hypertension

Hypertension

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

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

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）

PREVALENCE:• WHAT % of USA people have

hypertension?

PREVALENCE:• WHAT % of USA people have

hypertension?

• Answer: 25%

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

Hypothetical scheme for the pathogenesis of essential hypertension

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

Vascular pathology in hypertension

Left ventricular hypertrophy

Hypertensive heart disease with marked concentric thickening of

the left ventricular wall causing reduction in lumen size

HISTOPATHOLOGY• INCREASED FIBER (MYOCYTE)

THICKNESS

• INCREASED nuclear size

NEEDED for DIAGNOSIS:

• LVH (LV>2.0 and/or Heart>500 gm.)

• HTN (>140/90)

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.

Accelerated/malignant hypertension

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

HISTOPATHOLOGY ofESSENTIAL HYPERTENSION

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

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

INTRAPARENCHYMAL

INTRAVENTRICULAR

LEFT Heart FailureDyspnea

Orthopnea

PND (Paroxysmal Nocturnal Dyspnea)

Blood tinged sputum

Cyanosis

Elevated pulmonary “WEDGE” pressure (PCWP) (nl = 2-15 mm Hg)

HHD (Right) = COR PULMONALE

• ACUTE: Massive PE (No RVH)

• CHRONIC: COPD, CRPD, Pulmonary artery disease, chest wall motion impairment (RVH)

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 MovementKyphoscoliosisMarked obesity (pickwickian syndrome)Neuromuscular diseases

Disorders Inducing Pulmonary Arterial ConstrictionMetabolic acidosisHypoxemiaChronic altitude sicknessObstruction to major airwaysIdiopathic alveolar hypoventilation

RIGHT Heart FailureFATIGUE

“Dependent” edema

JVD

Hepatomegaly (congestion)

ASCITES, PLEURAL EFFUSION

GI

Cyanosis

Increased peripheral venous pressure (CVP) (nl = 2-6 mm Hg)

正确的血压测量

其他危险因素和病史

血压 (mmHg)1 级 （收缩压 140 ～159 或舒张压 90 ～99 ）

2 级 （收缩压 160 ～179 或舒张压 100 ～109 ）

3 级 （收缩压≥ 180或舒张压≥ 110 ）

无其他危险因素 低危 中危 高危1 ～ 2 个危险因素 中危 中危 极高危3 个以上危险因素，或糖尿病，或靶器官损害 高危 高危 极高危

有并发症 极高危 极高危 极高危

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

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

GENETIC vs.ENVIRONMENTAL

• GENETIC UN-CONTROLLABLE

• ENVIRONMENTAL CONTROLLABLE– STRESS– OBESITY– SMOKING– PHYSICAL ACTIVITY– NaCl INTAKE

降压药物的联合应用

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

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

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