趙怡荏 1 陳昭源 2 林忠順 3 前言 10 20% 9 0 9 5 % (essential hypertension) 5 10% (secondary hypertension) 5%NSAID ; 5% ; (pheochromocytoma) ( p r i m a r y h y p e r a l d o s e r o n i s m ) ( C u s h i n g s y n d r o m e ) ( c o a r c t a t i o n ) (Acromegaly) 1% 1 林口長庚醫院家庭醫學科總醫師 2 林口長庚醫院家庭醫學科主治醫師 3 林口長庚醫院家庭醫學科主任 secondary hypertension, Pheochromocytoma, aldosteronism, Cushing Syndrome, Renovascular disease 高血壓病患應該何時做續發性高血壓的篩檢? 1. ( 3 ) 2. 3. 30 4. 552 (BP 160/100mmHg) 常見續發性高血壓的原因及其臨床症狀 1. 腎血管性高血壓 1% 10 45% 268
2 0 0 5 A m e r i c a n C o l l e g e o f Cardiology/American Heart Association (ACC/AHA) guidelines 1. 30 ( ) 2. 55stage II ( 160/100 mmhg) 3. ( ) 4. 5. ( ) 6. Angiotensin II Receptor Blockers (A R B) A n g i o t e n s i n-c o n v e r t i n g E n z y m e I n h i b i t o r s ( A C E I ) Creatinine 2. 腎實質性高血壓 - - ( R e n i n - A n g i o t e n s i n - Aldosterone System) Creatinine 3 嗜鉻細胞瘤 catecholamines 10% 1 0 % 1 0 % 10%10% 4. 原發性醛固酮分泌過多症 269
5. 睡眠呼吸中止症 6. 藥物引起或與藥物相關 (1) 30 g 15 mmhg 7 10 mmhg (2) (licorice) carbenoxolone ( ) (mineralocorticosteroid) (3) (corticotropin, ACTH) (4) (nonsteroid antiinflammatory drug, NSAID) indomethacin (5) phenylpropanolamine (catecholamine) (MAO inhibitor) pargyline ( t y r a m i n e ) 7. 主動脈縮窄 270
表 1 導致高血壓或影響高血壓控制的藥物 1.estrogen-containing oral contraceptives (30-to 35 mcg estrogen oral contraceptives) 2.Non-steroidal anti-inflammatory drugs (Ibuprofen,naproxen,piroxicam) 3.Sympathomimetics (e.g. phenylpropanolamine, ephedrine) in cold cures or nasal decongestants,cocaine and amphetamines,nicotine 4.Immunosuppressive agents( Corticosteroids,tacrolimus,Cyclosporine) 5.COX-2 inhibitors(celecoxib,rofecoxib,valdecoxib) 6.Carbenoxolone 7.Sodium bicarbonate 8.Erythropoietin 9.Ergotamine 10.Monoamine oxidase inhibitors (Phenelzine,phenelzine) (with tyramine-containing foods) 11.Weight-loss agents(sibutramine,phentermine) 12.Mineralocorticoids(Fludrocortisone) 13.Antiparkinsoniam(Bromocriptine) 14.Anabolic steroids (Testosterone) 資料來源 : Onusko E: Diagnosing Secondary Hypertension. Am Fam Physicians. 2003; 67: 67-74. ductus arteriosus 8. 其他內分泌疾病 (1) hypothyroidism (2) (3) (glucocorticoids) (mineralocorticoid) (moon face) (plethora) buffalo hump) (supraclavicular fat pad) (abdominal striae) 續發性高血壓的評估與診斷 1. 嗜鉻細胞瘤 catecholamine (a) Urine Catecholamines: vanillyl mandelic acid 271
