HighBloodPressure

11.Thecommonestcardiovasculardisease(itinvolvesmorethan30%peopleindevelopedcountriesand8-30%Chinese,itis18.8%morbidityandatleast200millionpeopleadultsareinvolvedbasedonepidemiologicalsurveyin2001).

2.Itsmainproblemsaresecondarydamagesofheart,kidneysandbrain(mainriskfactorofheartdiseases,cerebralstroke,renalfailureandaortadiseases)DESCRIPTION2Hypertension

Highbloodpressure

Essentialhypertension

Primaryhypertension

SecondaryHypertensionScientificTerms3DEFINITIONSConceptualdefinitionOperationaldefinition

IncreasedIntraarteryBloodPressure4DistributionofBloodPressureinthePopulation5DEFINITIONOFHYPERTENSION

(WHO/IHA,2003)Definitionsandclassificationofbloodpressurelevels(mmHg)CategorySystolicDiastolicOptimal

12080Normal120–12980–84Highnormal130–13985–89Grade1hypertension(mild)140–15990–99Grade2hypertension(moderate)160–179100–109Grade3hypertension(severe)

>180>110Isolatedsystolichypertension

>140

906ComparisonofthedefinitionsorCriteriaofHypertensionatDifferentErasSBP140or170(twice)(once）

DBP>=90or>100(twice)(once）Normal：140/90Border：140-159/90-94Hypertension：160/95Optimal：120/80Normal：130/85highNormal：130-139/85-89Hypertension：140/90IsolatedSystolocHBP:BP140DBP<90

1959197919997DefinitionandClassificationofHypertensionofChineseHypertensionLeague(2010)ClassificationSystolicBPDiastolicBP(mmHg)(mmHg)Normal12080Highnormal120-13980-89Hypertension14090Grade1(mild)140-15990-99Grade2(moderate)160-179100-109Grade3(severe)180110IsolatedSystolicHypertension14090中國高血壓指南（2004，2010）8HowImportantisHypertension(1)beginningat115/75mmHg,CVDriskdoublesforeachincrementof20/10mmHg;thosewhoarenormotensiveat55yearsofagewillhavea90%lifetimeriskofdevelopinghypertension;prehypertensiveindividuals(systolicBP120–139mmHgordiastolicBP80–89mmHg)requirehealth-promotinglifestylemodificationstopreventtheprogressiveriseinbloodpressureandCVD;JNC-79HowimportantisHypertension(2)Foruncomplicatedhypertension,thiazidediureticshouldbeusedindrugtreatmentformost,eitheraloneorcombinedwithdrugsfromotherclasses;thisreportdelineatesspecifichigh-riskconditionsthatarecompellingindicationsfortheuseofotherantihypertensivedrugclasses(ACEinhibitors,ARBs,beta-blockers,calciumchannelblockers);JNC-710HowimportantisHypertension(3)twoormoreantihypertensivemedicationswillberequiredtoachievegoalBP(140/90mmHg,or130/80mmHg)forpatientswithdiabetesandchronickidneydisease;forpatientswhoseBPismorethan20mmHgabovethesystolicBPgoalormorethan10mmHgabovethediastolicBPgoal,initiationoftherapyusingtwoagents,oneofwhichusuallywillbeathiazidediuretic,shouldbeconsidered;regardlessoftherapyorcare,hypertensionwillbecontrolledonlyifpatientsaremotivatedtostayontheirtreatmentplan.JNC-711血壓水平的新定義和分類比較類別JNC7歐洲中國（2010）理想血壓<120及80正常血壓<120及80120-129或80-84<120及80正常高值（高血壓前期）120-139或80-89130-139或85-89120-139或80-891級高血壓（1期）140-159/90-99140-159或90-99140-159或90-992級高血壓（2期）>160/100160-179或100-109160-179或100-1093級高血壓>180或110>180或110單純收縮期高血壓>140或<90>140或<90中國高血壓指南（2010）EurHeartJ.2007;28(12):1462-536.Hypertension.2003;42:1206–125212HowtomeasureBloodpressure1.

requirementsforcuff:Children:7-8cmwide,adults:12-13cmwideand23cmlongcoveratleast2/3ofuparmand80%ofcircleofarm2.

correctplaceofcuff:2.5cmoverelbowtoleaveaspaceforstethoscope;3.

measuringmethod:inflationheightover20mmHg;

deflationspeed:2mmHg/secKorotkoffsoundandDiastolicbloodpressure13HowtomeasureBloodpressure4.

Fortheobesepeople:useforearm5.

Beforemeasuring,:bequietandrelaxatRTfor5min;6.

