1 / 85

夜间高血压研究进展

夜间高血压研究进展. 哈医大第一临床医学院 心内科. 李 悦. 正常血压昼夜节律. BP follows a circadian rhythm (Dipping) , with 10–20% lower values during sleep than during wakefulness. 靶器官灌注需要最低血压. Nocturnal dip < 10% of daytime pressure – No ndipping ( 非杓型）

amena-salinas
Télécharger la présentation

夜间高血压研究进展

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. 夜间高血压研究进展 哈医大第一临床医学院 心内科 李 悦 The First Clinical College of Harbin Medical University

  2. 正常血压昼夜节律 • BP follows a circadian rhythm (Dipping), with 10–20% lower values during sleep than during wakefulness. 靶器官灌注需要最低血压 The First Clinical College of Harbin Medical University

  3. Nocturnal dip < 10% of daytime pressure – Nondipping (非杓型） < significant increase – Reverse dipping (反杓型） > 20% of daytime pressure – Extreme dipping (超杓型） The First Clinical College of Harbin Medical University

  4. 定 义 • 夜间平均血压> 120/ 70 mmHg (ABPM)。 《中国高血压防治指南》2010 • 有学者建议用夜间睡眠血压替代夜间血压。 The First Clinical College of Harbin Medical University

  5. 流行病学 • 原发性高血压和继发性高血压常见现象。 Can J Cardiol 2009;25(9):e312-e316 Friedman等对白天血压正常组（未服用降压药,白天血压< 135/85mmHg）可控制高血压组（服用≤3种降压药,白天血压< 135/85mmHg）和难控制高血压组（服用≥3种达最大剂量降压药, 白天血压>135/85mmHg）人群夜间血压模式进行研究。 The First Clinical College of Harbin Medical University

  6. 无论白天血压正常人群还是白天高血压人群, 夜间高血压均有较高发生率, 常与非杓型并存。 The First Clinical College of Harbin Medical University

  7. 2009;53;466-472 Hypertension • 西班牙500个初级保健中心42947 例高血压患者，未治疗8384 例，已接受治疗34563 例，ABPM显示, 41%未治疗患者及52%治疗患者呈非杓型曲线。 The First Clinical College of Harbin Medical University

  8. 许多研究证实，亚洲人和黑人夜间血压增高比 高加索人（白人）更常见。 J Hypertens. 2002;20:2183–2189 Am J Cardiol. 1995; 75:1239–1243 Am J Hypertens. 2000;13:884–891 Am J Hypertens. 2002;15:525–530 The First Clinical College of Harbin Medical University

  9. 2007年,上海瑞金医院 观察浙江景宁畲族自治县14个村庄2059位受试者 The First Clinical College of Harbin Medical University

  10. 单纯夜间高血压（22:00 - 4:00平均血压≥ 120/70mmHg,白天血压正常)达10.9%；日夜高血压38.4%；单纯白天高血压(从 8: 00 到 16: 00 平均血压 135/ 85 mm Hg, 夜间血压正常)为4.9%。 The First Clinical College of Harbin Medical University

  11. 夜间高血压危害 相比夜间血压正常者, 夜间血压增高或下降迟缓病人伴发心、脑、肾等靶器官损害（左室肥厚、心衰、脑卒中、微量蛋白尿等）以及心血管死亡风险明显增加。 Expert Rev. Cardiovasc. Ther. 7(6), 607–618 (2009) The First Clinical College of Harbin Medical University

  12. Diabetes Metab. 34(6 Pt 1), 560–567 (2008). DM患者中反杓型高血压患者较其他血压类型患者心血管不良事件增加2.8倍。 Kidney Int. 57(6), 2485–2491 (2000) 透析患者伴夜间收缩压增高者心血管死亡率增加41%。 The First Clinical College of Harbin Medical University

  13. First study demonstrating that a diminished nocturnal decline in blood pressure is a risk factor for cardiovascular mortality • Ohasama研究证实，夜间血压下降每减少 5%， 心血管死亡率增加>20%。 The First Clinical College of Harbin Medical University

