1、第六章高血压（Hypertension）病因发病机制病理临床表现实验室检查诊断标准鉴别诊断治疗讲授主要内容Epidemiology of Hypertension Prevalence of Hypertension,by Country,District,Race and Sex,Age 18 and Older国家:发达发展地区:北方南方,城市农村种族:黑人白人年龄:老年性别:无明显差异发病机制(mechanisms of essential hypertension)-1nBP=cardiac output x peripheral vascular resistancen交感神经系统活
2、性亢进(Increased sympathetic nervous system activity)：情绪,应激等刺激神经中枢系统,交感神经系统活性亢进，儿茶酚胺浓度升高，阻力小动脉收缩增强,同时影响肾素分泌，升高血压（heightened vascular reactivity to alpha-adrenergic agonists by causing arteriolar and venous constriction or by altering the normalrenal pressure volume relationship)n肾性水钠潴留(Renal Retention
3、of Sodium)：各种病因引起的肾性水钠潴留，组织过渡灌注，全身阻力小动脉收缩(increased total body sodium and extracellular fluid volume in renal dysfuntion)发病机制(mechanisms of essential hypertension)-2n肾素血管紧张素醛固酮系统(Renin-Angiotensin Aldosterone System(RAAS)激活：血管紧张素II为主要效应物质，作用于AT1受体，使小动脉收缩，并刺激醛固酮和促进交感神经系统激活（ALL functions of renin are
4、mediated through the synthesis of angiotensin II.It will stimulate the secretion of aldosterone and hence mediates responses to varying sodium intake and volume load also Increased sympathetic nervous system activity)发病机制(mechanisms of essential hypertension)-3n血管重建(Vascular structural remodeling)多种
5、因素的参与，血压对血管壁的冲击，血管内皮受损，水钠储留（multiple factors can cause both functional contraction and structural remodeling and Hypertrophy)n内皮细胞功能受损(Endothelial Cell Dysfunction）舒张血管因子减少（NO,PGI2);收缩血管因子增加（ENDOTHELIN TXA2)promote abnormal Vascular structural remodeling.n胰岛素抵抗(insulin resistance):机制不明,可能与继发高胰岛素血症有关
6、(内皮细胞功能受损,钠储留等）病 理 功能-结构n心脏：左心室肥厚和扩大；冠状动脉粥样硬化（Left Ventricular Hypertrophy,coronary atherosclerotic heart disease)n脑：脑血管缺血和变性，易形成微动脉瘤，发生脑出血；脑动脉粥样硬化，发生脑血栓形成；脑小动脉闭塞性病变，引起腔隙性脑梗塞(ischemic stroke and intracerebral hemorrhage)n肾脏：肾小球纤维化、萎缩，以及肾动脉硬化导致肾功能减退(nephrosclerosis-renal dysfunction)临床表现症状症状:symptoms
7、:symptomsn大多起病缓慢、渐进，一般缺乏特异性临床表现n约1/5患者在测量血压和发生并发症时才发现n头晕、头痛、心悸,失眠等(dizzy,headaches,palpitations，sleep disturbance，sensitivity)n靶器官受损症状(target organ damage):心绞痛、心、肾功能不全，脑卒中(angina,heart and kidney failure,stroke or ischemic attack)体征：体征：signsn血压随季节、昼夜、情绪等因素有较大波动n听诊时可有主动脉瓣区第二心音亢进 收缩期杂音 少数在颈部或腹部可听到血管杂音
8、 靶器官受损体征：实验室检查n血压测量血压测量(Measurement of BP)Posture,Circumstances,Cuff size,Techniquen常规检查常规检查 Urine test,GLU,K+,NA+,Lipidprotein profile,BUN,sCr,UA,EKG,X-ray,UCG,eye examination（尿常规、血糖、血电解质、血胆固醇和甘油三酯、低密度脂蛋白和高密度脂蛋白、肾功能、血尿酸和心电图，胸片,超声心动图,眼底检查）n特殊检查特殊检查 ABPM,ABI ratio,PWV,RENIN(24小时动态血压检测、踝/臂血压比值、动脉弹性功能测
