内分泌高血压幻灯中.ppt_三一办公31ppt.com

2、P)肾上腺髓质素(AM)缓激肽（Bradykinin）降钙素 P 物质(Substance P),激素/血管活性物质与高血压,容量和/或血压前列环素(PGI2)一氧化氮(NO)一氧化碳(CO)内皮舒张因子(EDRF)内皮超极化因子(EDHF),激素/血管活性物质与高血压,Increased Renin Angiotensin Aldosterone Cortisol Catecholamine Endothelin EDCF GH PHF NPY Vasopressin,Decreased prostacyclin CGRP Adrenomedullin ANP,BNP,CNP EDRF B

3、radykinin NO CO PTH Substance P EDHF,BP,心血管激素与高血压 ANP ET-1 BNP eNOS HO-2 CNP,AM,NP,ET,NO,CO,VASOCONSTRICTION,VASODILATATION,心血管激素通过内分泌/旁分泌/自分泌机制调节心血管的功能和结构,ANPBNP,Endothelin(ET)CNP/AdrenomedullinNitric oxide(NO)Carbon monoxide(CO),心血管内分泌代谢学 Cardiovascular Endocrinology&Metabolism Heart-传统的循环器官&重要的内

4、分泌腺 Endothelium-做为体内最大的内分泌腺体具有分泌功能第一届国际心血管内分泌代谢学大会 The First International Conference of Cardiovascular Endocrinology and Metabolism(CVEM)已于1998年在日本举行.,Rethink Treatment,Hypertension is a Disease of Blood Vessels Vascular Biology is Altered(Structural and Functional)Target the VasculatureRisk Facto

5、rs(Traditional)Risk Factors(Nontraditional-Vascular Biology)Target Organs-Optimal Treatment,The Blood Vessel is an Organ,Largest Organ in the Body5 x Heart in Mass6 Tennis Courts in Area,The Vascular System RegulatesVascular Health and Tone ThroughChronic Active Balance Between:,Vasoconstrictors Vas

6、odilatorsGrowth Promoters Growth Inhibitors_ Vascular Tone Vascular Health(Damage),A new type of secondary hypertension Endothelin-secreting malignant hemangioendothelioma(Yokokawa et al,1991)Case 1.80 yr.F,Headache,nodule on scalp,HT(180/90)Case 2.74 yr.F,ibid.HT(160/106),Plasma ir-ET 10 fold Plasm

7、a ir-ET and BP after surgery immunostaining of ET(+)ir-ET in tissue extract(+)ET-mRNA expression(+),内分泌性高血压-非肾上腺性高血压,肾素肾血管性高血压肾素分泌瘤内皮素恶性血管内皮瘤生长激素、生长介素肢端肥大症、巨人症 T3,T4 甲状腺功能亢进症PTH,PHF 甲状旁腺功能亢进症口服避孕药女性高血压内皮功能受损糖尿病血管损伤甲状腺功能减退症,糖尿病,激素,疾病,内分泌性高血压-肾上腺性高血压,醛固酮原发性醛固酮增多症皮质醇库欣综合症皮质酮皮质酮瘤去氧皮质酮去氧皮质酮瘤 1

8、7-羟化酶缺乏症 11-羟化酶缺乏症儿茶酚胺嗜铬细胞瘤,激素,疾病,内分泌性高血压,激素机制疾病NE PR CO HR 嗜铬细胞瘤ALDO PV CO PR 原发性醛固酮增多症 F CO PR 库欣综合症AT II CO PR 肾素分泌瘤ET PR para/endo/autocrine 恶性血管内皮瘤,PR:peripheral resistance,PV:plasma volume,CO:cardiac output,原发性醛固酮增多症醛固酮瘤 aldosterone-producing adenoma(APA)特发性醛固酮增多症 idiopathic hyperaldoster

9、onism(IHA)糖皮质激素可抑制性醛固酮增多症 glucocorticoid-suppressible hyperaldosteronism(GSH)醛固酮癌 aldosterone-producing adrenal carcinoma 异位醛固酮瘤 ectopic aldosterone-producing adenoma 原发性肾上腺增生症 primary adrenal hyperplasia(PAH)肾素有反应性醛固酮腺瘤aldosterone-producing renin responsive adenoma(AP-RA),病因学,原发性醛固酮增多症,1、高血压缓慢发展的良