HowtoassessBP(confirmation):Readatleast2timesanddifferencesislessthan5mmHg.Takemeasurementatleast2weeksinterval14157.AmbulatoryBloodpressureMonitoring(ABPM):

diagnosisandassessmentoftherapeuticefficiency

Diagnosiscriteria:

DurationNormal95thpercentHypertension

24hrs<130/80133/82≥135/85

Day<135/85139/87≥140/90

Night<120/70124/74≥125/7516MorbidityisdifferentindifferentcountriesDevelopedCountries:>20%,Blacksarehigherthanwhite.Forexample,approximately50millionadultAmericanshavehypertensioninUSA.DevelopingCountries:10-20%,andkeepincreasing;InChina,themorbidityofhypertensionisapproximately15%basedontheSurveyin2001,andNorthernChinaishigherthaninSouthernChinaandCitiesishigherthaninCountryside.(5.11%,7.73%,11.88%and18.8%in1959,1979,1991and2001,respectively)Epidemiology(1)17Epidemiology(2)Theoverwhelmingmajorityofpeoplewillhavehypertensionbeforetheydie.18高血壓病的發(fā)病率-美國JNC-VI.ArchInternMed.1997;157:2413-2446.NHANESIII

高血壓的定義為140/90mmHg或在接受治療Percenthypertensive18-2930-3940-4950-5960-6970-7980+Age3%9%18%38%51%66%72%02040608019高血壓病的發(fā)病率-中國Hypertensionjournal1995;3:suppl9010203040506030354045505560657075男性女性1991年再次全國抽樣調(diào)查：發(fā)病率11.26%2000－2001年亞洲國際心血管病的大樣調(diào)查：發(fā)病率27.2%患者約1.3億患病率%年齡（歲）20EtiologyofHypertensionPrimaryhypertension:MostpopulationsofhypertensionareprimarySecondaryhypertension:Considerableproportionofhypertensivepatientshavesecondaryhypertension

Renalhypertension:

~10%

Primaryaldosteronism:higherthan10%RenovascularhypertensionSleepapneaMetabolichypertensionPheochromocytomaOralcontraceptiveuseOthers21

PathogenesisofPrimary

Hypertension

1.

Rolesofgenetics:

Estimatesofthegenetic

contributiontothevariabilityof

bloodpressurerangedfrom

30%-60%.22KnownGeneticDefects(monogenicsyndrome):

GenemutationPhenotype

l

Glucocorticoidreceptorincreasedglucocorticoidsl

Angiotensinogenincreasedangiotensinogenl

SAgeneunknownl

Lipoproteinlipaseinsulinresistancel

Glucocorticoidremediablealdosteronism(Apparentmineralocorticoidexcess):increased18-OHsteroidsl

CongenitaladrenalhyperplasiaincreasedcortisolPrecursorsl

Polycystickidneydiseaserenalcystsl

Liddle'ssyndromehypokalemial

Gitelman'ssyndromehypokalemia________________________________________________23242.Geneticsandcircumstances:stress

3.Obesity:(bodymassIndex,BMI):bloodvolume,insulinresistanceandcardiacoutputBMI=

GoodHealth18.5-23Overweight≥24Obesity≥284.Dietarystyles(excessivesodiumintake)BW(Kg)Height(M)225InteractionofGeneticswithEnvironments26Pathophysiology1)RegulationsofBloodPressureMeanBloodPressure=COtotalperipheralresistance2)RASandhypertension3)CentralNerveandsympatheticandhypertension4)Endothelialdysfunctionsandhypertension5)Insulinresistanceandhypertension27SmallarteryspasmorConstriction

anoxiahyperplasia,hypertrophyand

thenhyaline(glass-like)degeneration

persistenthypertension

ischemiaorgandamagesPathology28HEARTOverload(afterload)centrichypertrophyischemiaandremodeling

heartfailurehypertensionendothelialdysfunctionatherosclerosisCHD29動脈粥樣硬化的分期3031Brainatherosclerosisthrombosisspasmischemiasoftened(Dementia)spasmsmallaneurysmhemorrhageacuteandseverespasmhypertensioncrisis32動脈-動脈的栓塞3334WHO-MONICA急性腦卒中發(fā)病率的國際間比較(1/100,000)

男性

女性中國中國20200400ITA-FRISWE-GOTGER-RDMGER-HACDEN-GLOGER-KMSPOL-WARSWE-NSWYUG-NOSRUS-MOIFIN-TULCHN-BEIRUS-MOCFIN-NKALTU-KAUFIN-KUORUS-NOI中國腦卒中發(fā)生率27%635WHO-MONICA復發(fā)性腦卒中的國際間比較