表 2 有以下臨床特點, 須懷疑其高血壓有續發性病因 Finding 陣發性高血壓, 頭痛, 發汗, 心悸, 心搏過速 服用特定藥物 體重增加, 疲勞, 乏力, 多毛症, 無月經, 月亮臉, 腹部紫色條紋, 軀幹肥胖, 低血鉀 收縮期 / 舒張期腹部雜音 延遲或微弱的股動脈脈搏不正常的胸部 X 光 蛋白尿, 血尿,BUN 上昇,Cr 上昇, 水腫 高血鈉症, 低血鉀 (Na,K ) 肌肉無力, 多尿 打鼾, 白天嗜睡, 肥胖 使用交感神經興奮劑, 急性壓力, 心搏過速 高鹽攝取, 過量飲酒, 肥胖 腎病的病人使用 EPO 慢性阻塞性肺病的病人有紅血球增多症 疲勞, 體重下降, 脫髮, 舒張期高血壓, 肌肉無力 燥熱, 體重減輕, 心悸, 收縮期高血壓, 突眼震顫, 心搏過速 腎臟結石, 骨質疏鬆, 抑鬱, 嗜睡, 肌肉無力 頭痛, 疲勞, 視力問題, 手, 腳, 舌頭變大 Disorder suspected Pheochromocytoma 嗜鉻細胞瘤 藥物引起的高血壓 庫欣氏症候群 Cushing s syndrome 腎血管疾病 Coarctation of aorta 主動脈縮窄 腎實質性疾病 Conn's syndrome(aldosteronism) 原發性醛固酮增多症 Obstructive sleep apnea 阻塞性睡眠呼吸中止症 Excess catecholamines 過量兒茶酚胺 飲食副作用 促紅血球生成素 (Erythropoietin,EPO) 的副作用 Hypothyroidism 甲狀腺功能減退 Hyperthyroidism 甲狀腺功能亢進 Hyperparathyroidism 副甲狀腺功能亢進 Acromegaly 肢端肥大症 資料來源 : Onusko E: Diagnosing Secondary Hypertension. Am Fam Physicians. 2003; 67: 67-74. (VMA) 24Metanephrines 95%vanillyl mandelic acid (VMA) Metanephrines 98% (b) Plasma Epinephrine, Norepinephrine VMA Metanephrines P l a s m a catecholaminecatechol Norepinephrine Epinephrine 2. 藥物引起的高血壓 3. 庫欣氏症候群 dexamethasone-suppression test low-dose dexamethasone suppression test serum cortisol >10µg/dL 11 d e x a m e t h a s o n e 1mgcortisol 272
cortisol5µg/dl 10µg/dL 4. 原發性醛固酮過多症 (aldosterone) >30 () (A) (serum K + <3.5 meq/l) (B) (>25-30 meq/l) (C) C a p t o p r i l s u p p r e s s i o n t e s t captopril 25 mg > 15 ng/ ml Aldosterone/renin ratio > 50 結論 參考資料 5. 腎血管疾病 (A) (B)captopril- (C) 6. 主動脈縮窄 : 7. 腎實質性疾病 : Creatinine clearance(24 Cr) 8. 其他內分泌疾病 : 1. Hirsch AT, Haskal ZJ, Hertzer NR, et al: ACC/AHA 2005 Practice Guidelines for the management of patients with peripheral arterial disease. Circulation 2006; 113:463-5. 2. G a n d h i S K, P o w e r s J C, N o m e i r A-M, e t al:the pathogenesis of acute pulmonary edema associated with hypertension. NEJM 2001; 344:17-22. 3. Krijnen P, van Jaarsveld BC, Steyerberg EW, et al: A clinical prediction rule for renal artery stenosis. Ann Intern Med 1998;129:705-11. 4. Onusko E: Diagnosing Secondary Hypertension. Am Fam Physicians. 2003; 67: 67-74. 5. Ganong WF: Ganong 1997 :726-8 6. Williams GH: Approach to the patient with hypertension. In: Braunwald E, ed. Harrison's Principles of internal medicine. 15th ed. New York: McGraw-Hill, 2001:211-4. 273