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高血压:一般治疗 – 译学馆
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高血压:一般治疗

Hypertension: General Treatment – Family Medicine | Medical Video

那么继发性高血压呢
What about secondary hypertension?
我们何时会遇到呢
When do you see that?
个人认为 继发性高血压很少见
I think a secondary hypertension, it’s rare.
在高血压病例中只占10%
It’s only up to 10% of cases of hypertension.
或者还没这么多
It’s probably less than that.
但应注意 面对中年人群
But especially in a middle-aged adult,
如果他们就诊时血压特别高
when they come in with a very high blood pressure,
尤其是在一线用药没有很好地控制住血压的情况下
and particularly a blood pressure that’s not well controlled on initial therapy,
你可以考虑给出其他的诊断
you can consider some differential diagnosis.
甲状腺疾病诊断起来很容易 并且十分常见
Thyroid disease is very easy to test for and pretty common,
但通常会伴有其他症状
but often times it will also be associated with other symptoms,
如果是甲亢 他们会有心率加快的症状
and a pulse, if they’re hyperthyroid, that’s high.
所以你可以通过病史判断
So, therefore you can ferret out
他们是否患有甲状腺疾病
that they have thyroid disease from other historical factors.
无明显诱因的血压升高
It’s rare when it’s just sitting there and the only symptom
真的很少见
it’s really, you know, causing his high blood pressure.
醛甾酮过多症 或者说原醛症 也是病因之一
Hyperaldosteronism can be a problem, Conn’s syndrome.
所以需要检查与原醛症有关的电解质是否存在异常
So look for electrolyte abnormalities associated with that.
肾动脉狭窄是引起继发性高血压最常见的原因
Renal artery stenosis is the most common cause of secondary hypertension.
对于一个中年人来说
And if it’s middle-aged adults,
他患获得性肾动脉狭窄的可能性
you are probably talking about acquired renal artery stenosis,
比患先天性肾动脉狭窄的可能性大得多
as opposed to congenital renal artery stenosis.
这就需要关注病人的GFR 即肾小球滤过率
This in a watch what their GFR, their glomerular filtration rate, is doing.
还要监测肌酐水平
Watch their creatinine levels.
但一般还要结合辅助检查进行分析
But it often needs analysis with something like
比如电子计算机断层扫描或者肾动脉磁共振血管成像
either a CT or magnetic resonance angiography of the renal arteries.
而嗜铬细胞瘤 虽然我们大家都很关注
And pheochromocytoma, we all worry about it.
但实际上是相当罕见的
It’s actually incredibly rare.
还有就是 这些病人通常伴有其他症状
And again, these patients usually have other symptoms,
比如震颤 多汗和体重减轻
tremor, sweating, and weight loss,
这些症状都表明
that can give away the fact
患者体内儿茶酚胺浓度过高
that they have this excess of catecholamines.
我们基本不会见到
It’s rare that just,
没有诱因的血压升高
oh, the blood pressure is elevated by itself.
那么当患者确诊高血压后
What do you do to evaluate patients
你该如何评估患者的病情呢
once they’re diagnosed with hypertension?
每位患者都应该做一个基线心电图检查
Everybody gets a baseline electrocardiogram,
以确认是否存在左室肥厚或早期心肌损伤等疾病
looking for things like left ventricular hypertrophy or prior cardiac damage.
还要查血糖或者HbA1c水平
A glucose level or an HbA1c,
来判断患者是否有糖尿病
something to screen for diabetes,
还要做针对高脂血症的检查
something to screen for hyperlipidemia.
还要查肾功能和电解质以及血红蛋白含量
A check of their electrolytes along with their kidney function as well as a hemoglobin level.
还要检查尿常规或者微量白蛋白/肌酐比值
And urinalysis or a microalbumin/creatinine ratio
用来排除蛋白尿和早期肾病的可能性
to check for the possibility of proteinuria and early kidney disease.
这些都是你必须做的
That’s your baseline.
这些重要指标一定要定期复查
And these essentially should be repeated at least
比如说电解质和尿常规至少每年要查一次
when we talk about the electrolytes, the urinalysis on an annual basis.
至少 至少每年要查一次
And at least. At least on an annual basis.
我们说过 改变生活方式
Remember the lifestyle changes are still
是治疗高血压的基础
at the foundation for the treatment of hypertension.
事实上 如果你去了解一下DASH饮食
And actually if you look at something like the Dietary Approaches to Stop Hypertension,
平均血压下降11.5/5.5毫米汞柱的成果
that reduction on average with 11.5 or 5.5 points of mercury
是非常值得一提的
is really remarkable.
这比多数降压药的效果还要好
That’s more powerful than most antihypertensive agents.
而且显然 患者执行了高血压防治计划之后
And, obviously, patients can do a DASH.
在其他许多方面也能受益
