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Diseases of Circulatory System Hypertension Prof. Shen-Jiang Hu 讲授目的和要求 掌握高血压的诊断标准、危险分层和治疗 原则。 熟悉降压药物的种类及特点；降压药物的 选择和联合用药。 了解高血压的患病率、病因、发病机制和 并发症；以及较常见的几种继发性高血压。 教材及参考书 1、《内科学》，王吉耀主编，人民卫生 出版社 2、《实用高血压学》余振球等主编，科 学出版社 3、《现代内科学英语精要》王吉耀、刘 文忠摘编，人民卫生出版社 教学网站网址 《内科学》校级精品课程： http://10.15.11.50/kj/298/ 《内科学》省级精品课程： http://10.15.11.61/eln/2007051114434001 25/index.jsp?cosid=1033 Blood Pressure has a unimodal distribution in the Population “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 “高血压可能是一个重要的代偿机制，即使我们能够控制它，也不应 该处理它。” “The greatest danger 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 人类对高血压认识的历史 2003年 1970年 认识到高血压与卒中的关系 1980年 JNC VII：降压达标对减 少各类患者的心血管事 件至关重要 JNC II将舒张压作为确诊高 血压的和治疗建议的基础 世界卫生组织将“降 压要达标”作为高血 压日的宣传口号 2006年 1961年 1992年 Framingham心脏研 究：最早认识到 JNC V收缩压与舒 张压同等重要 高血压与心脏病 1978年 的关系 世界卫生组织首次提出 高血压阶梯治疗方案 2005年 中国高血压治疗指南更 新：降压药物治疗目标 在于，降低血压使其达 到相应病人的目标水平 Complications of Hypertension Atrial Fibrillation Heart LV Failure Hypertrophy MI Hypertensive Encephalopathy Aortic Dissection Hypertension CHD Dementia Chronic Renal failure Ischemic Cerebral Infarction Intracerebral Hemorrhage The Relationship between Blood Pressure and Cardiovascular Events Definition of Hypertension Hypertension is a clinical syndrome, defined as systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg. Hypertension should be considered a major risk factor for an array of cardiovascular and related disease as well as diseases leading to a marked increase in cardiovascular risk. 。 Hypertension in China(1991) ≥15% ≥10%~14.9% ＜10% 黑龙江 吉林 河北 北京 新疆 内蒙古 宁夏 青海 甘肃 西藏 天津 山东 陕西 山西 辽宁 江苏 河南 安徽 湖北 四川 江西 湖南 贵州 云南 上海 浙江 广西 福建 广东 台湾 海南 我国城市1999年前10位死亡原因 死亡原因 死亡率 占总死亡 死亡原因 1/10万 % 226.1 38.5 内分泌，代谢 - 脑血管病 127.2 21.6 - 心脏病 98.9 恶性肿瘤 死亡率 占总死亡 1/10万 % 营养，免疫病 16.9 2.9 16.8 泌尿生殖病 8.9 1.5 40.5 23.9 精神病 6.7 1.1 呼吸系病 81.7 13.9 神经病 5.3 0.9 损伤，中毒 36.9 6.3 消化系病 17.9 3.0 循环系病 中国1999年卫生统计 我国农村1999年前10位死亡原因 死亡原因 死亡专率 占总死亡 1/10万 % 186.6 30.8 - 脑血管病 111.6 - 心脏病 死亡原因 死亡率 占总死亡 1/10万 % 泌尿生殖病 9.2 1.5 18.4 * 新生儿病 810.3 1.3 75.0 12.4 (每10万出生） 呼吸系病 133.7 22.0 肺结核 7.9 1.3 恶性肿瘤 111.6 18.4 内分泌，代谢 损伤，中毒 67.0 11.0 营养，免疫病 6.4 1.0 消化系病 24.2 4.0 循环系病 中国1999年卫生统计 Trends in Awareness, Treatment, and Control of Hypertension in China Awareness(%) Treatment(%) Control(%) 1991 2002 26.6 30.2 12.2 24.7 2.9 6.1 中国心血管健康多中心合作研究 Etiology The pathogenesis of essential hypertension is multifactorial. Genetic factors play an important role. Children with one- or two-hypertensive parents have higher blood pressures. Environmental 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 levels; a combination of too much salt plus a genetic predisposition is required. Etiology Pathogenesis Sympathetic nervous system hyperactivity. It is most apparent in younger hypertensives, who may exhibit tachycardia and an elevated cardiac output. However, correlations between plasma catecholamines and blood pressure are poor. Pathogenesis Renin-angiotensin system. Renin acts on angiotensinogen to cleave of the tenamino-acid peptide angiotensin I. This peptide is then acted upon by angiotensin-converting enzyme to create the eight-amino-acid peptide angiotensin II, a potent vasoconstrictor and a major stimulant of aldosterone release from the adrenal glands. Pathogenesis Defect of natriuresis. Hypertensive patients exhibit a diminished ability to excrete a sodium load. This defect may result in increased plasma volume and hypertension. Pathogenesis Intracellular 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. Pathogenesis Exacerbating factors. The best-documented is obesity, which is associated 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. Pathology Heart. Left ventricular hypertrophy may cause or facilitate many cardiac complications of hypertension, including congestive heart failure, ventricular arrhythmias, myocardial ischemia, and sudden death. Pathology Brain. Hypertension is the major predisposing cause of stroke, especially intracerebral hemorrhage but also ischemic cerebral infarction. Pathology Kidney. Chronic hypertension leads to nephrosclerosis, a common cause of renal