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Hypertension

Hypertension

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Hypertension

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  1. Hypertension Pathology Department, Zhejiang University School of Medicine, Zhu keqing 竺可青, zhukeqing@yahoo.com, 2013-3-11

  2. Five categories of disease account for nearly all cardiac mortality: • Congenital heart disease • Ischemic heart disease • Hypertensive heart disease (systemic and pulmonary) • Valvular heart disease • Nonischemic (primary) myocardial disease

  3. Definition • Hypertension 140mmHg/90mmHg • Primary/Essential hypertension 5-10% • Secondary/ Symptomatic hypertension (3大原因:肾性/血管性/内分泌性)

  4. PREVALENCE: WHAT % of USA people have hypertension?

  5. PREVALENCE: WHAT % of USA people have hypertension? Answer: 25%

  6. Blood pressure regulation by the renin-angiotensin system and the central roles of sodium metabolism in specific causes of inherited and acquired forms of hypertension

  7. Hypothetical scheme for the pathogenesis of essential hypertension

  8. Chronic/benign hypertension 1 机能紊乱期—细小动脉痉挛 2 动脉系统病变期 Arteriolosclerosis/细动脉玻璃样变—肾入球动脉和视网膜动脉 3 内脏病变期(大心小肾脑出血) HHD:concentric hypertrophy/eccentric hypertrophy Arteriolar nephrosclerosis/Primary granulo-contracted kidney Hypertensive encephalopathy/Hypertensive crisis /Softening of brain(microinfarct) /Microaneurysm、脑出血 视网膜变化

  9. Vascular pathology in hypertension

  10. Left ventricular hypertrophy

  11. Hypertensive heart disease with marked concentric thickening of the left ventricular wall causing reduction in lumen size

  12. HISTOPATHOLOGY INCREASED FIBER (MYOCYTE) THICKNESS INCREASED nuclear size

  13. NEEDED for DIAGNOSIS: LVH (LV>2.0 and/or Heart>500 gm.) HTN (>140/90)

  14. The minimal criteria for the diagnosis of systemic HHD are the following: • (1) left ventricular hypertrophy (usually concentric) in the absence of other cardiovascular pathology that might have induced it • (2) a history or pathologic evidence of hypertension.

  15. Accelerated/malignant hypertension • Young • 230/130mmHg • Hyperplastic arteriolosclerosis • Necrotizing arteriolitis(内膜中膜纤维素样坏死) • Renal failure(1年)

  16. HISTOPATHOLOGY ofESSENTIAL HYPERTENSION “HYALINE” = BENIGN HTN. “HYPERPLASTIC” = MALIGNANT HTN. SYS>200 1) ONION SKIN 2) “FIBRINOID” NECR.

  17. SECONDARY Renal Acute glomerulonephritis     Chronic renal disease     Polycystic disease     Renal artery stenosis     Renal artery fibromuscular dysplasia Renal vasculitis     Renin-producing tumors     Endocrine Adrenocortical hyperfunction (Cushing syndrome, primary aldosteronism, congenital adrenal hyperplasia, licorice ingestion) Exogenous hormones (glucocorticoids, estrogen [including pregnancy-induced and oral contraceptives], sympathomimetics and tyramine-containing foods, monoamine oxidase inhibitors) Pheochromocytoma, acromegaly, HYPO-thyroidism (myxedema), HYPER-thyroidism pregnancy-induced     Cardiovascular: Coarctation of aorta, polyarteritis nodosa (or other vasculitis) Increased intravascular volume MISC: Increased cardiac output, Rigidity of the aorta, neurologic, Psychogenic, Increased intracranial pressure, sleep apnea, acute stress, including, surgery

  18. INTRAPARENCHYMAL

  19. INTRAVENTRICULAR

  20. LEFT Heart Failure Dyspnea Orthopnea PND (Paroxysmal Nocturnal Dyspnea)‏ Blood tinged sputum Cyanosis Elevated pulmonary “WEDGE” pressure (PCWP) (nl = 2-15 mm Hg)

  21. HHD (Right) = COR PULMONALE ACUTE: Massive PE (No RVH) CHRONIC: COPD, CRPD, Pulmonary artery disease, chest wall motion impairment (RVH)

  22. Diseases of the Pulmonary Parenchyma Chronic obstructive pulmonary disease Diffuse pulmonary interstitial fibrosis Pneumoconioses Cystic fibrosis Bronchiectasis Diseases of the Pulmonary Vessels Recurrent pulmonary thromboembolism Primary pulmonary hypertension Extensive pulmonary arteritis (e.g., Wegener granulomatosis) Drug-, toxin-, or radiation-induced vascular obstruction Extensive pulmonary tumor microembolism Disorders Affecting Chest Movement Kyphoscoliosis Marked obesity (pickwickian syndrome) Neuromuscular diseases Disorders Inducing Pulmonary Arterial Constriction Metabolic acidosis Hypoxemia Chronic altitude sickness Obstruction to major airways Idiopathic alveolar hypoventilation

  23. RIGHT Heart Failure FATIGUE “Dependent” edema JVD Hepatomegaly (congestion)‏ ASCITES, PLEURAL EFFUSION GI Cyanosis Increased peripheral venous pressure (CVP)‏ (nl = 2-6 mm Hg)

  24. 正确的血压测量

  25. 高血压患者心血管危险分层标准 用于分层的危险因素:男性>55岁,女性>65岁;吸烟;血胆固醇>5.72mmol/L;糖尿病;早发心血管疾病家族史(发病年龄女性<65岁,男性<55岁) 靶器官损害:左心室肥厚(ECG或超声心动图);蛋白尿和/或血肌酐轻度升高(106-177μ mol/L);超声或X线证实有动脉粥样硬化;视网膜动脉局灶或广泛狭窄 并发症:心脏疾病;脑血管疾病;肾脏疾病;血管疾病;重度高血压性视网膜病变

  26. 治 疗 改善生活行为 • 减轻体重 • 减少钠盐摄入 • 补充钙和钾盐 • 减少脂肪摄入 • 限制饮酒 • 增加运动

  27. GENETIC vs.ENVIRONMENTAL GENETIC UN-CONTROLLABLE ENVIRONMENTAL CONTROLLABLE STRESS OBESITY SMOKING PHYSICAL ACTIVITY NaCl INTAKE

  28. 降压药物的联合应用

  29. 血压控制目标值: • 原则上将血压降到患者能最大耐受的水平,主张血压控制目标值至少<140/90mmHg • 合并糖尿病或慢性肾脏病者血压控制目标值<130/80mmHg • 老年收缩期性高血压的降压目标水平,收缩压140~150mmHg,舒张压<90mmHg但不低于65~70mmHg

  30. 顽固性高血压治疗 • 定义:使用了3种以上合适剂量降压药物联合治疗,血压仍未能达到目标血压 • 常见原因: 血压测量错误 降压治疗方案不合理(如无利尿剂) 药物干预降压作用 容量超负荷 胰岛素抵抗 继发性高血压

  31. 高血压病理 (小结) • 心脏:左心室肥厚和扩大;冠状动脉粥样硬化和微血管病变 • 脑:脑血管缺血和变性,易形成微动脉瘤,发生脑出血;脑动脉粥样硬化,发生脑血栓形成;脑小动脉闭塞性病变,引起腔隙性脑梗塞 • 肾脏:肾小球纤维化、萎缩,以及肾动脉硬化 • 视网膜:视网膜小动脉痉挛、硬化