1、IntroductionHypertension is a major public health problem throughout the world because of its high prevalence and its association with increased risk of cardiovascular disease.Approximately 100 million Chinese have elevated BP.Of these,77%are aware of their diagnosis,70%are receiving treatment,and o
2、nly 33%are under control.Definition Hypertension is defined as a SBP of 140 mmHg or Hypertension is defined as a SBP of 140 mmHg or greater and/or a DBP of 90 mmHg or greater in greater and/or a DBP of 90 mmHg or greater in subjects who are not taking antihypertensive subjects who are not taking ant
3、ihypertensive medication.medication.Essential or primary hypertension is a Essential or primary hypertension is a hypertension of hypertension of ununknown cause.known cause.Isolated systolic hypertension is defined as SBP Isolated systolic hypertension is defined as SBP of 140 mmHg or greater and d
4、iastolic BP less than 90 of 140 mmHg or greater and diastolic BP less than 90 mmHg.mmHg.Classification of Blood Pressure Levels(mmHg)Category Category Systolic DiastolicSystolic DiastolicOptimal 120 80Normal 130 85High-normal 130-139 85-89Grade 1 hypertension(mild)140-159 90-99 Subgroup:borderline 1
5、40-149 90-94Grade 2 hypertension(moderate)160-179 100-109Grade 3 hypertension(severe)180 110 Isolated systolic hypertension 140 90 Subgroup:borderline 140-149 90 Notes1.When a patients SBP and DBP fall into different categories,the higher category should apply.e.g.154/100 mmHg is defined as grade 2
6、hypertension.180/82 mmHg is defined as grade 3 isolated systolic hypertension.Notes(Continue)2.BP is based on the average of two or more readings taken at each of two or more visits after an initial screening(筛查).e.g.12/2 first visit:172/102 mmHg,168/104 mmHg.13/2 second visit:158/98 mmHg,158/96mmHg
7、.The average BP is 164/100 mmHg,which is defined as grade 2 hypertension.Notes(continue)3.The patient should be clearly informed that a single elevated reading does not constitute a diagnosis of hypertension but is a sign that further observation is required.For instance:21/3 1st visit:146/98mmHg,15
8、0/98mmHg23/3 2nd visit:128/84,126/8027/3 3rd visit:130/80,130/82 Notes(continue)4.Optimal BP with respect to cardiovascular risk is less than 120/80 mmHg.However,unusually low readings should be evaluated for clinical significance.For example,70/50 mmHg is less than 120/80 mmHg,but it is not optimal
9、.Classification of Blood Pressure Levels(mmHg)Category Category Systolic DiastolicSystolic DiastolicHypotension?90 60Optimal 120 80Normal 130 85High-normal 130-139 85-89Grade 1 hypertension(mild)140-159 90-99 Subgroup:borderline 140-149 90-94Grade 2 hypertension(moderate)160-179 100-109Grade 3 hyper
10、tension(severe)180 110 Isolated systolic hypertension 140 90 Subgroup:borderline 140-149 90 EpidemiologyPrevalence ratePrevalence rate（患病率）of hypertension in China:of hypertension in China:In 1959,In 1959,5.11%5.11%In 1979,In 1979,7.73%7.73%In 1991,11.88%In 1991,11.88%The prevalence of high BP incre
11、ases with age.The prevalence of high BP increases with age.Hypertension is more common in men than in women Hypertension is more common in men than in women up to age 50,after that age,hypertension is up to age 50,after that age,hypertension is more common in women.more common in women.Hypertension
12、is more common in northern China than Hypertension is more common in northern China than in southern China.in southern China.Etiology and pathogenesis of EHNo cause can be establishedNo cause can be establishedPossible mechanismsPossible mechanisms Genetic tendencyGenetic tendency Spontaneous hypert
13、ension ratSpontaneous hypertension rat EH tends to cluster in familiesEH tends to cluster in families High salt intakeHigh salt intake some hypertensives some hypertensives VascularVascular endotheliumendothelium dysfunction dysfunction nitric oxidenitric oxide endothelinendothelin Pathogenesis of E