10、性过程，少数为恶性高血压一般降压药效果不好眼底变化与高血压程度不平行病程长者可出现心、脑、肾等并发症,临床表现,原发性醛固酮增多症,临床表现,2、高尿钾、低血钾血钾25mmol/24h 20mmol/24h 低钾血症软瘫、乏力、周期性麻痹 ECG-U波、心律失常多尿、夜尿量日尿量碱中毒、手足麻木、抽搐肾功不全,原发性醛固酮增多症,临床表现,3、糖耐量减退或糖尿病4、儿童生长发育障碍5、散发性或家族性,原发性醛固酮增多症,血清钾浓度尿钾水平醛固酮/肾素活性比值 Captopril 试验,筛选试验,原发性醛固酮增多症,Aldosterone Plasma Renin Acti

11、vity Cortisol-normal 18-hydroxycorticosterone(18-OHB)APA,PAH 100ng/dl IHA,EH 100ng/dl,诊断,原发性醛固酮增多症,CT scan-首选，薄层扫描（2-3mm)MRI-价格贵,不如 CT清楚 I 131-6-b-iodomethylnorcholesterol(NP-59)扫描肾上腺静脉插管取血 18-OHB,18-OHF测定,定位诊断,原发性醛固酮增多症,钙通道阻滞剂（CCB）安体舒通（Spironolactone）氯化钾制剂阿米诺利（Amiloride）手术-APA,PAH 地塞米松-GSH,治疗,原发性

12、醛固酮增多症,除有严重的心、脑、肾等血管病变外，大多数原醛腺瘤病人术后病情可缓解或治愈术后低血钾的纠正较快而血压恢复较慢 IHA及GSH病人需终生服药,预后,嗜铬细胞瘤（Pheochromocytoma）,诊断的临床思路病史:发作性症状三联征:头痛、心悸、多汗体位性低血压难治性高血压家族史：嗜铬细胞瘤 Von Hippel-Lindau Syndrome MEN,嗜铬细胞瘤（Pheochromocytoma）,诊断的临床思路体格检查:不稳定性、难治性高血压体位性低血压 VHLS-或 MEN-相关体征,嗜铬细胞瘤（Pheochromocytoma）,激素测定尿儿茶酚胺(NE,E,

13、DA)代谢产物(VMA,MN,NMN)血浆儿茶酚胺(NE,E,DA)Clonidine 抑制试验(if plasma CA 1000-2000pg/ml)血浆嗜铬粒蛋白 A(chromogranin A),嗜铬细胞瘤（Pheochromocytoma）,解剖定位形态学:(most sensitive,less specific)CT MRI 形态学与功能:(most specific,less sensitive)131I-metaiodobenzylguanidine(MIBG),嗜铬细胞瘤 Pheochromocytoma,药理学诊断试验 Clonidine 抑制试验 plasma ca

14、techolamine 1000-2000pg/ml clonidine 0.3mg Regitine 抑制试验 BP170/110 mmHg regitine 5mg Glucagon 激发试验 glucagon 1mg,嗜铬细胞瘤（Pheochromocytoma）,药物治疗-adrenergic blockade phentolamine 1+2 phenoxybenzamine 1 2 prazosin 1 urapidil 1 2-adrenergic blockade propranolol 1+2 atenolol 1 2 esmolol 1 calcium channel bl

15、ockades ACE inhibitors nitroprusside,嗜铬细胞瘤（Pheochromocytoma）治疗,131-I-MIBG-甲基酪氨酸（-methyl paratyrosine）血液动力学监测（Hemadynamic monitor）血容量补充手术,嗜铬细胞瘤Pheochromocytoma rule of 10s 10%双侧 10%肾上腺外 10%腹腔外 10%恶性 10%家族性 10%儿童 10%血压正常,Characteristics of Endocrine Hypertension,Morbidity-1.1%,4.7-7.9%,more?Etiology-hormones secrete abnormal Pathogenesis-effects of hormones on PVR,CO,CI,HR,VSMC,et al.Curability-remove tumor,Think it firstDiagnose it earlyTreat it correctlyCure it probably,Endocrine Hypertension,

展开阅读全文