繼發(fā)性高血壓篩查的意義及診斷策略

繼發(fā)性高血壓診斷意義及篩查策略精選課件什么是高血壓2013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTheTaskForceforthemanagementofarterialhypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC)精選課件高血壓癥狀大多數高血壓沒有明顯癥狀部分高血壓患者會出現如下癥狀頭痛、頭暈失眠耳鳴手腳麻木、頸背部肌肉酸痛、緊張精選課件高血壓風險等級2013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTheTaskForceforthemanagementofarterialhypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC)精選課件高血壓的危害精選課件KearneyPM,WheltonM,ReynoldsK,MuntnerP,WheltonPK,HeJ.Globalburdenofhypertension:analysisofworldwidedata.Lancet.2005;365(9455):217-23.高血壓人群狀態(tài)中國中國精選課件中國高血壓人群KearneyPM,WheltonM,ReynoldsK,MuntnerP,WheltonPK,HeJ.Globalburdenofhypertension:analysisofworldwidedata.Lancet.2005;365(9455):217-23.精選課件繼發(fā)性高血壓篩查歷史精選課件繼發(fā)性高血壓篩查現狀精選課件Theprevalenceofsecondaryformsofhypertensionwas10.2%,includingrenovascularhypertension(3.1%),primaryaldosteronism(1.4%),Cushing'ssyndrome(0.5%),pheochromocytoma(0.3%),primaryhypothyroidism(3.0%)Conclusions:Increasingageandcoexistingatherosclerosishavesignificanteffectsontheprevalenceofsecondaryformsofhypertension.Theeffectofageonprevalenceofsecondaryformsofhypertensionin4429consecutivelyreferredpatientsAnderson,GunnarH.Jr;Blakeman,Nancy;Streeten,DavidH.P.繼發(fā)性高血壓篩查現狀繼發(fā)性高血壓的發(fā)病率為10.2%,包含腎血管性高血壓3.1%，原發(fā)性醛固酮增多癥1.4%，庫欣綜合征0.5%，嗜鉻細胞瘤0.3%，原發(fā)性甲狀腺功能減退3.0%；結論：年齡的增長及伴隨的動脈粥樣硬化疾病，與繼發(fā)性高血壓的發(fā)病率存在明顯的關系。精選課件繼發(fā)性高血壓篩查意義繼發(fā)性高血壓診斷的意義在于，將有可能將不可治愈的疾病變成可以治愈的疾病。哪怕潛在疾病可能無法治愈，也可通過提供特異性的治療方案使血壓得到更好的控制，同時，潛在的疾病通常會造成比血壓升高更加嚴重的后果，因此需要對其進行治療。精選課件常見的內分泌高血壓ProspectiveStudyonthePrevalenceofSecondaryHypertensionamongHypertensivePatientsVisitingaGeneralOutpatientClinicinJapanMasaoOMURA,JunSAITO,KunioYAMAGUCHI,YukioKAKUTA,andTetsuoNISHIKAWA原發(fā)性醛固酮增多癥庫欣綜合征嗜鉻細胞瘤肢端肥大癥精選課件腎素--血管緊張素--醛固酮系統(tǒng)（RAAS）RAAS系統(tǒng)精選課件原發(fā)性醛固酮增多癥癥狀高血壓原因未知的低血鉀特點癥狀無特異性與麻痹、肌無力臨床

