冠心病的高血压管理.ppt

冠心病的高血压管理 武警后勤学院附属医院 姜铁民 高血压从 “无需治疗”时代穿越 “Franklin D. Roosevelt’s health was excellent”！？－－1944年 罗斯福总统最后一个任期时的文件詳細记载了他的健康 Franklin D. Roosevelt （FDR） was referred to Dr.?Howard Bruenn, a cardiologist at Bethesda Naval Hospital who, on March 27, 1944 found him cyanotic, breathless, with an enlarged left ventricle and a blood pressure of 186/108. Bruenn diagnosed hypertensive heart disease and wanted to give digitalis, but was prohibited by Dr.?Ross McIntire, the presidents personal physician and then surgeon-general of the U.S. Navy. The next day, FDR developed moist rales at the base of the right lung. During a press conference that day, FDR was asked about his physical condition and answered, I got bronchitis. By March 30 crackles were present at the base of both lungs. Bruenn diagnosed congestive heart failure, but it was not until the next day, after FDR was examined by civilian consultants, that digitalis was begun. FDR would continue the digitalis for the rest of his life. By April 3, FDR was better. His color was better, he could lie flat without dyspnea, and the crackles disappeared from both lungs. His blood pressure, however, was 210/110. The nation was stunned when FDR died unexpectedly on April 12, 1945 -- less than six months after being elected to a fourth term in office. The death was unexpected because the presidents personal physician, VADM Ross McIntire, whenever asked, had proclaimed that FDRs health was excellent. 1944年3月27日：血压186/108 1944年4月3日：血压210/110 总统的医生宣称：罗斯福总统健康状况很好！ 1945年4月12日，罗斯福总统死於脑溢血。 即使控制血压，高血压患者的冠心病风险仍显著高于常人 荟萃分析：单纯降压治疗的冠心病获益存在瓶颈 高血压加剧动脉粥样硬化发生 即使年轻高血压患者，AS发生率已高达约50% 阵线前移：从“亡羊补牢”推进到“未雨稠繆” 高血压的治疗目标 高血压患者中危险因素越多，心血管病风险越高 冠状动脉的血流特点 　 冠状动脉系统中的大部分分支走行在心肌内，心肌的收缩使心脏壁内和心腔内的压力剧增，挤压冠脉分支，增加血流阻力，使冠状血流减少，甚至因受压倒流。 心脏舒张时，心肌内压力急剧下降，血管外的压力解除，在主动脉压力的驱动下，冠脉血流才大大增加，冠脉血流约有７０%～８０%发生在舒张期。因此，舒张期的主动脉压和舒张期的长短，是决定冠脉血流的两个最重要因素 要保证冠状动脉有充分的血液灌注量，必须有足够高的压力，主要是舒张压。 ACS合并高血压的降压策略 ACS合并高血压患者多具有更多冠心病易患因素，并发症多预后较差。降低血压可为患者带来很多获益。但降压并不是“越低越好”。 心血