高血压英文ppt精品课件hypertensive heart _1
Hypertensive Heart Disease,Gene Bukhman January 12th, 2005,Epidemiology I,Number of Patients with Hypertension in the United States: 50 million Number of Patients with Heart Failure: 5 million Percent of Heart Failure Patients with Hypertension: 75%,JNC 7. 2004 Jessup and Brozena. NEJM. 2003,Mosterd et al. NEJM. 1997,Mortality in Hypertension,50% from ischemic heart disease or heart failure 33% from cerebrovascular disease 10 to 15% from renal failure,Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005,Hypertensive Heart Disease,Coronary Artery Disease Heart Failure Diastolic Dysfunction Impaired relaxation Left ventricular myocyte hypertrophy Interstitial fibrosis Systolic Dysfunction Ischemic cardiomyopathy Late consequence of afterload Arrhythmias Atrial fibrillation Left atrial enlargement Ventricular Arrythmias,Kaplan in Zipes, Libby, Bonow, and Braunwald. 2005,Left Ventricular Hypertrophy I,Concentric increase in LV mass Compensatory response to increased afterload Collagen Myocyte hypertrophy,Lorell and Carabello. Circulation. 2000,Left Ventricular Hypertrophy II,Effect of mechanical loading most clear in rapid regression following aortic valve replacement In systemic hypertension confounded by role of angiotensin II and sympathetic hormones LVH often develops after other signs of diastolic dysfunction in HTN LVH also seen to precede development of systemic HTN,Lorell and Carabello. Circulation. 2000,Jessup and Brozena. NEJM. 2003,Consequences of LVH,Although initially compensatory, LVH ultimately associated with risk of cardiovascular events similar to history of prior myocardial infarction Ischemia Decreased coronary reserve with increased LV mass angina Greater risk of death following myocardial infarction Heart Failure Depressed LV systolic and diastolic function Arrhythmia Atrial fibrillation Ventricular arrhythmias Nonuniform action potential prolongation Altered repolarization Specific vulnerability to torsades Ischemic ventricular arrhythmia,Dunn and Pfeffer. NEJM. 1999,Echocardiography Findings in Systemic HTN,Left atrial enlargement Mitral annular calcification Mild to moderate mitral regurgitation Aortic root dilatation Aortic valve sclerosis Mild aortic regurgitation Diastolic dysfunctionImpaired relaxationRestrictive pattern Reduced ejection fraction Usually late consequence with ventricular dilatation Symmetric left ventricular hypertrophy,Otto. 2000,Aurigemma and Gaasch. NEJM. 2004,Diastolic Dysfunction,Aurigemma and Gaasch. NEJM. 2004 Redfield. NEJM. 2004,Possible Role of LVH determination in systemic HTN,Selection of patients for treatment Choice of treatment agent Monitoring,Echocardiographic evaluation of LVH,Framingham adds echocardiography in 1979 ECG probably has 1/8th the sensitivity of echocardiography Probably 20 percent prevalence in those over 40 years old Present in 20 to 30 percent of otherwise low risk patients with HTN,Lorell and Carabello. Circulation. 2000,Multiple methods of echocardiographic left ventricular mass calculation,LVM = 0.8 x 1.04 x (LVID + LVPWT + IVST)3 LVID3 Limits set by 2 standard deviations of the Framingham cohort mean Poor reproducibility Possible advantage of cardiac MR (Manning 2004),Lorell and Carabello. Circulation. 2000,Treatment of Hypertension and Absolute Cardiovascular Risk,Benefit of treatment proportional to overall cardiovascular risk Risk increases with level of blood pressure without clear threshold,MacMahon. NEJM. 2000,LVH and treatment of HTN,Regression of LVH with treatment by all classes of agents except direct vasodilators Possible superiority of ace inhibitors and angiotensin receptor blockers Not clear if benefit to LVH regression independent from overall benefit of blood pressure reduction,Losartan Intervention for endpoint reduction (LIFE) trial,Dahlof et al. Lancet. 2002,ACC/AHA/ASE 2003 Guidelines: Echocardiography in HTN I,Class I Indications: 1. When assessment of resting LV function, hypertrophy, or concentric remodeling is important in clinical decision making 2. Detection and assessment of functional significance of concomitant CAD by stress echocardiography. 3. Follow-up assessment of LV size and function in patients with LV dysfunction when there has been a documented change in clinical status or to guide medical therapy.,Cheitlin et al. ACC/AHA/ASE. 2003,ACC/AHA/ASE 2003 Guidelines: Echocardiography in HTN II,Class IIa Indications: 1. Identification of LV diastolic filling abnormalities with or without systolic abnormalities. 2. Assessment of LV hypertrophy in a patient with borderline hypertension without LV hypertrophy on ECG to guide decision making regarding initiation of therapy. A limited goal-directed echocardiogram may be indicated for this purpose.,Cheitlin et al. ACC/AHA/ASE. 2003,ACC/AHA/ASE 2003 Guidelines: Echocardiography in HTN III,Class IIb Indications: 1. Risk stratification for prognosis by determination of LV performance.Class III Indications: 1. Re-evaluation to guide antihypertensive therapy based on LV mass regression. 2. Re-evaluation in asymptomatic patients to assess LV function.,