andTetsuoNISHIKAWA原發(fā)性醛固酮增多癥庫欣綜合征嗜鉻細(xì)胞瘤肢端肥大癥當(dāng)前第12頁\共有41頁\編于星期五\11點(diǎn)腎素--血管緊張素--醛固酮系統(tǒng)（RAAS）RAAS系統(tǒng)當(dāng)前第13頁\共有41頁\編于星期五\11點(diǎn)原發(fā)性醛固酮增多癥癥狀高血壓原因未知的低血鉀特點(diǎn)癥狀無特異性與麻痹、肌無力臨床

癥狀相似篩查項(xiàng)目腎素活性PRA腎素濃度PRC醛固酮濃度ALD當(dāng)前第14頁\共有41頁\編于星期五\11點(diǎn)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β-受體阻斷劑美托洛爾、阿替洛爾及艾可洛爾等腎素↓ARR↑ACE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當(dāng)前第15頁\共有41頁\編于星期五\11點(diǎn)原發(fā)性醛固酮增多癥篩查ThePAC/PRCratiooffersseveralpracticaladvantagescomparedwiththePAC/PRAscreeningmethod.ThepresentstudyofferspreliminaryevidencethatitmaybeausefulscreeningtestforPHA.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(shí)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)。當(dāng)前第16頁\共有41頁\編于星期五\11點(diǎn)原發(fā)性醛固酮增多癥RapidScreeningTestforPrimaryHyperaldosteronism:RatioofPlasmaAldosteronetoReninConcentrationDeterminedbyFullyAutomatedChemiluminescenceImmunoassaysFrankHolgerPerschel,1*RudolfSchemer,3LysannSeiler,4MartinReincke,4JaapDeinum,5ChristianeMaser-Gluth,6DavidMechelhoff,1RudolfTauber,1andSvenDiederich2ClinicalChemistry2004當(dāng)前第17頁\共有41頁\編于星期五\11點(diǎn)國外的研究進(jìn)展及結(jié)論當(dāng)前第18頁\共有41頁\編于星期五\11點(diǎn)ARR比值的應(yīng)用和現(xiàn)狀基層臨床機(jī)構(gòu)原醛癥的普及篩查高端醫(yī)療機(jī)構(gòu)的原醛癥的確認(rèn)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(shí)現(xiàn)互換性，PA篩查率差異很大當(dāng)前第19頁\共有41頁\編于星期五\11點(diǎn)ARR與AARR的差異AARR-AldosteroneActiveReninRatio醛固酮/活性腎素比值-PAC/PRCARR-AldosteroneReninRatio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20-30ng/ml/hourAARR參考范圍32Recentstudiesusingtheratioofplasmaaldosteroneconcentration(PAC)toPRAasthescreeningtestforprimaryaldosterondisminhypertensivepopulationssuggestedthattheprevalencemaybeashighas5–15%.-PrevalenceofPrimaryAldosterondismamongAsianHypertensivePatientsinSingaporeKEH-CHUANLOH,EVELYNS.KOAY,MIN-CHEHKHAW,SHANTAC.EMMANUEL,ANDWILLIAMF.YOUNG,JR.當(dāng)前第20頁\共有41頁\編于星期五\11點(diǎn)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,2000MayoClinicPA篩查率4.6%StowasserM調(diào)整對ARR篩查影響小的降壓藥物后，確認(rèn)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)特異性當(dāng)前第21頁\共有41頁\編于星期五\11點(diǎn)原醛癥的篩查思路當(dāng)前第22頁\共有41頁\編于星期五\11點(diǎn)原醛癥的篩查和診斷策略Minireview:PrimaryAldosteronism—ChangingConceptsinDiagnosisandTreatmentWILLIAMF.YOUNG,JR.ProfessorofMedicine,MayoMedicalSchool;Consultant,DivisionofEndocrinology,Metabolism,NutritionandInternalMedicine,MayoClinicandMayoFoundation,Rochester,Minnesota55905當(dāng)前第23頁\共有41頁\編于星期五\11點(diǎn)原醛癥的確認(rèn)診斷鹽抑制試驗(yàn)鹽水負(fù)荷試驗(yàn)氟氫可的松抑制試驗(yàn)ComparisonofConfirmatoryTestsfortheDiagnosisofPrimaryAldosteronismPaoloMulatero,AlbertoMilan,FrancescoFallo,GiuseppeRegolisti,FrancescaPizzolo,CarlosFardella,LorenaMosso,LisaMarafetti,FrancoVeglio,andMauroMaccario當(dāng)前第24頁\共有41頁\編于星期五\11點(diǎn)原醛癥的確認(rèn)診斷SaltLoadingTestisareasonablygoodalternativetothemoreexpensiveandcomplexFSTforthediagnosisofPAafterapositivescreeningtest.