男性

女性(%)27%27%02550SWE-GOTPOL-WARITA-FRIFIN-NKAGER-RDMGER-HACFIN-KUOYUG-NOSSWE-NSWDEN-GLORUS-MOCGER-KMSGER-RHNLTU-KAURUS-MOIFIN-TULRUS-NOICHN-BEI36Kidneysarterysclerosisglomerulusglass-likedegenerationandfibrinosisrenalfailureandrefractoryhypertensionatherosclerosisischemiarefractoryhypertension37AortaAtherosclerosisAorticAneurysmAorticDissectingHematoma3839Clinicalmanifestations（1）

Clinicalsymptoms:occurrenceandprogressionareslow.So70-75%patientsdon'thavesymptomsatearlystage.Dizziness,headache,unclearvision,syrigmus(耳鳴)fatigueandsleepdisorder.Somepatientshavepalpitation(心悸)discomfortinfrontofheart,andangina.高血壓病人絕大多數(shù)不頭昏頭昏絕大多數(shù)不是高血壓所致

——汪道文40Clinicalmanifestations（2）

Signs:(1)forcefulsustainedheartbeat;(2)apexbeatisdisplacedtoleft;(3)frequentatrialsound;(4)Intensivesecondheartsoundinaortasite(5)othersignswhencomplicationscome:heartfailure,renalfailure,andcerebralcomplications41DiagnosisandDifferentiation1.

Establishmentofdiagnosisofchronichypertensionanditslevel2.ExcludeorIdentify

secondaryhypertension:3.

Evaluationoforgandamagesandtheirdegree4.Evaluationofothercardiovasculardiseasesriskfactorswhichaffectprognosisandtherapy,andclinicalsituationsFourSteps42

DiagnosisandDifferentiation

(1)1.

EstablishmentofdiagnosisofchronichypertensionanditslevelToestablishhypertensiondiagnosis:

2ormorereadings2ormorevisitswith2weekinterval;

43DiagnosisandDifferentiation(2)

2.ExcludeorIdentify

secondaryhypertension:(1)

Medicalhistoryandclinicalcharacters

(2)

CarefulPE,paymoreattentiontokidneyarea,includingfindingmass,vascularmurmur,asymmetricalbloodpressurefordifferentarmsandsoon(3)NecessaryLabandothertests:bloodbiochemistry(BUN,Creatin);testsofurineroutineandprotein,catecholaminemetabolites(VMA),aldosterone/reninratio;ultrasonicexaminationsforkidneys,vessels

(4)Genetictestsfordiagnosisofsinglegenehypertension44SecondaryCausesofHypertensionCommonObstructivesleepapneaRenalparenchymaldiseases

Primaryaldosterism

RenalarterystenosisUncommon

Pheochromacytoma

Cushingdisease

Aorticcoarctation

Drug-relatedhypertensionIntracranialtumor45DiagnosisandDifferentiation(3)3.

Evaluationoforgandamagesandtheirdegree:(1)carefulphysicalexaminations,includingfundusexamination(2)Labtests:bloodbiochemistry,urinetests,ECG,chestX-rayfilm(3)Ultrasonicforheart,kidneysandvessels,CTforbrainifnecessary,andbloodinsulinmeasurement.46DiagnosisandDifferentiation(4)4.Evaluationofothercardiovasculardiseasesriskfactorswhichaffectprognosisandtherapyandclinicalsituations

47othercardiovasculardiseasesandriskfactors(seelist)Unchangeable:

Age,sex(maleandpostmenopausalfemale),pastcardiovascularevents,pastcerebrovascularevents,familialhistoryofcardiovasculareventsatearlystage.Changeable:

smoking,increasedT-Chol,LDLanddecreasedHDLlevel;left-ventricularhypertrophy,DM,nephropathy,proteinuria,inactionlifestyle,fat.48TheRiskFactorsAffectingPrognosis(1)1.Obesityisdefinedas‘a(chǎn)bdominalobesity’,inordertogivespecificattentiontoanimportantsignofthemetabolicsyndrome.2.Diabetesislistedasaseparatecriterioninordertounderlineitsimportanceasariskfactor,atleasttwiceaslargeasinabsenceofdiabetes.3.Microalbuminuriaiscategorizedasasignoftargetorgandamage,butproteinuriaasasignofrenaldisease(associatedclinicalcondition).494.Slightelevationofserumcreatinineconcentration(107–133mol/l,1.2–1.5mg/dl)istakenasasignoftargetorgandamage,andconcentrations133mol/l(1.5mg/dl)asanassociatedclinicalcondition.5.Generalizedorfocalnarrowingoftheretinalarteriesisomittedfromsignsoftargetorgandamage,sinceitisseentoofrequentlyinsubjectsaged50yearsorolder,butretinalhaemorrhages,exudatesandpapilledemaareretainedasassociatedclinicalconditions.6.SerumHCY≥10mol/lTheRiskFactorsAffectingPrognosis(2)50STRATIFICATIONOFRISKDEGREES2007ESH/ESCGuidelinesforthemanagementofhypertension51總的心血管危險分層其他危險因素,OD或疾病正常血壓SBP120~129或DBP80~84正常高值血壓SBP130~139或DBP85~891級HTSBP140~159或DBP90~992級HTSBP160~179或DBP100~1093級HTSBP≥180或DBP≥110無其他危險因素平均危險平均危險危險低度增加危險中度增加危險高度增加1-2個危險因素危險低度增加危險低度增加危險中度增加危險中度增加危險極度增加≥3個危險因素,MS,OD危險中度增加危險高度增加危險高度增加危險高度增加危險極度增加明確的CV疾病或腎臟疾病，DM危險極度增加危險極度增加危險極度增加危險極度增加危險極度增加血壓(mmHg)SBP：收縮壓,DBP：舒張壓,CV：心血管，HT=高血壓，OD=亞臨床器官損害，MS：代謝綜合征2013歐洲高血壓防治指南5250－69歲男性患者血壓與死亡的相關性050100150200250158-167148-157138-147128-13798-12768-8283-8788-9293-9798-102SocietyofActuaries.BloodPressureStudy,1993.實際死亡：預期死亡(%)收縮壓(mmHg)舒張壓(mmHg)53SIGNIFICANCEofSTRATIFICATIONOFRISKDEGREES

------Evaluateofanapproximateabsolute10-yearriskofcardiovasculardisease

accordingtoFraminghamcriteria

oranapproximateabsoluteriskoffatalcardiovasculardiseaseaccordingtotheSCOREchartThetermslow

moderatehighveryhighrisk15%15–20%20–30%30%4%4–5%5–8%8%54HypertensionandTroubles55起始降壓治療其他危險因素,器官損害(OD)

或疾病無其他危險因素1-2個危險因素≥3個危險因素,OD或MS糖尿病明確的心血管疾病或腎臟疾病正常血壓SBP120~129或DBP80~84不需干預改變生活方式改變生活方式改變生活方式改變生活方式+立即藥物治療3級高血壓

SBP≥180或DBP≥110改變生活方式+立即藥物治療改變生活方式+立即藥物治療改變生活方式+立即藥物治療改變生活方式+立即藥物治療正常高值血壓SBP130~139或DBP85~89不需干預改變生活方式改變生活方式，并考慮藥物治療改變生活方式+藥物治療改變生活方式+立即藥物治療2級高血壓SBP160~179或DBP100~109改變生活方式，持續(xù)數(shù)周后，若血壓未得到控制，則開始藥物治療改變生活方式，持續(xù)數(shù)周后，若血壓未得到控制，則開始藥物治療改變生活方式+藥物治療改變生活方式+立即藥物治療1級高血壓SBP140~159或DBP90~99改變生活方式，持續(xù)數(shù)月后，若血壓未得到控制，則開始藥物治療改變生活方式，持續(xù)數(shù)周后，若血壓未得到控制，則開始藥物治療改變生活方式+藥物治療改變生活方式+立即藥物治療56PreventionandManagement57PREVENTIONOFHYPERTENSION

(recently5-49g/day)Kaplaned.Hypertension58SpecialProgram:TargetRiskFactorsHighsaltObeseandmetabolicsyndromeFamilyhistoryStressInfection59

Therapy

Purposeoftreatment:

Preventcardio-andcerebro-vasculareventsandrenalfailure

60Goaloftreatment:中國高血壓指南20106162TREATMENTSofHYPERTENSION

1.Changelifestyleorbehaviortherapy

2.Drugtherapy——majorway6364Diuretics:Thiazide,DHCTPotassiumsparing:spironolactoneLoopdiuretics:FurosemideBeta-receptorblockers:propranolol,Metoprolol,atenolol

Calciumchannelblocker:1)FelodipineNifedipineNitrendipinePerdipine2)DiltiazemVerapamilACEIs:Captopril,

Lisinopril,EnalaprilAT1receptorblocker:Losartan,Valsartan,IrbesartanAnti-adrenergics1receptorblockers:prazosinOthers:RecommendedDrugsforHypertensionTreatments65Combinationofantihypertensives66Howtochoosemedications(1)1.

GeneralPrinciples:

?Reductionofhighbloodpressuretotargetlevelorlower

?Keepbloodpressurestable,don’tmakeitdance

?Choosedrugsbasedonpathophysiology;

?Avoidsideeffectsandwiselycombinedifferentclassesofdrugs67Howtochoosemedications(2)

2)

Specialorindividualchoice

LVH:ARBsandCCB;Insulin-resistantorcomplicatingDM:ACEI/1-blocker;

ComplicatingCHD:-blocker,ACEIs