癥狀相似篩查項目腎素活性PRA腎素濃度PRC醛固酮濃度ALD精選課件藥物在原醛篩查中的影響藥物種類臨床常用藥物對ARR比值影響β-受體阻斷劑美托洛爾、阿替洛爾及艾可洛爾等腎素↓ARR↑ACE抑制劑、AT1受體拮抗劑依那普利、西拉普利、纈沙坦、氯沙坦等醛固酮↓腎素↑ARR↓鈣通道阻斷劑硝苯地平、氨氯地平等無顯著影響利尿劑呋塞米、乙噻嗪等無顯著影響精選課件原發(fā)性醛固酮增多癥篩查ThePAC/PRCratiooffersseveralpracticaladvantagescomparedwiththePAC/PRAscreeningmethod.ThepresentstudyofferspreliminaryevidencethatitmaybeausefulscreeningtestforPHA.針對原發(fā)性醛固酮增多癥，PAC/PRC的比值，相比于PAC/PRA的篩查方法更加有效和實用，目前的研究已經提供了其可以作為一個有效篩查工具的初步證據。精選課件原發(fā)性醛固酮增多癥RapidScreeningTestforPrimaryHyperaldosteronism:RatioofPlasmaAldosteronetoReninConcentrationDeterminedbyFullyAutomatedChemiluminescenceImmunoassaysFrankHolgerPerschel,1*RudolfSchemer,3LysannSeiler,4MartinReincke,4JaapDeinum,5ChristianeMaser-Gluth,6DavidMechelhoff,1RudolfTauber,1andSvenDiederich2ClinicalChemistry2004精選課件國外的研究進展及結論精選課件ARR比值的應用和現狀基層臨床機構原醛癥的普及篩查高端醫(yī)療機構的原醛癥的確認診斷標準化降壓藥物藥效研究和對AARR篩查的影響單一降壓藥物對AARR篩查比值的影響研究方法學一致性Cut-off無法實現互換性，PA篩查率差異很大精選課件ARR與AARR的差異AARR-AldosteroneActiveReninRatio醛固酮/活性腎素比值-PAC/PRCARR-AldosteroneReninRatio血液醛固酮/活性腎素-PAC/PRAARR單位ng/ml/hour酶活力單位ARR參考范圍20-30ng/ml/hourAARR參考范圍32Recentstudiesusingtheratioofplasmaaldosteroneconcentration(PAC)toPRAasthescreeningtestforprimaryaldosterondisminhypertensivepopulationssuggestedthattheprevalencemaybeashighas5–15%.-PrevalenceofPrimaryAldosterondismamongAsianHypertensivePatientsinSingaporeKEH-CHUANLOH,EVELYNS.KOAY,MIN-CHEHKHAW,SHANTAC.EMMANUEL,ANDWILLIAMF.YOUNG,JR.精選課件ARR篩查發(fā)展ARR比值20ng/dl，且PAC濃度>15pg/ml原醛癥檢出率4.6%-Loh,2000MayoClinicPA篩查率4.6%StowasserM調整對ARR篩查影響小的降壓藥物后，確認PA檢出率18%影響因素樣本人群藥物種類和干擾原醛癥篩查思路血鉀濃度檢測系統(tǒng)特異性精選課件原醛癥的篩查思路精選課件原醛癥的篩查和診斷策略Minireview:PrimaryAldosteronism—ChangingConceptsinDiagnosisandTreatmentWILLIAMF.YOUNG,JR.ProfessorofMedicine,MayoMedicalSchool;Consultant,DivisionofEndocrinology,Metabolism,NutritionandInternalMedicine,MayoClinicandMayoFoundation,Rochester,Minnesota55905精選課件原醛癥的確認診斷鹽抑制試驗鹽水負荷試驗氟氫可的松抑制試驗ComparisonofConfirmatoryTestsfortheDiagnosisofPrimaryAldosteronismPaoloMulatero,AlbertoMilan,FrancescoFallo,GiuseppeRegolisti,FrancescaPizzolo,CarlosFardella,LorenaMosso,LisaMarafetti,FrancoVeglio,andMauroMaccario精選課件原醛癥的確認診斷SaltLoadingTestisareasonablygoodalternativetothemoreexpensiveandcomplexFSTforthediagnosisofPAafterapositivescreeningtest.