JClinEndocrinolMetab91:2618–2623,2006操作簡單、實(shí)用性高可對門診病人進(jìn)行操作可替代氟氫可的松抑制試驗(yàn)，可信度高ComparisonofConfirmatoryTestsfortheDiagnosisofPrimaryAldosteronismPaoloMulatero,AlbertoMilan,FrancescoFallo,GiuseppeRegolisti,FrancescaPizzolo,CarlosFardella,LorenaMosso,LisaMarafetti,FrancoVeglio,andMauroMaccario當(dāng)前第25頁\共有41頁\編于星期五\11點(diǎn)篩查常用輔助篩查手段CT影像學(xué)的局限性CTScanning,thereforeclearlylocalizesadenomasin50%ofhistologicallyprovencases,andcanalsoproducemisleadingresults.-RoleforadrenalvenoussamplinginprimaryaldosteronismWilliamF.Young,Jr,MD,AnthonyW.Stanson,MD,GeoffreyB.Thompson,MD,CliveS.Grant,MD,DavidR.Farley,MD,andJonA.vanHeerden,MB,ChB,Rochester,Minn當(dāng)前第26頁\共有41頁\編于星期五\11點(diǎn)篩查常用輔助篩查手段MagneticResonanceImaging-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(jìn)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(xì)胞內(nèi)脂質(zhì)移動的圖象。RoleforadrenalvenoussamplinginprimaryaldosteronismWilliamF.Young,Jr,MD,AnthonyW.Stanson,MD,GeoffreyB.Thompson,MD,CliveS.Grant,MD,DavidR.Farley,MD,andJonA.vanHeerden,MB,ChB,Rochester,Minn當(dāng)前第27頁\共有41頁\編于星期五\11點(diǎn)篩查常用輔助篩查手段AdrenalVeinSampling-腎上腺靜脈采血OnthebasisofCTfindingsalone,42patients(21.7%)wouldhavebeenincorrectlyexcludedascandidatesforadrenalectomy,and48(24.7%)mighthavehadunnecessaryorinappropriateadrenalectomy.AVSisanessentialdiagnosticstepinmostpatientstodistinguishbetweenunilateralandbilateraladrenalaldosteronehypersecretion.Surgery2004;136:1227-35.單獨(dú)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)。當(dāng)前第28頁\共有41頁\編于星期五\11點(diǎn)腎上腺靜脈采血國內(nèi)外現(xiàn)狀當(dāng)前第29頁\共有41頁\編于星期五\11點(diǎn)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(rèn)醛固酮分泌腺瘤腎上腺靜脈采血當(dāng)前第30頁\共有41頁\編于星期五\11點(diǎn)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MedicalManagementofAldosterone-ProducingAdenomasRanjanP.Ghose,MD;PhillipM.Hall,MD;andEmmanuelL.Bravo,MD當(dāng)前第31頁\共有41頁\編于星期五\11點(diǎn)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提高存在血鉀水平正常的原醛癥患者篩查策略的運(yùn)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當(dāng)前第32頁\共有41頁\編于星期五\11點(diǎn)庫欣綜合征（Cushing’ssyndrome)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(yàn)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)檢測庫欣綜合征當(dāng)前第33頁\共有41頁\編于星期五\11點(diǎn)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(shí)驗(yàn)，合適的生理糖皮

質(zhì)激素替代治療內(nèi)源性-過夜地塞米松抑制實(shí)驗(yàn)、24小試尿排泄皮質(zhì)醇實(shí)驗(yàn)當(dāng)前第34頁\共有41頁\編于星期五\11點(diǎn)庫欣癥的篩查意義及診斷策略ProspectiveStudyonthePrevalenceofSecondaryHypertensionamongHypertensivePatientsVisitingaGeneralOutpatientClinicinJapanMasaoOMURA,JunSAITO,KunioYAMAGUCHI,YukioKAKUTA,andTetsuoNISHIKAWA當(dāng)前第35頁\共有41頁\編于星期五\11點(diǎn)庫欣癥的篩查策略Urinaryfreecortisolversus17-hydroxycorticosteroids:acomparativestudyoftheirdiagnosticvalueinCushing'ssyndromeT.Mengden,P.Hubmann,J.Mfiller,P.Greminger,andW.VetterDepartementffirInhereMedizin,Universit/itsspitalZ/irich當(dāng)前第36頁\共有41頁\編于星期五\11點(diǎn)不同病因Cushin