中国高血压防治指南培训手册

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1、D Definitionefinition Hypertension is defined as a SBP of Hypertension is defined as a SBP of 140 mmHg or greater and/or a DBP of 90 140 mmHg or greater and/or a DBP of 90 mmHg or greater in subjects who are mmHg or greater in subjects who are not taking antihypertensive medication.not taking antihy

2、pertensive medication.95%Essential or primary hypertension95%Essential or primary hypertension 5%Secondary hypertension 5%Secondary hypertension EpidemiologyPrevalence rate（患病率）（患病率）of hypertension in China:In 1959-5.11%In 1979-7.73%In 1991-11.88%In 2004-18.80%The prevalence of high BP increases wit

3、h age.Hypertension is more common in men than in women up to age 50,after that age,hypertension is more common in women.Hypertension is more common in northern China than in southern China.Etiology and pathogenesis of EHEtiology and pathogenesis of EH No cause can be established Possible factors Gen

4、etic tendency Spontaneous hypertension rat EH tends to cluster in families Environemnts 高血压高血压遗遗 传传 环环 境境 高高 盐盐 饮饮 食食肥胖肥胖精神压力过重精神压力过重饮饮 酒酒体育锻炼少体育锻炼少 Pathogenesis of EHPathogenesis of EH sympathetic nervous system activity RAAS 肾脏潴钠肾脏潴钠 Vessel remolding Vascular endothelium dysfunction nitric oxide e

5、ndothelin Insulin resistance(胰岛素抵抗胰岛素抵抗)sodium reabsorption,sympathetic nervous system activity,intracellular Na Ca 病病 理理 血管：全身细小动脉病变血管：全身细小动脉病变大中大中动脉病变动脉病变 心：左心室后负荷增加心：左心室后负荷增加心肌肥厚心肌肥厚 与扩大与扩大心力衰竭；动脉粥样硬化心力衰竭；动脉粥样硬化 脑：脑小动脉硬化。脑血栓、脑出血、脑：脑小动脉硬化。脑血栓、脑出血、脑水肿脑水肿 肾：肾细小动脉硬化。肾单位萎缩肾：肾细小动脉硬化。肾单位萎缩 肾功能衰竭肾功能衰竭Cli

6、nical findingsClinical findingsBPBP波动波动-，White coat EHWhite coat EHSymptoms-Symptoms-Mild to moderate EH is usually associated with normal health for many years.Some patients have headache,tinnitus（耳鸣）耳鸣）,palpitation,tiredness（疲劳）疲劳）,and so on.Signs-Signs-BP is elevated.Some patients have a loud aor

7、tic second sound and an early systolic ejection click(收缩期喷射喀喇音收缩期喷射喀喇音).).Clinical Clinical findingsfindings(Continue(Continue)Complications:Hypertensive cardiovascular disease,CHD Hypertensive cerebrovascular disease Hypertension is the major predisposing cause of stroke.Hypertensive renal disease

8、Chronic hypertension leads to nephrosclerosis(肾肾硬化症硬化症)Aortic dissection（主动脉夹层）（主动脉夹层）blood pressure measurementblood pressure measurement WHOWHO不同测量方法的高血压定义不同测量方法的高血压定义 SBP DBPSBP DBP 诊室偶测血压诊室偶测血压 140 90 140 90 在家测量血压在家测量血压 135 85 135 852424小时动态测压小时动态测压 130 80 130 80 Normal reference of ABPM(24h Da

9、ytime Nighttime SBP DBP SBP DBP SBP DBPStaessen 133 82 140 88 125 76JNC-7 135 85 120 75China3 130 80 135 85 125 75 Routine investigationsUrinalysis（尿液检查）（尿液检查）Serum potassium,BUN（尿素氮（尿素氮),Cr（肌（肌苷苷),Serum uric acid(尿酸尿酸),Fasting glucose,Plasma cholesterol,and so on.ECGUCG ventricular hypertrophyChest