JClinEndocrinolMetab91:2618–2623,2006操作簡單、實用性高可對門診病人進行操作可替代氟氫可的松抑制試驗，可信度高ComparisonofConfirmatoryTestsfortheDiagnosisofPrimaryAldosteronismPaoloMulatero,AlbertoMilan,FrancescoFallo,GiuseppeRegolisti,FrancescaPizzolo,CarlosFardella,LorenaMosso,LisaMarafetti,FrancoVeglio,andMauroMaccario精選課件篩查常用輔助篩查手段CT影像學的局限性CTScanning,thereforeclearlylocalizesadenomasin50%ofhistologicallyprovencases,andcanalsoproducemisleadingresults.-RoleforadrenalvenoussamplinginprimaryaldosteronismWilliamF.Young,Jr,MD,AnthonyW.Stanson,MD,GeoffreyB.Thompson,MD,CliveS.Grant,MD,DavidR.Farley,MD,andJonA.vanHeerden,MB,ChB,Rochester,Minn精選課件篩查常用輔助篩查手段MagneticResonanceImaging-磁共振成象磁共振成象在診斷醛固酮分泌腺瘤APA時具有高度的特異性。正如非功能性亢進腫瘤一樣，醛固酮分泌腺瘤APA和雙側腎上腺增生BAH，能夠通過磁共振成象顯示出細胞內脂質移動的圖象。RoleforadrenalvenoussamplinginprimaryaldosteronismWilliamF.Young,Jr,MD,AnthonyW.Stanson,MD,GeoffreyB.Thompson,MD,CliveS.Grant,MD,DavidR.Farley,MD,andJonA.vanHeerden,MB,ChB,Rochester,Minn精選課件篩查常用輔助篩查手段AdrenalVeinSampling-腎上腺靜脈采血OnthebasisofCTfindingsalone,42patients(21.7%)wouldhavebeenincorrectlyexcludedascandidatesforadrenalectomy,and48(24.7%)mighthavehadunnecessaryorinappropriateadrenalectomy.AVSisanessentialdiagnosticstepinmostpatientstodistinguishbetweenunilateralandbilateraladrenalaldosteronehypersecretion.Surgery2004;136:1227-35.單獨使用CT篩查，約有21.7%的病人被錯誤地取消腎上腺切除術，24.7%的病人接受到了不必要或不合適的腎上腺切除術。精選課件腎上腺靜脈采血國內外現狀精選課件腎上腺靜脈F濃度與外周比值大于2提示插管成功F校正后比值大于2有意義確認醛固酮分泌腺瘤腎上腺靜脈采血精選課件治療策略確診的醛固酮腺瘤患者-腎上腺組織切除術腹腔鏡下腎上腺切除術的日益成熟，創(chuàng)傷和時間大大縮短雙側腎上腺增生-醛固酮受體拮抗劑類藥物治療副作用-男子女性型乳房征、性欲減退、月經不規(guī)律等問題腎上腺腫瘤切除的患者，約有60%患者停藥糾正低血鉀癥得以治愈，血壓改善MedicalManagementofAldosterone-ProducingAdenomasRanjanP.Ghose,MD;PhillipM.Hall,MD;andEmmanuelL.Bravo,MD精選課件現狀與未來腎素/醛固酮比值的普及應用，原醛癥的檢出率日益提高存在血鉀水平正常的原醛癥患者篩查策略的運用，有助于提高血壓控制率醛固酮受體的分布與高醛固酮癥的危害原醛癥篩查的成本有效性精選課件庫欣綜合征（Cushing’ssyndrome)的診斷典型的庫欣綜合征患者，ATCH和皮質醇分泌喪失節(jié)律地塞米松抑制試驗呈現地塞米松無法抑制皮質醇水平的現象，導致高血壓癥狀影像學檢測庫欣綜合征精選課件庫欣綜合征臨床癥狀明顯，無需特殊診斷篩查與非疾病特定人群性狀類似-肥胖擦傷、多血癥、以及肌肉病變在庫欣綜合征中占有很高的比重外源性與內源性庫欣綜合征外源性-二十四肽促皮質刺激實驗，合適的生理糖皮

質激素替代治療內源性-過夜地塞米松抑制實驗、24小試尿排泄皮質醇實驗精選課件庫欣癥的篩查意義及診斷策略ProspectiveStudyonthePrevalenceofSecondaryHypertensionamongHypertensivePatientsVisitingaGeneralOutpatientClinicinJapanMasaoOMURA,JunSAITO,KunioYAMAGUCHI,YukioKAKUTA,andTetsuoNISHIKAWA精選課件庫欣癥的篩查策略Urinaryfreecortisolversus17-hydroxycorticosteroids:acomparativestudyoftheirdiagnosticvalueinCushing'ssyndromeT.Mengden,P.Hubmann,J.Mfiller,P.Greminger,andW.VetterDepartementffirInhereMedizin,Universit/itsspitalZ/irich精選課件不同病因Cushing綜合癥鑒別Cushing病異位ACTH綜合征腎上腺皮質癌腎上腺皮質瘤大劑量地米刺激能被抑制不能被抑制不能被抑制不能被抑制血ACTH升高明顯增高降低降低腎上腺CT雙側腎上腺增大雙側腎上腺增大腫瘤腫瘤垂體MRI微腺瘤、大腺瘤無無無精選課件嗜鉻細胞瘤嗜鉻細胞瘤的發(fā)病率在高血壓人群中約占0.2%間歇性或持續(xù)性高血壓，劇烈頭痛，全身大汗淋漓、心悸、心動過速等嗜鉻細胞瘤(pheochromocytoma)精選課件嗜鉻細胞瘤起源于腎上腺髓質，致死率高因嗜鉻細胞瘤致死患者，近1/3對患病一無所知積極的診斷和治療誤診和不合適的治療可能是致命的精選課件嗜鉻細胞瘤精選課件嗜鉻細胞瘤持續(xù)或間斷地釋放大量兒茶酚胺，引起持續(xù)性或陣發(fā)性高血壓和多個器官功能及代謝紊亂

TheLaboratoryDiagnosisofAdrenalPheochromocytoma:TheMayoClinicExperienceYOGISHC.KUDVA,ANNAM.SAWKA,ANDWILLIAMF.YOUNG,JR.DivisionofEndocrinology,MetabolismandNutrition,andInternalMedicine(Y.C.K.,W.F.Y.),MayoClinic,R