Diseases of Circulatory System

Hypertension

Prof. Shen-Jiang Hu

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。

讲授目的和要求

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

教材及参考书

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/200705111443400125/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

Framingham 心脏研究：最早认识到高血压与心脏病的关系

1961 年

认识到高血压与卒中的关系1970 年

世界卫生组织首次提出高血压阶梯治疗方案

1978 年

JNC II 将舒张压作为确诊高血压的和治疗建议的基础

1980 年

JNC V 收缩压与舒张压同等重要

1992 年

JNC VII ：降压达标对减少各类患者的心血管事件至关重要

2003 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

2005 年

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

HypertensionHypertensionHypertensionHypertension

Atrial Fibrillation

Aortic Dissection

Dementia

Chronic Renal failure

Heart Failure

LV Hypertrophy MI

Hypertensive Encephalopathy

CHD

Intracerebral HemorrhageIschemic

CerebralInfarction

Complications of Hypertension

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%15%

≥≥10%~14.9%10%~14.9%

＜＜ 10%10%

河南河南青海青海

云南云南

山东山东

安徽安徽

湖南湖南四川四川

贵州贵州

甘肃甘肃

海南海南

天津天津

黑龙江黑龙江

北京北京

上海上海

河北河北

西藏西藏

吉林吉林

内蒙古内蒙古

辽宁辽宁

湖北湖北

江苏江苏

新疆新疆

山西山西

陕西陕西

广东广东

宁夏宁夏

广西广西

浙江浙江江西江西

福建福建

台湾台湾

死亡原因 死亡率 占总死亡 死亡原因 死亡率 占总死亡

1/10 万 % 1/10 万 %

循环系病 226.1 38.5 内分泌，代谢

- 脑血管病 127.2 21.6 营养，免疫病 16.9 2.9

- 心脏病 98.9 16.8 泌尿生殖病 8.9 1.5

恶性肿瘤 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

我国城市 1999 年前 10 位死亡原因

中国中国 19991999 年卫生统计年卫生统计

死亡原因死亡原因 死亡专率死亡专率 占总死亡占总死亡 死亡原因死亡原因 死亡率死亡率 占总占总死亡死亡

1/101/10 万万 %% 1/101/10 万万 %%

循环系病循环系病 186.6186.6 30.830.8 泌尿生殖病泌尿生殖病 9.29.2 1.5 1.5

- - 脑血管病 脑血管病 111.6111.6 18.418.4 * * 新生儿病新生儿病 810.3810.3 1.31.3

- - 心脏病 心脏病 75.075.0 12.412.4 (( 每每 1010 万出生）万出生）

呼吸系病呼吸系病 133.7133.7 22.022.0 肺结核肺结核 7.97.9 1.31.3

恶性肿瘤恶性肿瘤 111.6111.6 18.418.4 内分泌，代谢内分泌，代谢

损伤，中毒损伤，中毒 67.067.0 11.011.0 营养，免疫病营养，免疫病 6.46.4 1.01.0

消化系病消化系病 24.224.2 4.0 4.0

我国农村 1999 年前 10 位死亡原因

中国中国 19991999 年卫生统计年卫生统计

Trends in Awareness, Treatment, and Control of Hypertension in China

Awareness(%) Treatment(%) Control(%)

19911991 26.6 12.2 2.9 26.6 12.2 2.9

2002 30.2 24.7 6.12002 30.2 24.7 6.1

中国心血管健康多中心合作研究

Etiology The pathogenesis of essential hypertension is multifa

ctorial. 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 ten-amino-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.

Category JNC 7 （ USA ） European China

Optimal <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

Definition and Classification of Blood Pressure Levels in different Country

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 High Moderate Low

>30% 20-30% 15-20% <15%

SCORE charts ： the risk of dying from cardiovascular disease over 10 years

Very high High Moderate Low

>8% 5-8% 4-5% <4%

Factors influencing prognosis

Factors influencing prognosis

Management

Goals of treatment

Goals of treatment

降压是硬道理！降压是硬道理！微小的血压差异，显著的心血管收益微小的血压差异，显著的心血管收益

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

0

-5

-10

-15

-20

-25

-30

卒中 CHD 心衰 总死亡

23%

15% 16%14%

－ 4/3 mmHg N ＝ 20 888

主要 CV 事件

15%

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 tr

eatment 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

β-blockers

Calcium antagonists

Diuretics

Angiotesin II antagonists

α-blockers

ACE inhibitors

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!