10、 X-ray ventricular enlargementFunduscopic examination retina arteriolar narrowing arteriovenous nicking(动静脉交叉压迫动静脉交叉压迫)hemorrhage,exudate(渗出渗出)papilledema(视神经乳头水肿视神经乳头水肿)Diagnosis&differential diagnosisDiagnosis&differential diagnosisTo confirm a chronic elevation of blood pressure and determine its

11、 levelTo identify secondary causes of hypertension To determine the presence of target-organ damage and to quantify its extentTo search for other cardiovascular risk factors&clinical conditions that may influence prognosis&treatmentC Classificationlassification of Blood Pressure Levels(mmHg)of Blood

12、 Pressure Levels(mmHg)Category Systolic DiastolicOptimal 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 hypertension(severe)180 110 Isolated systolic hypertension 140 90 Subgrou

13、p:borderline 140-149 90 2003 美国美国JNC-7 血压水平分类血压水平分类80和和100或或1602 期高血压期高血压舒张压舒张压mmHg收缩压收缩压mmHg血压分类血压分类中国中国2004高血压指南高血压指南 类类 别别 收缩压收缩压(mmHg)舒张压舒张压(mmHg)正常血压正常血压 120 80 正常高值正常高值 120139 8089 高血压高血压 140 90 1级高血压（轻度级高血压（轻度)140159 9099 2级高血压级高血压(中度中度)160179 100109 3级高血压级高血压(重度重度)180 110 单纯收缩期高血压单纯收缩期高血压 14

14、0 55 yearsWomen65 yearsSmokingTC5.72mmol/L DiabetesFamily history of premature cardiovascular disease（早发心血管病家族史）早发心血管病家族史）（Men55 years，Women177mol/L）Vascular diseaseVascular diseaseDissecting aneurysmArtery diseaseAdvanced hypertensive Advanced hypertensive retinopathyretinopathyHemorrhage or exudat

15、esPapilledema高血压高血压危险度分层危险度分层 其他危险其他危险因素和病史因素和病史血压血压1级级轻度高血压轻度高血压SBP140-159或或DBP90-992级级中度高血压中度高血压SBP160-179DBP100-1093级级重度高血压重度高血压SBP180DBP110I 无其他危险因素无其他危险因素II 1-2个危险因素个危险因素III 3个危险因素或个危险因素或 TOD或糖尿病或糖尿病IV ACC低危低危中危中危高危高危极高危极高危中危中危中危中危高危高危极高危极高危高危高危极高危极高危极高危极高危极高危极高危Secondary hypertensionSecondary

16、hypertension It is a hypertension of known cause.The importance of identifying patients with SH is that they can sometimes be cured by surgery or by specific medical treatment.Renal Renal parenchymalparenchymal diseases diseases The most common causes of SH Any diseases of the renal parenchyma(肾实肾实质

17、质):glomerulonephritis(肾小球肾小球肾炎肾炎),diabetic nephropathy(肾病肾病),polycystic kidneys(多囊肾多囊肾).).Most cases are related to increased intravascular volume or increased activity of the RASRenovascularRenovascular hypertension hypertensionDiagnostic clues:The onset is below age 20 or after age 50 The hyperten

18、sion is difficult to control Upper abdominal bruit(杂音杂音)Abrupt deterioration（恶化）恶化）in renal function after administration of ACEIRenal angiography（肾肾血管造影术）血管造影术）is the best diagnostic test.PheochromocytomaPheochromocytoma(嗜铬细胞瘤嗜铬细胞瘤)Clinical clues:Paroxysmal（阵发性）阵发性）hypertensionEpisodes of diaphores

19、is(出汗出汗),),palpitation,headache,pallor(苍白苍白)。Laboratory investigations:Blood catecholamines（儿茶酚胺）are elevatedUrinary vanillylmandelic acid（香草基杏任酸）CT or MRI(magnetic resonance imaging)Primary hyperaldosteronism Slight to moderate blood pressure elevated Episodes of generalized muscular weakness or pa