That’s gonna yield other good things
比如胆固醇水平 新陈代谢水平 体重等等
in terms of their cholesterol and their metabolism, their body weight,
也就是说这种饮食在其他方面也有很大价值
so there are side benefits to that diet that are really wonderful,
不过最让人瞩目的还是这种饮食的降压效果
but that reduction in blood pressure values is outstanding.
体重下降对降压自然也是有帮助的
Weight loss certainly promotes a lower blood pressure as well,
这也是减肥手术的好处之一
so that’s one of the benefits of, say, bariatric surgery.
减肥手术后体重的显著下降
A lot of patients are cured of hypertension,
让许多患者的高血压被治愈
following the significant weight loss they experience with bariatric surgery.
即便是通过节食和运动减下来4公斤
But even following a good diet and exercise and losing 4 kilos
也能让血压显著下降
can result in significant reduction in blood pressure.
而且 就像我之前提到的
And exercise, as I mentioned, in and of itself,
运动本身也可以降低血压
can reduce blood pressure as well,
这些其实是最重要的
so these are the keys.
但实际上我们还是会发现 对于部分患者来说
And you can see that if you put all of these things together,
即便节食和运动都很好地做到了
many patients wouldn’t, you know, could avoid medical therapy completely
仍然可能无法完全规避药物治疗
if they really embraced diet and exercise.
接下来再看看我们的病例
So let’s return to our case.
最近她来复诊了
She’s actually come back to clinic now.
很遗憾
And a repeat blood pressure, unfortunately,
尽管过去的两周里她尽力改变了生活方式
despite trying to do her lifestyle changes in the past 2 weeks,
她的血压还是没有下降 仍然是150/94
is 150/94.
心率86次每分钟
Her pulse is 86 beats per minute.
现在怎么办
So now what do you wanna do?
你想让她继续通过改变生活方式来降压
Do you want to allow 6 months for lifestyle changes
坚持到做满6个月为止吗
to have an effect since she started them?
你想现在就开始使用噻嗪类利尿剂
Do you want to start a thiazide diuretic,
或者α肾上腺素能受体阻滞剂或β受体阻滞剂吗
start an alpha adrenergic blocker or start a beta blocker?
你想怎么做
Which one would you choose?
我可能会使用噻嗪类利尿剂
I would go with a thiazide diuretic.
因为指南里说这是一线用药
That is recommended as a first-line therapy by JNC 8.
这些是高血压治疗方案中排在改变生活方式后的一线用药
So here are the first-line treatments after lifestyle for hypertension.
指南在这方面给出的建议是开放性的
And JNC 8 left this fairly open.
还是那句话 这些只是建议
And again, these are only recommendations,
不过我觉得这些建议还是具有普遍性的
but the recommendations are broad
还是能适用于大多数患者的
and catch most patients I think.
噻嗪类利尿剂对于患者来说是一个很好的选择
Thiazide diuretics are great option for patients.
每当我要使用利尿剂时
One thing whenever I prescribe a diuretic is that
我都会询问患者是否有泌尿系疾病
I will ask them if they have any urinary issues.
许多高龄患者会有膀胱过动症或良性前列腺肥大
Many older adults have overactive bladder or benign prostatic hypertrophy,
因此可能已然存在泌尿生殖系统的不适
and therefore already maybe struggling with genitourinary issues.
我不想因为使用噻嗪类利尿剂而加重这种不适
I don’t want to exacerbate that by giving them a thiazide diuretic.
所以我会为他们选择一些其他的方案
I would choose something else for those patients.
还有一件事 在单纯使用噻嗪类药物时
The other thing is prescribing a thiazide alone,
要密切监测血钾水平
watch closely for the potassium,
因为噻嗪类可能导致低钾血症
because thiazide promotes hypokalemia.
而血管紧张素转换酶抑制剂和血管紧张素Ⅱ受体拮抗剂
Whereas ACE inhibitors and ARBs
同样是一线用药 它们可能导致高钾血症
also considered a first-line agent can promote hyperkalemia.
所以 将它们与噻嗪类药物联合使用
So therefore, a combination of one of those agents with a thiazide
会对维持患者血钾正常更有好处
is helpful in terms of maintaining normokalemia.
而钙离子通道阻滞剂的副作用范围和其他药物不同
And calcium channel blockers have their own range of side effects,
不过有一点 它们对电解质的影响不大
but one thing they don’t do much is affect electrolytes.
还有一点需要注意
It’s also worth noting
指南不推荐使用阿替洛尔
that atenolol is not recommended by JNC8.
因为它对降低心血管疾病死亡率的贡献
It doesn’t confer overall the same mortality benefit for cardiovascular disease
比其他药物低很多
that these other agents maintain.

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视频概述

继发性高血压的分类及诊疗

听录译者

【MED】清泉

翻译译者

【MED】清泉

审核员

审核员E

视频来源

https://www.youtube.com/watch?v=Y037iWa773g

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