14、H(Continue)Insulin Insulin resistance(resistance(胰岛素抵抗胰岛素抵抗)sodium reabsorptionsodium reabsorption,sympathetic nervous,sympathetic nervous system activitysystem activity,intracellular Na Caintracellular Na Ca Cigarette smoking Cigarette smoking by increasing plasma norepinephrine(by increasing plasm
15、a norepinephrine(去甲肾上腺素)Excessive use of alcoholExcessive use of alcohol p e r h a p s b y i n c r e a s i n g p l a s m a p e r h a p s b y i n c r e a s i n g p l a s m a catecholaminescatecholamines儿茶酚胺S o,t h e p a t h o g e n e s i s o f E H i s S o,t h e p a t h o g e n e s i s o f E H i s mul
16、tifactorialmultifactorial.Clinical findingsSymptoms:Symptoms:Mild to moderate EH is usually associated Mild to moderate EH is usually associated with normal health for many years.with normal health for many years.Some patients have headache,tinnitus Some patients have headache,tinnitus（耳耳鸣）鸣）,palpit
17、ationpalpitation,tirednesstiredness（疲劳）疲劳）,and so and so on.on.Signs:Signs:BP is elevated.BP is elevated.Some patients have a loud aortic second sound Some patients have a loud aortic second sound and an early systolic ejection clickand an early systolic ejection click(收缩期喷射喀喇音).Clinical findings(Co
18、ntinue)Complications:Complications:Hypertensive cardiovascular diseaseHypertensive cardiovascular disease Hypertensive cerebrovascular disease Hypertensive cerebrovascular disease Hypertension is the major predisposing Hypertension is the major predisposing cause of stroke.cause of stroke.Hypertensi
19、ve renal diseaseHypertensive renal disease C h r o n i c h y p e r t e n s i o n l e a d s t o C h r o n i c h y p e r t e n s i o n l e a d s t o nephrosclerosis(nephrosclerosis(肾硬化症)Aortic dissection Aortic dissection Routine investigationsRoutine investigationsHemoglobin,urinalysis&renal function
20、 studies,Hemoglobin,urinalysis&renal function studies,to detect hematuria,proteinuria,and casts,to detect hematuria,proteinuria,and casts,Serum potassium,since hypokalemia Serum potassium,since hypokalemia is typical of is typical of hyperaldosteronismhyperaldosteronism（醛固酮增多症）醛固酮增多症）Fasting glucose
21、,since hyperglycemia is noted Fasting glucose,since hyperglycemia is noted in diabetes and pheochromocytomain diabetes and pheochromocytoma（嗜铬细胞瘤）嗜铬细胞瘤）Plasma cholesterol Plasma cholesterol,as an indicator of as an indicator of atherosclerosisatherosclerosis riskriskSerum uric acid(Serum uric acid(尿
22、酸),since if elevated it is,since if elevated it is a contraindication to diuretic therapya contraindication to diuretic therapyElectrocardiography,Electrocardiography,to detect ventricular to detect ventricular hypertrophyhypertrophyChest X-ray,to detect left ventricular Chest X-ray,to detect left v
23、entricular enlargementenlargementFunduscopic examination:Funduscopic examination:retina arteriolar narrowing retina arteriolar narrowing arteriovenous nicking(arteriovenous nicking(动静脉交叉压迫)hemorrhage,exudate(hemorrhage,exudate(渗出)papilledema(papilledema(视神经乳头水肿)Optional investigationsOptional invest
24、igations Plasma reninPlasma renin(肾素肾素)activity&aldosterone activity&aldosterone(醛固酮),urinary VMAurinary VMA（香草杏仁酸），to identifyto identify secondary hypertensionsecondary hypertension Echocardiography,to detect ventricular Echocardiography,to detect ventricular hypertrophyhypertrophy Vascular ultras
25、onography should be Vascular ultrasonography should be performed if arterial disease is performed if arterial disease is suspected.suspected.Renal ultrasonography should be Renal ultrasonography should be performed if renal disease is suspected.performed if renal disease is suspected.Clinic blood pr