20、ralysis(瘫痪瘫痪)polyuria and nocturia(夜尿)Hypokalemia Aldosterone（醛固酮）醛固酮）concentrations in urine Patients with a solitary(孤立的孤立的)adenoma(腺瘤腺瘤)should undergo resection of the tumor Patients with bilateral adrenal hyperplasia(增生增生)are treated with spironolactone(螺内酯螺内酯)Other causes of secondary Other cau

21、ses of secondary hypertensionhypertension Cushings syndrome Coarctation of the aorta(主动脉缩窄主动脉缩窄)Drug use Pregnancy(妊娠妊娠)Treatment strategies&risk stratificationTreatment strategies&risk stratificationLow-risk group:monitor BP and other risk factors for 6-12 months，if goal BP is not attained,drug tre

22、atment should be initiated.Medium-risk group:monitor BP and other risk factors for 3-6 months，if goal BP is not attained,begin drug treatment High-risk group&Very-high-risk group:should begin drug treatment Lifestyle modification should be used in all hypertensive patientsTreatmentTreatment To achie

23、ve high normal BP(140/90 mmHg)in elderly patients To achieve normal BP(130/80mmHg)in young,middle-aged or diabetic subjects Include:Weight reduction Complex dietary changes Increased physical activity Moderation of alcohol consumption Smoking cessation Others(psychologic equilibrium)The use of low d

24、oses of drugs to initiate therapyThe use of long-acting drugs providing 24h efficacy on a once-daily basisThe use of appropriate drug combinations to maximize hypotensive efficacy while minimizing side effectsSix main drug classesSix main drug classesDiuretics(利尿剂利尿剂):DHCT,Furosemide(呋塞米呋塞米)-blocker

25、s:Atenolol,Metoprolol Ca antagonists:Nifedipine,Amlodipine ACE inhibitors:Enalapril,Captopril AII antagonists:Losartan,Valsartan -blockers:Prazosin,Terazosin Indication Drug treatment Diabetes with proteinuria ACEI,ARBHeart failure ACEI,ARB,diureticsIsolated systolic hypertension Diuretics,Ca blocke

26、rsMyocardial infarction -blocker,ACEI,ARBAngina -blocker,Ca blockersBenign prostatic hyperplasia -blocker Dyslipidemia -blocker Tachyarrhythmias -blocker,Ca blockers 高血压药物治疗步骤高血压药物治疗步骤第一步：单药应用第一步：单药应用 根据病情，选择一种一线药物，从小剂量开始，根据病情，选择一种一线药物，从小剂量开始，逐步达到有效剂量。逐步达到有效剂量。方案选择：选用下列药物中的一种方案选择：选用下列药物中的一种利尿剂利尿剂（双克

27、、吲哒帕胺）、（双克、吲哒帕胺）、受体阻滞剂、受体阻滞剂、CCBCCB、ACEIACEI、ARB ARB。JNC-7 JNC-7推荐噻嗪类利尿剂可作为大多数无合并症的推荐噻嗪类利尿剂可作为大多数无合并症的高血压患者的首选，但在有合并症存在的高危情况高血压患者的首选，但在有合并症存在的高危情况下，应首选其它类型的降压药。下，应首选其它类型的降压药。第二步第二步 联合用药联合用药利尿药利尿药ACE抑制剂抑制剂 钙拮抗剂钙拮抗剂 阻滞剂阻滞剂AT1受体阻滞剂受体阻滞剂 阻滞剂阻滞剂高血压危象高血压危象（Hypertensive crisisHypertensive crisis）高血压急症（高血压急症（Hypertensive urgencies）急进型恶性高血压急进型恶性高血压 血循环儿茶酚胺水平过高血循环儿茶酚胺水平过高 围手术期高血压围手术期高血压 高血压危症（高血压危症（Hypertensive emergencies）伴急性靶器官损害伴急性靶器官损害治疗要点治疗要点 静脉给药静脉给药 口服给药，长期控制；口服给药，长期控制；综合治疗，因病、因人而异；综合治疗，因病、因人而异；降压迅速降压迅速-适度；适度；高血压危症应立即降压；高血压急症在数小高血压危症应立即降压；高血压急症在数小时至时至24小时逐渐降血压降至安全水平。小时逐渐降血压降至安全水平。