  14. JAMA. 2006 Jun 28;295(24):2859-66 • 一项爱尔兰研究显示： 夜间SBP每增加10 mmHg，心血管死亡率增加 21%； 夜间DBP增加5mmHg，心血管死亡率增加 9%。 The First Clinical College of Harbin Medical University

  15. 发生机制 The timing and amplitude of BP rhythm is affected by • Intrinsic factors, such as neurohormonal regulation (e.g., sympathetic nervous system and RAAS system) . • Extrinsic factors, such as sodium load, sleep quality physical activity, and behavioral and lifestyle factors (smoking and alcohol intake) . • Demographic factors, such as age and race. Am. J. Hypertens. 6(6 Pt 2), S166–S169 (1993). Am. J. Hypertens. 6(6 Pt 2), S170–S173 (1993). The First Clinical College of Harbin Medical University

  16. 2008;52;925-931 Hypertension • Grassi等观察杓型、极度杓型、非杓型以及反杓型 原发性高血压患者肌肉交感神经活性。 The First Clinical College of Harbin Medical University

  17. 超杓型 高血压 (17) 正常 血压 (17) 反杓型 高血压 (10) 杓型 高血压 (34) 非杓型 高血压 (18) The First Clinical College of Harbin Medical University

  18. 与血压正常者比, 高血压患者肌肉交感神经系统异常兴奋, 反杓型者为甚，提示交感神经在夜间高血压发生发展中起重 要作用。 The First Clinical College of Harbin Medical University

  19. 研究发现：主动脉瓣膜病变患者夜间血压下降程度与肾素、醛固酮活性呈负相关, 提示肾素、醛固酮活性增加是引起夜间高血压的主要原因之一。 J. Hypertens. 8(1) 85–95 (1990). The First Clinical College of Harbin Medical University

  20. 常伴随疾病 CKD and end-stage kidney disease DM Sleep apnea Autonomic neuropathy and autonomic failure Primary aldosteronism Pheochromocytoma (嗜铬细胞瘤） Cushing’s syndrome Solid organ transplantation Pre-eclampsia and eclampsia （子痫和先兆子痫） CHF The First Clinical College of Harbin Medical University

  21. 正常肾脏功能对于保证血压昼夜节律非常重要。正常肾脏功能对于保证血压昼夜节律非常重要。 • 肾小球滤过率（GFR）与夜间/白天血压比值呈反比。 • CKD患者血压非杓型比率高达70%-80%。 The First Clinical College of Harbin Medical University

  22. DM • 23% of patients (188 T1D）with clinical normotension had masked nocturnal hypertension. • Hypertensives with diabetic nephropathy have significantly higher night-time SBP compared with patients with nondiabetic glomerulopathy(142 versus 132 mmHg; p = 0.02) . The First Clinical College of Harbin Medical University

  23. 阻塞性睡眠呼吸暂停低通气综合征 (Obstructive sleep apnea-hyponea syndrome, OSAHS) • 40岁以上人群中，美国患病率为2%-4%，澳大利亚高达6.5%，我国香港地区4.1%，上海市3.62%，长春市4.81% ，男性多于女性，老年人、肥胖患病率更高。 The First Clinical College of Harbin Medical University

  24. 约50%OSAHS患者伴高血压, 至少30%高血压患者伴有OSAHS。 The First Clinical College of Harbin Medical University

  25. 新近研究表明，OSAHS 患者, 无论是否有高血压，睡眠时血压杓型变化的规律性减弱或消失,出现不同程度的血压升高或夜间高血压。 • OSAHS 程度越重，平均血氧浓度及最低血氧浓度越低, 非杓型血压发生率越高。 Hypertension Res, 2009, 32 (6) : 428 -432 Sleep, 2008, 31(6) : 795-800. The First Clinical College of Harbin Medical University

  26. 盐与夜间高血压 • 有证据提示，夜间血压下降缓慢、夜间高血压者与高盐饮食及盐敏感关系密切。 Hypertension. 1996;28:139–142 Circulation. 1997;96:1859–1862 Am J Hypertens. 1999;12:35–39 Hypertension. 1997;30:163-167 Am J Hypertens. 1995;8:970–977 J Hypertens. 1998;16:1745–1748 The First Clinical College of Harbin Medical University