26、essure measurementWith the patients sitting after 5 or more With the patients sitting after 5 or more minutes of rest.minutes of rest.Two or three measurements should be taken at Two or three measurements should be taken at each visit.each visit.The systolic reading is taken as the level of The syst
27、olic reading is taken as the level of BP at which clear sounds are heard with each BP at which clear sounds are heard with each heartbeat.The diastolic reading is taken at heartbeat.The diastolic reading is taken at the level when sounds the level when sounds disappeardisappear.Ambulatory BP monitor
28、ing(动态血压监测)Noninvasive automatic device is available for ambulatory BP monitoring over periods of 24 h or more.ABPM offers the advantages of providing a more realistic setting for BP measurements.There are limited data available about the prognostic value of ABPM.ABPM is not a substitute for office
29、measurement.Normal reference of ABPM(2424h h Daytime NighttimeDaytime Nighttime SBP DBP SBP DBP SBP DBPStaessen1 133 82 140 88 125 76JNC-VI2 135 85 120 75China3 130 80 135 85 125 751.J Hyperten.1994;12:(Suppl 7):S1;2.Arch Intern Med.1997;157:2413;3.中华心血管杂志，1995；23：325。Unusual variability of blood pr
30、essure over Unusual variability of blood pressure over the same or different visitsthe same or different visitsOffice or white coat hypertensionOffice or white coat hypertension(白大衣性高血压)Symptoms suggesting hypotensive episodesSymptoms suggesting hypotensive episodesHypertension resistant to drug tre
31、atmentHypertension resistant to drug treatmentDiagnosis&differential diagnosisTo confirm a chronic elevation of blood pressure To confirm a chronic elevation of blood pressure and determine its leveland determine its levelTo determine the presence of target-organ damage To determine the presence of
32、target-organ damage and to quantify its extentand to quantify its extentTo search for other cardiovascular risk factors&To search for other cardiovascular risk factors&clinical conditions that may influence prognosis&clinical conditions that may influence prognosis&treatmenttreatmentTo identify seco
33、ndary causes of hypertensionTo identify secondary causes of hypertensionClassification of hypertension(mmHg)Category Category Systolic DiastolicSystolic DiastolicGrade 1 hypertension(mild)140-159 90-99 Subgroup:borderline 140-149 90-94Grade 2 hypertension(moderate)160-179 100-109Grade 3 hypertension
34、(severe)180 110 Isolated systolic hypertension 140 90 Subgroup:borderline 140-149 55 yearsMen55 yearsWomen65 yearsWomen65 yearsSmokingSmokingTC5.72mmol/L TC5.72mmol/L DiabetesDiabetesFamily history of premature cardiovascular Family history of premature cardiovascular diseasedisease（早发心血管病家族史）（Men55
35、 yearsMen55 years，Women65 yearsWomen177mol/L）Vascular diseaseDissecting aneurysmAdvanced hypertensive retinopathyHemorrhage or exudatesPapilledema Blood Pressure（mmHg）Other Risk Factors Grade 1 Grade 2 Grade 3&Disease History SBP140-159 SBP160-179 SBP180 or or DBP90-99 or DBP100-109 DBP110I no other
36、 risk factors Low Risk MED Risk High RiskII 1-2 risk factors MED Risk MED Risk Very-High-RiskIII 3 risk factors or TOD High Risk High Risk Very-High-Risk or DiabetesIV ACC Very-High-Risk Very-High-Risk Very-High-RiskTreatment strategies&risk stratificationLow-risk group:monitor BP and other Low-risk
37、 group:monitor BP and other risk factors for 6 monthsrisk factors for 6 months，if goal BP is if goal BP is not attained,drug treatment should be not attained,drug treatment should be initiated.initiated.Medium-risk group:begin drug Medium-risk group:begin drug treatmenttreatment High-risk group&Very
38、-high-risk group:High-risk group&Very-high-risk group:should begin drug treatmentshould begin drug treatment Lifestyle modification should be used Lifestyle modification should be used in all hypertensive patientsin all hypertensive patientsExampleA patient with diabetesA patient with diabetes（糖尿病）&
