继发性高血压筛查的时机与治疗国家心血管病中心阜外医院-高血压中心国家心血管病中心高血压专病医联体天津市中心目录1.继发性高血压定义和流行病学2.继发性高血压病因3.继发性高血压筛查时机与治疗•继发性高血压(secondaryhypertension)–是病因明确的高血压，当查出病因并有效去除或控制病因后，作为继发症状的高血压可被治愈或明显缓解。–继发性高血压在高血压人群中占5%-10%，但随着对高血压发病机制研究的深入以及诊断技术的不断提高，这比例正逐渐上升。定义及流行病学•肾实质性•肾血管性•肾外伤性肾性•甲状腺•肾上腺•垂体内分泌性•睡眠呼吸暂停综合征睡眠呼吸疾病•主动脉缩窄•动静脉瘘•主动脉瓣关闭不全机械性血流障碍•脑肿瘤•脑外伤•自主神经功能异常神经源性•中毒•药物外源性•妊娠期高血压•真性红细胞增多症其他继发性高血压分类1.发病年龄<30岁且无高血压家族史；2.血压增高的幅度大，常达高血压3级（>180/110mmHg）；3.血压难以控制,需要使用三种或以上降压药；4.常用的五大类降压药物效果不佳；5.血压波动大或阵发性高血压；6.坚持服药情况下控制良好的血压突然明显升高；7.双上肢血压不对称；8.体检闻及血管杂音；9.未服用或服用小剂量利尿剂即出现明显低血钾，排除进食差、腹泻等诱因；10.服用ACEI/ARB后出现肾功能的急剧恶化，血肌酐明显升高；11.高血压伴有尿常规异常，如大量蛋白尿，多量红白细胞等；12.急性心力衰竭或一过性肺水肿，尤其以晨起和夜间多见；13.单侧肾萎缩。继发性高血压筛查重点人群1a)CKD家族史（多囊肾）b)肾病、尿路感染、血尿、滥用止痛剂（肾实质疾病）c)药物/化学物质的摄入，如口服避孕药、甘草、甘草次酸、血管收缩滴鼻剂、可卡因、安非他命、糖/盐皮质激素、NSAID、EPO、环孢素d)反复发作出汗、头痛、焦虑、心悸（嗜铬细胞瘤e)发作性肌肉无力及抽搐（醛固酮增多症）f)甲状腺疾病症状2013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTable8Personalandfamilymedicalhistory1.DurationandpreviouslevelofhighBP,includingmeasurementsathome.2.Secondaryhypertensiona)FamilyhistoryofCKD(polycystickidney).b)Historyofrenaldisease,urinarytractinfection,hematuria,analgesicabuse(parenchumalrenaldisease).c)Drug/substanceintake,e.g.oralconteaceptives,liquorice,carbenoxolone,vasoconstrictivenasaldrops,cocaine,amphetamines,gluco-andmineralocorticosteroids,non-steroidalanti-inflammatorydrugs,erythropoietin,cycolsporine.d)Repetitivecpisodesofsweating,headache,anxiety,palpitations(pheochromocytoma).e)Episodesofmuscleweaknessandtetany(hyperaldosteronism).f)Symptomssuggestibeofthyroiddisease.3.Riskfactors病史•Cushing综合征体征•神经纤维瘤病的皮肤改变（嗜铬细胞瘤）•触诊肾脏肿大（多囊肾）。•听诊腹部杂音（肾血管性高血压）。•听诊心前区或胸部杂音（主动脉缩窄，主动脉疾病;上肢动脉疾病）•上下肢血压差异（主动脉缩窄，主动脉疾病，下肢动脉疾病）•左右臂血压差异（主动脉缩窄;锁骨下动脉狭窄）。22013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTable9Physicalexaminationfousecondaryhypertension,organdamageandobesitySignssuggestingsecondaryhypertension•FeaturesofCushingsyndrome.•Skinstigmataofneurofibromatosis(pheochromocytoma).•Palpationofenlargedkidneys(polycustickidney).•Auscultationofabdominalmurmurs(renocascularhypertension).•Auscultationofprecordialorchestmurmurs(aorticcoarctation;aorticdisease;upperextremityarterydisease).•DiminishedanddelayedfemoralpulsesandreducedfenoralbloodpressurecomparedtosimultaneousarmBP(aoriticcoarctation;aorticdisease;lowerextremityarterydisease).•Left-rightarmBPdifference(aorticcoarctation;subclavianarterystenosis).Signsoforgandamage体格检查3常规•血红蛋白、红细胞压积。•空腹血糖•TC、LDL-C、HDL-C、TG•血清钾，钠。•血清尿...
