难治高血压治疗再评价.pptVIP

传统将难治性高血压定义为：合理、全量、联合使用三类降压药物（其中包括利尿剂）的治疗后，血压仍难以达到目标水平。一般认为目标血压为：普通人群血压140/90mmHg，糖尿病患者或是有肾功能损害[血肌酐133μmol/L，或尿蛋白300mg/24h]患者血压≤130/80mmHg。2005年版中国高血压防治指南提出：在应用改善生活方式和至少3种抗高血压药物治疗的措施持续3个月以上，仍不能将收缩压和舒张压控制在目标水平时，称为难治性高血压Framinghan研究显示BMI30kg/m2比BMI25kg/m2者不能控制血压高50%，HYDRA研究证实BMI40kg/m2需3~4种抗高血压药物控制血压比BMI25kg/m2者分别高5.3和3.2倍.老年假性高血压一些表现为难治性高血压的老年患者,可能由于严重的动脉粥样硬化和钙化可导致血压测量不准确,一般可通过Osers试验辅助诊断,即在将袖带充气使压力超过收缩压20mmHg以上,若仍能触及桡动脉搏动则提示假性高血压可能。此种情况下为确定实际血压水平可以通过桡动脉穿刺直接测压ObesityMechanismsofobesity-inducedhypertensionarecomplexandnotfullyelucidatedbutincludeimpairedsodiumexcretion,increasedsympatheticnervoussystemactivity,andactivationoftherenin-angiotensin-aldosteronesystemdietarySaltExcessivedietarysodiumintakecontributestothedevelopmentofresistanthypertensionboththroughdirectlyincreasingbloodpressureandbybluntingthebloodpressure–loweringeffectofmostclassesofantihypertensiveagents.25–27Theseeffectstendtobemorepronouncedintypicalsalt-sensitivepatients,includingtheelderly,AfricanAmericans,and,inparticular,patientswithCKD.28Althoughexcessivedietarysodiumisfairlywidespread,ithasbeenspecificallydocumentedasbeingcommoninpatientswithresistanthypertension.Inananalysisofpatientsreferredtoauniversityhypertensioncenterforresistanthypertension,averagedietarysaltingestionbasedon24-hoururinarysodiumexcretionexceeded10gaday.23AlcoholHeavyalcoholintakeisassociatedwithbothanincreasedriskofhypertension,aswellastreatment-resistanthypertension.Inacross-sectionalanalysisofChineseadultsingesting30drinksaweek,theriskofhavingvariousformsofhypertensionincreasedfrom12%to14%.29InaFinnishhypertensionclinic,heavydrinkers,assuggestedbyincreasesinlivertransaminaselevels,weremuchlesslikelytohavetheirbloodpressurecontrolledduringa2-yearfollow-upcomparedwithpatientsw