39、BP of BP of 140/94 mmHg plus left ventricular 140/94 mmHg plus left ventricular hypertrophy hypertrophy should be classified as having grade 1 should be classified as having grade 1 hypertension with target organ disease hypertension with target organ disease and with another major risk factor.and w
40、ith another major risk factor.would be categorized as“grade 1 would be categorized as“grade 1 hypertension,high-risk”hypertension,high-risk”would be recommended for immediate would be recommended for immediate initiation of drug treatment and also initiation of drug treatment and also lifestyle modi
41、ficationlifestyle modificationTreatment发病率)死亡率)To achieve high normal BP(below 140/90 To achieve high normal BP(below 140/90 mmHg)in elderly patientsmmHg)in elderly patients To achieve normal BP(below 130/85mmHg)in To achieve normal BP(below 130/85mmHg)in young,middle-aged or diabetic subjectsyoung,
42、middle-aged or diabetic subjects S Should be used in all hypertensive patients,hould be used in all hypertensive patients,either as definitive treatment or as an adjunct either as definitive treatment or as an adjunct to drug therapy.to drug therapy.Should be tailored to the individual Should be tai
43、lored to the individual characteristics of each patient,such as weight characteristics of each patient,such as weight reduction for an overweight patient.reduction for an overweight patient.I Include:nclude:Weight reductionWeight reduction Complex dietary changesComplex dietary changes Increased phy
44、sical activityIncreased physical activity Smoking cessationSmoking cessation OthersOthers Weight reductionWeight reductionThrough a combination of dietary caloric Through a combination of dietary caloric restriction&increased physical restriction&increased physical activityactivitySustained weight r
45、eduction is so Sustained weight reduction is so difficult to achieve,so,more emphasis difficult to achieve,so,more emphasis should be placed on prevention of weight should be placed on prevention of weight gain.gain.Patients should avoid appetite Patients should avoid appetite suppressant drugsuppre
46、ssant drug（食欲抑制药）食欲抑制药）and diet and diet pillpill(减肥药丸减肥药丸)Complex dietary changes Complex dietary changes Reduction in salt intake Reduction in salt intake 6 6g/d of sodium chloride(3g/d of sodium chloride(3*6 6*30=540)30=540)Reducing fat intakeReducing fat intake Increasing fruit and vegetableIncr
47、easing fruit and vegetable Moderation of alcohol consumptionModeration of alcohol consumption for a heavy drinkerfor a heavy drinkerIncreased physical activityIncreased physical activity Regular aerobic physical activity can Regular aerobic physical activity can lower BP and is recommended for all l
48、ower BP and is recommended for all hypertensive individuals.hypertensive individuals.Patients with advanced cardiovascular Patients with advanced cardiovascular disease may require medical evaluation disease may require medical evaluation before initiation of exercisebefore initiation of exerciseKee
49、ping psychologic equilibriumKeeping psychologic equilibriumSmoking cessationSmoking cessationThe use of low doses of drugs to initiate The use of low doses of drugs to initiate therapytherapyThe use of long-acting drugs providing 24h The use of long-acting drugs providing 24h efficacy on a once-dail
50、y basisefficacy on a once-daily basisThe use of appropriate drug combinations to The use of appropriate drug combinations to maximize hypotensive efficacy while minimizing maximize hypotensive efficacy while minimizing side effectsside effectsSix main drug classesDiureticsDiuretics(利尿剂):DHCT,Furosem