  27. 我国人群食盐摄入量严重超标 WHO组织建议每人每日食盐摄入量≤5g 北方: 每人每天约 12-18g 南方:每人每天约 7-8g 1.《中国高血压指南2005》 The First Clinical College of Harbin Medical University 2.Report of a WHO Forum and Technical meeting 5–7 October 2006,Paris, France

  28. 我国高血压患者盐敏感型为主 我国盐敏型高血压占高血压总人群的50%-60% 盐敏感： 盐敏感型高血压患者血压随钠的摄入量的增加(或减少) 有更显著的增加(或减少)。 ＊ 正常 盐抵抗 盐敏感 正常盐摄入 钠摄入量 低盐摄入 血压(mmHg) ＊正常：血压正常的个体 1.刘杰等，高血压杂志 1999 7(3):251-253 2.Journal of Hypertension 2008, 26:381–391 The First Clinical College of Harbin Medical University 3.Hypertension. 1996;27:481-490

  29. 诊 断 与传统诊所血压相比, 24 h 动态血压监测 (ABPM )对夜间高血压诊断、昼夜节律观察及临床结果预测方面更有价值。 The First Clinical College of Harbin Medical University

  30. 有研究显示, ABPM 监测出的夜间高血压患74 例在使用诊室血压监测时仅有4 名被检测出患有高血压。 Hypertension. 2007;50:333-339 The First Clinical College of Harbin Medical University

  31. Hypertension. 2006 Jul;48(1):e3 • AHA夜间血压诊断标准： The First Clinical College of Harbin Medical University

  32. 根据欧洲高血压学会（ESH）指南 白天平均值 < 135/ 85 mm Hg 夜间平均值 < 125/ 70 mm Hg The First Clinical College of Harbin Medical University

  33. 中国ABPM正常标准： 24 h 平均值 < 130/ 80 mm Hg 白天平均值 < 135/ 85 mm Hg 夜间平均值 < 125/ 75 mm Hg (<120/70mmHg，2010中国，台湾） 《中国高血压防治指南》 2005 《中国高血压防治指南》 2010 J Formos Med Assoc. 2010. 109(10): 740-73 The First Clinical College of Harbin Medical University

  34. ABPM局限性 患者佩戴ABPM • 觉醒期间运动明显减少，坐位时间平均增加27分钟 （P=0.002）。 • 夜间睡眠时间减少98分钟（P＜0.0001），睡眠效率由82% 降至77%（P=0.02）。 • 日间血压值相对降低、夜间血压相对升高，倾向非杓型。 J Am Soc Nephrol. 2010. 5(2): 281-5 The First Clinical College of Harbin Medical University

  35. 对准确性低血压数值进行舍弃，其标准为： • 收缩期ABP＞260mmHg或＜70mmHg； • 舒张期ABP＞150mmHg或＜40mmHg； • ABP脉压＞150mmHg或＜20mmHg； • 被舍弃血压读数约占全部读数的10~15%。 The First Clinical College of Harbin Medical University

  36. 夜间高血压治疗 • 降压同时重视纠正血压昼夜节律, 包括非杓型血压、血压晨峰现象。 • 临床治疗涉及生活方式干预、 药物治疗的时间学 和相关疾病的治疗。 The First Clinical College of Harbin Medical University

  37. 生活方式干预 • 盐敏感者应首先限制钠摄入，补充钾盐。 Uzu 等证实：盐敏感性高血压患者限盐程度 与夜间血压下降幅度呈正相关。 盐敏感性高血压患者限盐后血压可由非杓型恢复为杓型。 Circulation. 1997 Sep 16;96(6):1859-62 The First Clinical College of Harbin Medical University

  38. 荟萃分析显示（33项随机对照研究，2609）： 补钾治疗能够明显降低收缩压和舒张压。 （3.1 / 1.9mmHg) 高钠盐摄入者血压降低更明显。 JAMA. 1997 May 28;277(20):1624-32. The First Clinical College of Harbin Medical University