9、定、血浆肾素活性等)诊断标准(Diagnosis)nThe measurement should be repeated after at least 30s and the two readings averaged.高血压的诊断必须以未服用降压药物情况下2次或2次以上非同日多次血压测定所得的平均值为依据(systolic/diastolic blood pressure over 140/90 mmHg)n鉴别原发性还是继发性n高血压分级n高血压危险分层正确的血压测量类别类别JNC 7（美国）（美国）欧洲欧洲 中国中国(Optimal)理想血压理想血压(mmHg)120和和80正常血压正常
10、血压(Normal)120和和80120-129或或80-85120和和80正常高值（高血压前期）正常高值（高血压前期）(High-Normal)120-139或或80-89130-149或或80-89120-139或或80-89高血压高血压(Hypertension)1级级(STAGE1)140-159或或90-99140-159或或90-99140-159或或90-992级级(STAGE2)160或或100160-179或或100-109160-179或或100-1093级级(STAGE3)180或或110 180或或110单纯收缩期高血压单纯收缩期高血压(ISH)140和和90 140和
11、和55岁，女性岁，女性65岁；吸烟；血脂异常；早发心血管疾病家岁；吸烟；血脂异常；早发心血管疾病家族史（一级亲属发病年龄女性族史（一级亲属发病年龄女性50岁）岁）,腹型肥胖，腹型肥胖，CRP升高升高 靶器官损害：左心室肥厚（靶器官损害：左心室肥厚（ECG或超声心动图）；蛋白尿和或超声心动图）；蛋白尿和/或血肌酐轻度升高（或血肌酐轻度升高（106-177 mol/L）；超声或）；超声或X线证实有动脉粥样硬化；视网膜动脉局灶或广泛狭窄线证实有动脉粥样硬化；视网膜动脉局灶或广泛狭窄 并发症：心脏疾病；脑血管疾病；肾脏疾病；血管疾病；重度高血压性视网膜病变并发症：心脏疾病；脑血管疾病；肾脏疾病；血管疾
12、病；重度高血压性视网膜病变继发性高血压（secondary hypertension）n定义：由某些确定的疾病或病因引起的血压升高n主要病因 慢性肾脏疾病（chronic renal diseases)肾血管性高血压(renovascular hypertension)原发性醛固酮增多症(primary hyperaldosteronism)嗜铬细胞瘤(pheochromocytoma)库欣综合症（cushingssyndrome)睡眠呼吸暂停综合症（Obstructive sleep apnea）主动脉缩窄（Coarctation of the aorta)药源性高血压（Drug-induc
13、ed hypertension)鉴别诊断(Differential Diagnosis)病因：病因：n chronic renal diseasesn Diabetic nephropathyn Hypertension during chronic dialysis and after renal transplantation发病机制：发病机制：n肾单位大量丢失，导致水钠潴留和细胞外容量增加nRAAS激活与排钠激素减少n高血压又加重肾小球囊内压，加重肾脏病变慢性肾脏疾病肾实质性高血压n原发性高血压伴肾脏损害的鉴别原发性高血压伴肾脏损害肾实质性高血压长时间高血压控制不佳后出现肾功能异常肾功能
14、不良后出现高血压肾小管浓缩功能障碍（夜尿、低比重尿）肾小球滤过功能障碍（蛋白尿）面色红润面色苍白（合并贫血）血压较容易控制血压高且难以控制治疗：治疗：(treatment)(treatment)nSodium intake 3g/dnGoal BP,130/80mmHgnACEI或ARB肾实质性高血压 Two major forms:atherosclerosis,Fibromuscular dysplasiasnClinical clues:onset of hypertension before 30 or after 50 years of age Abrupt onset of hyp
15、ertension Severe or resistant hypertention Symptoms of AS disease elsewhere Smoker orsening renal function with ACEI Abdominal or flank bruit Tests:ultrasonography,magnetic resonance angiography,CT scan,Angiography.(gold standard test)肾血管性高血压renovascular hypertension治疗：治疗：treatmenttreatmentn 经皮肾动脉成形
16、术n 手术治疗：血运重建；肾移植；肾切除n 药物治疗:不适宜上述治疗的可采用药物治疗n 双侧肾动脉狭窄、肾功能已受损或非狭窄侧肾功能较差的患者禁用ACEI或ARB肾血管性高血压病因及发病机理：病因及发病机理：肾上腺皮质增生或肿瘤分泌过多的醛固酮，导致水钠潴留所致(aldosterone-producing adenoma70-80%,idiopathic hyperaldosteronism 20-30%.诊断：诊断：excessive production of aldosterone,excessive production of aldosterone,sodium retention,
17、weight sodium retention,weight gain,hypertension,hypokalemia and metabolic alkalosis,gain,hypertension,hypokalemia and metabolic alkalosis,多数患者长期低血钾，有无力、周期性麻痹、烦渴、多尿等症,血压轻、中度升高 实验室检查低血钾、高血钠、代碱,血浆肾素活性降低，血尿醛固酮增多（醛固酮/肾素 ）,超声、放射性核素、CT可确定病变性质和部位。治疗治疗：首选手术治疗 肾上腺皮质增生术后仍需降压治疗，宜选择螺内酯和长效钙拮抗剂原发性醛固酮增多症primary hy
