难治性高血压.ppt

Resistant Hypertension:Diagnosis,Evaluation,and TreatmentJENNY(A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research).Objective Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.1Contents23DiagnosisEvaluationTreatment.Definition blood pressureremains above goalthree anti-hypertensive agents of different classesone ofthe 3 agents should be a diureticall agents should beprescribed at optimal dose amounts.Resistant Resistant hypertensionhypertension.Prevalence1NHANES53%Framingham Heart Study48%ALLHAT250%.Patient CharacteristicsPatient Characteristics Associated With Resistant HypertensionOlder ageHigh baseline blood pressureObesityExcessive dietary salt ingestionChronic kidney diseaseDiabetesLeft ventricular hypertrophyBlack raceFemale sexResidence in southeastern United States.PseudoresistancePoor Blood Pressure TechniquePoor AdherenceLifestyle FactorsWhite-Coat EffectSecondary Causes.measuring the blood pressure before letting the patient sit quietlyuse of too small a cuffPoor Blood Pressure Technique.a major cause of lack of blood pressure controlPoor Adherenceless than 40%of patients40%of patientsthe first year of treatment45 to 10 years of follow-up3.White-Coat Effect Studies indicate that a significant white-coat effect(when clinic blood pressures are persistently elevated while out-of-office values are normal or significantly lower)is as common in patients with resistant hypertension as in the more general hypertensive population,with a prevalence in the range of 20%to 30%.5.Lifestyle FactorsObesity is a common feature of patients with resistant hypertension.Excessive dietary sodium intakeHeavy alcohol intake is associated with both an increased risk of hypertension,as well as treatment-resistant hypertension.Non-narcotic analgesics Non-steroidal anti-inflammatory agents,including aspirin,selective COX-2 inhibitors Sympathomimetic agents(decongestants,diet pills,cocaine)Stimulants(methylphenidate,dexmethylphenidate,dextroamphetamine,amphetamine,methamphetamine,modafinil)AlcoholOral contraceptivesCyclosporineEPONatural licoriceHerbal compounds(ephedra or ma huang)Drug-Related Causes.Renal artery stenosisPrimary aldosteronismRenal parenchymal diseaseHyperparathyroidismCushings diseasePheochromocytomaSecondary CausesObstructive Sleep ApneaAortic coarctation.EvaluationMedical History:duration,severity,progression of the hypertension;treatment adherence;response to prior medicationsAssessment of AdherenceBlood Pressure Measurementsit quietlycorrect cuff size;support the arm at heart levelthe average of 2 readingssupine and upright blood pressuresPhysical Examination.A mean ambulatory daytime blood pressure of 135/85 mm Hg is considered elevated.EvaluationAmbulatory Blood Pressure MonitoringBiochemical EvaluationA routine metabolic profileUrinalysisA paired,morning plasma aldosterone Plasma renin activityNoninvasive Imaging.1.Maximize Adherence the use of a long-acting combination of products 2.Non pharmacological Recommendations Weight Loss Dietary Salt Restriction Moderation of Alcohol Intake Increased Physical Activity Ingestion of a High-Fiber,Low-Fat Diet3.Treatment of Secondary Causes of Hypertension4.Pharmacological Treatment.AliskirenEffects of aliskiren and valsartan on plasma ANG I and II levels.Aliskiren alone or in combination with valsartan was tested in 120 mildly sodium depleted,Nor-motensive adults(age,18 to 35 years)in a double-dummy,double blind,randomized,placebo-controlled,4-period crossover study.Subjects received single doses of aliskiren 300 mg alone,aliskiren 150 mg in combination with valsartan 80 mg,valsartan 160 mg alone,and placebo separated by 2-week washout periods.There is no doubt that aliskiren is an effective antihypertensive agent and that at effective doses it is well tolerated.It appears to be safe,but this statement is made with the obvious qualification for any novel drug or class that rare or long-term adverse events may take time to become apparent.7AliskirenDOSE:75mg-300mg qd p.o.Darusentan Darusentan provides additional reduction in blood pressure in patients who have not attained their treatment goals with three or more antihypertensive drugs.As with other vasodilator drugs,fluid management with effective diuretic therapy might be needed.a Vaccine Against Hypertension Targeting Angiotensin II,Reduces Early-Morning and Day-Time Blood PressureCYT006-AngQb a virus-like-particle based conjugate vaccine targeting(Ang II)72 mild-to-moderate hypertensive patients.the vaccine with an optimized dose regimeninjections of either 100 or 300 g.CYT006-AngQb reduced blood pressure in situations where the renin-angiotensin-aldosterone system is stimulated,and was particularly effective in the morning hours when most cardiovascular events occur.CYT006-AngQb.1.Catheter ablation of renal sympathetic nerve 2.Implantable pulse generator to stimulate the carotid sinus baroreceptorOther Therapies.