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继发性高血压诊断意义及筛查策略什么是高血压2013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTheTaskForceforthemanagementofarterialhypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC)高血压症状大多数高血压没有明显症状部分高血压患者会出现如下症状•头痛、头晕•失眠•耳鸣•手脚麻木、颈背部肌肉酸痛、紧张高血压风险等级2013ESH/ESCGuidelinesforthemanagementofarterialhypertensionTheTaskForceforthemanagementofarterialhypertensionoftheEuropeanSocietyofHypertension(ESH)andoftheEuropeanSocietyofCardiology(ESC)高血压的危害KearneyPM,WheltonM,ReynoldsK,MuntnerP,WheltonPK,HeJ.Globalburdenofhypertension:analysisofworldwidedata.Lancet.2005;365(9455):217-23.高血压人群状态中国中国中国高血压人群KearneyPM,WheltonM,ReynoldsK,MuntnerP,WheltonPK,HeJ.Globalburdenofhypertension:analysisofworldwidedata.Lancet.2005;365(9455):217-23.继发性高血压筛查历史继发性高血压筛查现状Theprevalenceofsecondaryformsofhypertensionwas10.2%,including•renovascularhypertension(3.1%),•primaryaldosteronism(1.4%),•Cushing'ssyndrome(0.5%),•pheochromocytoma(0.3%),•primaryhypothyroidism(3.0%)Conclusions:Increasingageandcoexistingatherosclerosishavesignificanteffectsontheprevalenceofsecondaryformsofhypertension.Theeffectofageonprevalenceofsecondaryformsofhypertensionin4429consecutivelyreferredpatientsAnderson,GunnarH.Jr;Blakeman,Nancy;Streeten,DavidH.P.继发性高血压筛查现状继发性高血压的发病率为10.2%,包含肾血管性高血压3.1%，原发性醛固酮增多症1.4%，库欣综合征0.5%，嗜铬细胞瘤0.3%，原发性甲状腺功能减退3.0%；结论：年龄的增长及伴随的动脉粥样硬化疾病，与继发性高血压的发病率存在明显的关系。继发性高血压筛查意义继发性高血压诊断的意义在于，将有可能将不可治愈的疾病变成可以治愈的疾病。哪怕潜在疾病可能无法治愈，也可通过提供特异性的治疗方案使血压得到更好的控制，同时，潜在的疾病通常会造成比血压升高更加严重的后果，因此需要对其进行治疗。常见的内分泌高血压ProspectiveStudyonthePrevalenceofSecondaryHypertensionamongHypertensivePatientsVisitingaGeneralOutpatientClinicinJapanMasaoOMURA,JunSAITO,KunioYAMAGUCHI,YukioKAKUTA,andTetsuoNISHIKAWA•原发性醛固酮增多症•库欣综合征•嗜铬细胞瘤•肢端肥大症肾素--血管紧张素--醛固酮系统（RAAS）RAAS系统原发性醛固酮增多症症状•高血压•原因未知的低血钾特点•症状无特异性•与麻痹、肌无力临床症状相似筛查项目•肾素活性PRA•肾素浓度PRC•醛固酮浓度ALD药物在原醛筛查中的影响药物种类临床常用药物对ARR比值影响β-受体阻断剂美托洛尔、阿替洛尔及艾可洛尔等肾素↓ARR↑ACE抑制剂、AT1受体拮抗剂依那普利、西拉普利、缬沙坦、氯沙坦等醛固酮↓肾素↑ARR↓钙通道阻断剂硝苯地平、氨氯地平等无显著影响利尿剂呋塞米、乙噻嗪等无显著影响原发性醛固酮增多症筛查ThePAC/PRCratiooffersseveralpracticaladvantagescomparedwiththePAC/PRAscreeningmethod.ThepresentstudyofferspreliminaryevidencethatitmaybeausefulscreeningtestforPHA.针对原发性醛固酮增多症，PAC/PRC的比值，相比于PAC/PRA的筛查方法更加有效和实用，目前的研究已经提供了其可以作为一个有效筛查工具的初步证据。