  39. 年轻非高血压黑人高钾摄入（80mg/d) 使所有非杓型血压状态恢复为杓型血压状态，但白天血压无明显变化。 Blood press monit. 1996 Dec;1(6):447-455 补钾可减轻高盐对靶器官损害， 可能与其抗氧化作用有关。 Hypertension, 2008, 51: 2252-2231 The First Clinical College of Harbin Medical University

  40. 美国全国高血压教育项目协调委员会（NHBPEP） 推荐的钾与钠摄入比为2：1。 陕西农民调查，摄取钾约为35 mmol/ d ， 而钠摄入为 230 mmol/ d , 钾与钠摄入比仅0.15。 补钾最可通过多食用含钾丰富的水果、蔬菜等或 添加钾盐。 The First Clinical College of Harbin Medical University

  41. 戒烟、戒酒 吸烟是重要的心血管危险因素，但戒烟对24小时血压控制影响不明显，尚无证据显示戒烟能够降低夜间血压。 Arq. Bras. Cardiol. 87(4), 504–511 (2006). Am. J. Hypertens. 14(9 Pt 1), 942–949 (2001). The First Clinical College of Harbin Medical University

  42. 过量饮酒增加睡眠时交感神经活性，加重血压晨峰效应。过量饮酒增加睡眠时交感神经活性，加重血压晨峰效应。 Hypertension 53(1), 13–19 (2009). 研究证实，戒酒能够降低24小时血压，但不影响血压模式。 Hypertension 33(2), 653–657 (1999). The First Clinical College of Harbin Medical University

  43. 保证良好睡眠。 Blood Press. 2007;16(2):101-5 睡眠障碍者非杓型高血压发生率增加3倍。 The First Clinical College of Harbin Medical University

  44. 对严重自主神经病变导致仰卧位高血压者, 睡眠时头部抬高有助于降低仰卧位血压 。 The First Clinical College of Harbin Medical University

  45. 药物治疗 • Blockers of the RAAS 肾素活性夜间增加，到凌晨达高峰. Evening dosing consistently results in better nocturnal BP reduction and increased dipping than with morning dosing. Pharmaco. Ther. 111(3), 629–651 (2006). J. Hypertens. 23(10), 1913–1922 (2005). Hypertension 50(4), 715–722 (2007). Chronobiol. Int. 26(1), 61–79 (2009). The First Clinical College of Harbin Medical University

  46. Am J Hypertens 2008, 21(8):948-54 • CCB 180 patients (50% nondippers) receiving nifedipine GITS in a prospective, open-label, parallel-group design comparing morning and bedtime administration. Bedtime dosing resulted in greater sleep-BP lowering(9.6% vs 6% fall; p = 0.004), also accompanied by better 24-h SBP control(9% vs 6.5% fall; p = 0.035) and a decrease in the number of nondippers from 51% to 35%. The First Clinical College of Harbin Medical University

  47. 利尿剂 利尿剂对血压昼夜模式无明显影响（盐敏感高血压除外）, 仍有待大规模临床研究证实。 Circulation 100(15), 1635–1638 (1999) Chronobiol. Int. 25(6), 950–970 (2008) Hypertension 47(3), 352–358 (2006). The First Clinical College of Harbin Medical University

  48. β受体阻滞剂 The BP-lowering effects are more pronounced during wakefulness(失眠) and OSAHS. β-blockers have not been well studied to date. Curr.Opin.Nephrol. Hypertens. 14(5), 453–459 (2005). Pharmaco. Ther. 111(3), 629–651 (2006). The First Clinical College of Harbin Medical University

  49. 其他药物 • 褪黑素 由松果体腺分泌，能够改善内皮功能，增加NO合成， 导致血管扩张和降压效应。 高血压病人夜间褪黑素分泌明显降低。 对夜间高血压治疗作用仍有待大规模临床研究证实。 Am. J. Med. 119(10), 898–902 (2006). Am. J. Hypertens. 18(12 Pt 1), 1614–1618 (2005) The First Clinical College of Harbin Medical University

  50. 阿司匹林 A potent antioxidative agent that reduces vascular production of superoxide, prevents angiotensin II–induced hypertension, and induces NO release. The First Clinical College of Harbin Medical University

More Related