18、peraldosteronism病因：病因：the 4th leading cause of congenital heart disease诊断：诊断：nDiminished femoral pulses and a systolic pressure gradient between BPs obtained in the arms and legs上肢血压增高而下肢血压不高或反而降低nA loud systolic murmur 肩胛间区、胸骨旁、腋部有侧枝循环的动脉搏动和杂音、腹部听诊血管杂音n3 sign:胸片见肋骨受侧支动脉侵蚀引起的切迹nDefinite diagnosis re
19、quires aortography;主动脉造影可确定诊断治疗：治疗：surgery 主动脉缩窄Coarctation of the aorta)发病机制：发病机制：90%arise from adrenal gland,嗜铬细胞间歇或持续释放过多肾上腺素、去甲肾上腺素、多巴胺诊断：诊断：n five Hs:hypertension,headache,hypermetabolism,hyperhydrosis,hyperglycemia,典型的发作表现为阵发性血压升高伴心动过速sinus tachycardia、头痛、出汗、面色苍白n24-hr urine for metanephrines,
20、VMA,catecholamines.此时血尿儿茶酚胺及其代谢产物VMA(3-甲氧基4羟基苦杏仁酸）显著升高n 超声、放射性核素、CT或磁共振等可作定位诊断治疗：治疗：大多为良性，首选手术治疗；不能手术者选用和受体阻滞剂联合降压嗜铬细胞瘤pheochromocytoma 发病机制：发病机制：促肾上腺皮质激素分泌过多导致肾上腺皮质增生或者肾上腺皮质腺瘤，引起糖皮质激素过多所致。诊断：诊断：nClassic physical findings:Central obesity,moon facies,buffalo hump,purple stiae 向心性肥胖、满月脸、水牛背、皮肤紫纹、毛发增多等
21、n血糖增高、24小时尿17羟、17酮类固醇增多、地塞米松抑制试验、肾上腺皮质兴奋试验可帮助诊断n 放射性核素、CT或颅内蝶鞍x线检查可作定位诊断治疗：治疗：手术、放射、药物治疗；利尿剂或合并其他降压药皮质醇增多症hypercortisolism（Cushing syndrome)Differential Diagnosis)n睡眠呼吸暂停综合症（Obstructive sleep apnea）:is associated with cardiovascular abnormalities,including myocardial infarction,left ventricular hype
22、rtrophy.nContinuous postive airway pressure is effective therapy.nAntihypertensive medications should be prescribed if daytime hypertension persists.(Differential Diagnosis)n药源性高血压（Drug-induced hypertension)nOral contracceptive pills(estrogen-containing),anti-inflamamtory drugs(NSAIDs),steroids,anti
23、depressants,Nasal decongestannts,cocaine,Cyclosporine,nSALT AND WATER retention.n Clinical features:mild hypertension,in some,it may accelerate rapidly and cause severe renal damage BP falls to normal if the pills is discontinued.治疗（Ttreatment）（一）Target BP 140/90 mmHg,120或130mmHg,伴有重要脏器组织的严重功能障碍或不可逆
24、性损害,以是否伴有靶器官受损分为高血压急症和高血压亚急症(MI,HF,CEREBROVASCULAR AND RENAL DISEASE)高血压危象（hypertensive crisis)n治疗原则：rapid,control,appropiate 迅速降低血压intravenous furosemide is needed（可静脉使用硝普钠nitroprusside、硝酸甘油nitroglycerin、尼卡地平nicardipine等）控制性降压(降压速度：intravenous 1-2days-oral，12周内降至正常）合理选择降压药物 n脑出血：当血压极度升高（200/130mmHg
25、）时才考虑严密血压监测下进行降压治疗，目标值不能低于160/100 mmHg 硝普钠nitroprussiden脑梗死：血压不太高时，一般不做降压处理n急性冠脉综合征：可选择硝酸甘油或地尔硫卓静滴，也可口服受体阻滞剂和ACEI，血压控制目标是疼痛消失，舒张压100mmHgn急性左心衰：硝普钠、硝酸甘油是最佳选择，必要时应静注袢利尿剂n急性主动脉夹层：nitroprusside，B-blocker.几种常见高血压急症的处理原则1.掌握高血压判断标准，原发性高血压（高血压病）的临床表现、诊断、鉴别诊断及治疗原则2.熟悉降压药物种类及特点；降压药物的选择和联合用药3.了解原发性高血压的发病机制，高血压急症的治疗目的和要求复习思考题1.中国高血压联盟制订的血压判别标准是什么？2.常见的继发性高血压有哪几种？各有什么临床特点？3.如何诊断原发性高血压？4.原发性高血压的治疗原则是什么？常用降压药物有哪几类？5.高血压急症如何处理？