insufficiency. Clinical Findings Symptoms: Elevations in pressure are often intermittent early. Even in established case, the blood pressure fluctuates widely in response to emotional stress and physical activity. Clinical Findings Symptoms: Mild to moderated essential hypertension is usually associated with normal health and well-being for many years. Clinical Findings Symptoms: Suboccipital pulsating headaches, but any type of headache, may occur. Accelerated hypertension is associated with somnolence, confusion, palpitation. Signs： High blood pressure. Physical findings depend upon the duration and severity, and the degree of effect on target organs. A loud aortic second sound and an early systolic ejection click may occur. Definition and Classification of Blood Pressure Levels in different Country Category JNC 7（USA） Optimal European China <120 and <80 Normal <120 and <80 120-129 and/or 80-84 <120 and <80 High-normal 120-139 or 80-89 130-139 and/or 85-89 120-139 or 80-89 Hypertension ≥ 140 or ≥ 90 Grade I 140-159 or 90-99 140-159 and/or 90-99 140-159 or 90-99 Grade II ≥ 160 or 100 160-179 and/or 100-109 160-179 or 100-109 Grade III ≥ 180 and/or ≥ 110 ≥ 180 or ≥ 110 Isolated Systolic Hypertension ≥ 140 and <90 ≥ 140 and <90 Stratification of CV Risk Stratification of CV Risk in four categories. SBP: systolic blood pressure; DBP: diastolic blood pressure; CV: Cardiovascular events; HT: hypertension. Low, moderate, high and very high risk refer to 10 year risk of a CV fatal or non-fatal event. The term “added” indicates that in all categories risk is greater than average. OD: subclinical organ damage; MS: metabolic syndrome. The dashed line indicates how definition of hypertension may be variable, depending on the level of total CV risk. Estimate total cardiovascular risk Framingham Study：Risk for cardiovascular events over 10 years Very high >30% High Moderate 20-30% 15-20% Low <15% SCORE charts：the risk of dying from cardiovascular disease over 10 years Very high >8% High Moderate Low 5-8% 4-5% <4% Factors influencing prognosis Factors influencing prognosis Management Goals of treatment Goals of treatment 降压是硬道理！ 微小的血压差异，显著的心血管收益 － 4/3 mmHg 卒中 N＝20 888 CHD 心衰 主要CV事件 总死亡 15% 16% 15% 14% 0 -5 -10 -15 -20 -25 23% -30 治疗组间的血压差异与卒中、CHD、主要CVD事件、 CVD死亡及总死亡率风险的差异直接相关 Lancet 2003;362:1527-45 Management Lifestyle Modification Weight Loss Sodium Restriction Calcium and Potassium Supplementation High-Fiber, Low-Fat Diet Alcohol Moderation Exercise When to initiate antihypertensive treatment Based on two criteria: The level of systolic and diastolic blood pressure The level of total cardiovascular risk Initiation of antihypertensive treatment Choice of antihypertensive drugs Five major classes of antihypertensive agents – thiazide diuretics, calcium antagonists, ACE inhibitors, angiotensin receptor antagonists and β-blockers – are suitable for the initiation and maintenance of antihypertensive treatment, alone or in combination. Choice of antihypertensive drugs Choice of antihypertensive drugs Choice of antihypertensive drugs Antihypertensive treatment: Preferred drugs Antihypertensive treatment: Preferred drugs Antihypertensive treatment: Preferred drugs Compelling and possible contraindications to use of antihypertensive drugs Monotherapy versus combination therapy Monotherapy could be the initial treatment for a mild BP elevation with a low or moderate total cardiovascular risk. Monotherapy versus combination therapy A combination of two drugs at low doses should be preferred as first step treatment when initial BP is in the grade 2 or 3 range or total cardiovascular risk is high or very high. Monotherapy versus combination therapy In several patients BP control is not achieved by two drugs, and a combination of three of more drugs is required. Monotherapy versus combination therapy strategies Possible combinations between some classes of antihypertensive drugs Diuretics β-blockers ACE inhibitors α-blockers Calcium antagonists Angiotesin II antagonists Journal of Hypertension 2007, 25:1105–1187. 复习思考题 1、中国血压水平的定义和分级？ 2、如何进行高血压的危险分层？ 3、高血压的治疗原则是什么？ Thanks for your attention!
