继发性高血压筛查的时机与治疗.pptx

继发性高血压筛查的时机与治疗 目 录1. 继发性高血压定义和流行病学2. 继发性高血压病因3. 继发性高血压筛查时机与治疗 继发性高血压(secondary hypertension) 是病因明确的高血压，当查出病因并有效去除或控制病因后，作为继发症状的高血压可被治愈或明显缓解。继发性高血压在高血压人群中占5%-10%，但随着对高血压发病机制研究的深入以及诊断技术的不断提高，这比例正逐渐上升。定义及流行病学3 肾性肾实质性肾血管性肾外伤性内分泌性甲状腺肾上腺垂体睡眠呼吸疾病睡眠呼吸暂停综合征机械性血流障碍主动脉缩窄动静脉瘘主动脉瓣关闭不全神经源性脑肿瘤脑外伤自主神经功能异常外源性中毒药物其他妊娠期高血压真性红细胞增多症继发性高血压分类4 发病年龄30岁且无高血压家族史；血压增高的幅度大，常达高血压3级（180/110mmHg）；血压难以控制,需要使用三种或以上降压药；常用的五大类降压药物效果不佳；血压波动大或阵发性高血压；坚持服药情况下控制良好的血压突然明显升高；双上肢血压不对称；体检闻及血管杂音；未服用或服用小剂量利尿剂即出现明显低血钾，排除进食差、腹泻等诱因；服用ACEI/ARB后出现肾功能的急剧恶化，血肌酐明显升高；高血压伴有尿常规异常，如大量蛋白尿，多量红白细胞等；急性心力衰竭或一过性肺水肿，尤其以晨起和夜间多见；单侧肾萎缩。继发性高血压筛查重点人群5 1CKD家族史（多囊肾）肾病、尿路感染、血尿、滥用止痛剂（肾实质疾病）药物/化学物质的摄入，如口服避孕药、甘草、甘草次酸、血管收缩滴鼻剂、可卡因、安非他命、糖/盐皮质激素、NSAID、EPO、环孢素反复发作出汗、头痛、焦虑、心悸（嗜铬细胞瘤 发作性肌肉无力及抽搐（醛固酮增多症）甲状腺疾病症状 2013 ESH/ESC Guidelines for themanagement of arterial hypertensionTable 8 Personal and family medical history1.Duration and previous level of high BP,including measurements at home.2. Secondary hypertension a)Family history of CKD (polycystic kidney). b) History of renal disease,urinary tract infection,hematuria,analgesic abuse(parenchumal renal disease). c) Drug/substance intake, e.g.oral conteaceptives, liquorice, carbenoxolone, vasoconstrictive nasal drops, cocaine,amphetamines, gluco-and mineralocorticosteroids, non-steroidal anti-inflammatory drugs,erythropoietin,cycolsporine. d) Repetitive cpisodes of sweating, headache, anxiety, palpitations (pheochromocytoma). e) Episodes of muscle weakness and tetany (hyperaldosteronism). f) Symptoms suggestibe of thyroid disease.3.Risk factors病 史6 Cushing综合征体征神经纤维瘤病的皮肤改变（嗜铬细胞瘤）触诊肾脏肿大（多囊肾）。?听诊腹部杂音（肾血管性高血压）。?听诊心前区或胸部杂音（主动脉缩窄，主动脉疾病;上肢动脉疾病）?上下肢血压差异（主动脉缩窄，主动脉疾病，下肢动脉疾病）左右臂血压差异（主动脉缩窄;锁骨下动脉狭窄）。22013 ESH/ESC Guidelines for themanagement of arterial hypertensionTable 9 Physical examination fou secondary hypertension, organ damage and obesitySigns suggesting secondary hypertensionFeatures of Cushing syndrome.Skin stigmata of neurofibromatosis (pheochromocytoma).Palpation of enlarged kidne