原发性醛固酮增多症RapidScreeningTestforPrimaryHyperaldosteronism:RatioofPlasmaAldosteronetoReninConcentrationDeterminedbyFullyAutomatedChemiluminescenceImmunoassaysFrankHolgerPerschel,1*RudolfSchemer,3LysannSeiler,4MartinReincke,4JaapDeinum,5ChristianeMaser-Gluth,6DavidMechelhoff,1RudolfTauber,1andSvenDiederich2ClinicalChemistry2004国外的研究进展及结论ARR比值的应用和现状•基层临床机构原醛症的普及筛查•高端医疗机构的原醛症的确认诊断•标准化降压药物药效研究和对AARR筛查的影响•单一降压药物对AARR筛查比值的影响•研究方法学一致性•Cut-off无法实现互换性，PA筛查率差异很大ARR与AARR的差异•AARR-AldosteroneActiveReninRatio•醛固酮/活性肾素比值-PAC/PRC•ARR-AldosteroneReninRatio•血液醛固酮/活性肾素-PAC/PRA•ARR单位ng/ml/hour酶活力单位•ARR参考范围20-30ng/ml/hour•AARR参考范围32Recentstudiesusingtheratioofplasmaaldosteroneconcentration(PAC)toPRAasthescreeningtestforprimaryaldosterondisminhypertensivepopulationssuggestedthattheprevalencemaybeashighas5–15%.-PrevalenceofPrimaryAldosterondismamongAsianHypertensivePatientsinSingaporeKEH-CHUANLOH,EVELYNS.KOAY,MIN-CHEHKHAW,SHANTAC.EMMANUEL,ANDWILLIAMF.YOUNG,JR.ARR筛查发展ARR比值20ng/dl，且PAC浓度15pg/ml原醛症检出率4.6%-Loh,2000MayoClinicPA筛查率4.6%StowasserM调整对ARR筛查影响小的降压药物后，确认PA检出率18%影响因素•样本人群•药物种类和干扰•原醛症筛查思路•血钾浓度•检测系统特异性原醛症的筛查思路原醛症的筛查和诊断策略Minireview:PrimaryAldosteronism—ChangingConceptsinDiagnosisandTreatmentWILLIAMF.YOUNG,JR.ProfessorofMedicine,MayoMedicalSchool;Consultant,DivisionofEndocrinology,Metabolism,NutritionandInternalMedicine,MayoClinicandMayoFoundation,Rochester,Minnesota55905原醛症的确认诊断•盐抑制试验•盐水负荷试验•氟氢可的松抑制试验ComparisonofConfirmatoryTestsfortheDiagnosisofPrimaryAldosteronismPaoloMulatero,AlbertoMilan,FrancescoFallo,GiuseppeRegolisti,FrancescaPizzolo,CarlosFardella,LorenaMosso,LisaMarafetti,FrancoVeglio,andMauroMaccario原醛症的确认诊断SaltLoadingTestisareasonablygoodalternativetothemoreexpensiveandcomplexFSTforthediagnosisofPAafterapositivescreeningtest.JClinEndocrinolMetab91:2618–2623,2006•操作简单、实用性高•可对门诊病人进行操作•可替代氟氢可的松抑制试验，可信度高ComparisonofConfirmatoryTestsfortheDiagnosisofPrimaryAldosteronismPaoloMulatero,AlbertoMilan,FrancescoFallo,GiuseppeRegolisti,FrancescaPizzolo,CarlosFardella,LorenaMosso,LisaMarafetti,FrancoVeglio,andMauroMaccario筛查常用辅助筛查手段CT影像学的局限性CTScanning,thereforeclearlylocalizesadenomasin50%ofhistologicallyprovencases,andcanalsoproducemisleadingresults.-RoleforadrenalvenoussamplinginprimaryaldosteronismWilliamF.Young,Jr,MD,AnthonyW.Stanson,MD,GeoffreyB.Thompson,MD,CliveS.Grant,MD,DavidR.Farley,MD,andJonA.vanHeerden,MB,ChB,Rochester,Minn筛查常用辅助筛查手段MagneticResonanceImaging-磁共振成象磁共振成象在诊断醛固酮分泌腺瘤APA时具有高度的特异性。正如非功能性亢进肿瘤一样，醛固酮分泌腺瘤APA和双侧肾上腺增生BAH，能够通过磁共振成象显示出细胞内脂质移动的图象。RoleforadrenalvenoussamplinginprimaryaldosteronismWilliamF.Young,Jr,MD,AnthonyW.Stanson,MD,GeoffreyB.Thompson,MD,CliveS.Grant,MD,DavidR.Farley,MD,andJonA.vanHeerden,MB,ChB,Rochester,Minn筛查常用辅助筛查手段AdrenalVeinSampling-肾上腺静脉采血OnthebasisofCTfindingsalone,42patients(21.7%)wouldhavebeenincorrectlyexcludedascandidatesforadrenalectomy