張瓊文 1 張君睿 2 許秀卿 3 前言 5~10% [1] 何時需要懷疑續發性高血壓? [2] 1 醫療財團法人徐元智先生醫藥基金會附設亞東紀念醫院一般科住院醫師 2 醫療財團法人徐元智先生醫藥基金會附設亞東紀念醫院一般科住院醫師 3 醫療財團法人徐元智先生醫藥基金會附設亞東紀念醫院家庭醫學科主治醫師 secondary hypertension, pseudo-hypertension, obstructive sleep apnea (1) (2) (3) 30 (4) ( ) 考慮續發性高血壓前需要排除的問題 1. (white coat syndrome) 20 30% 24 (Ambulatory blood pressure monitoring) 2. (1) 5 (2) ( 15 mmhg) 3. 40% 131
4. (pseudo-hypertension) 15 mmhg ( ) ( ) Osler (Osler maneuver) 5. (1) (Non-steroid antiinflammatory drug, NSAID) 24 4-5 mmhg (2) (glucocorticoids) (3) ( ) ( phenylpropanolamine) (4) 5% (5) (cyclosporine A) (monoamine oxidase inhibitors) (VEGFi) 續發性高血壓發生之原因 表一造成血壓升高的藥物種類與機制 擬交感神經 分類藥物舉例機制 安非他命, Phenylpropanolamine, ephedrine, pseudoephedrine 刺激神經系統 非類固醇抗發炎藥物和 COX-2 抑制劑 Ibuprofen, Diclofenac, Celecoxib 阻斷前列腺素產生, 使血管阻力增加 類固醇 Prednisone, Hydrocortisone 造成鹽分及水分滯留 中樞神經刺激劑 Caffeine 刺激神經系統 雌激素 口服避孕藥 雌激素刺激肝臟生成 angiotensinogen, 進而轉換成 renin 保健食品甘草減少水分及鹽分排出 抗憂鬱劑 (SNRIs) Venlafaxine, Sibutramine 增加正腎上腺及其他神經傳導物 質的濃度 免疫抑制劑 Cyclosporine, Tacrolimus 減少水分及鹽分排出 資料來源 : 參考資料 9 132
常見原因 1. (obstructive sleep apnea) - - (RAAS)/ (polysomnography) AHI(apnea-hypopnea index) (5-15 ) (16-30) (>30) (positive airway pressure) (oral appliances) [3] 2. (renal parenchymal disease) 3. (renal artery stenosis) (bruit) ACEI/ ARB (percutaneous angioplasty) (fibromuscular dysplasia, FMD) RAAS FMD 4. (primary aldosteronism) 表二造成續發性高血壓疾病的盛行率在高血壓病人中盛行率頑固性高血壓中盛行率 Obstructive sleep apnea > 5 ~ 15% > 30% Renal parenchymal disease 1.6 ~ 8.0% 2 ~ 10% Renal artery stenosis 1.0 ~ 8.0% 2.5 ~ 20% Primary aldosteronism 1.4 ~ 10% 6 ~ 23% Cushing s syndrome 0.5% < 1% Thyroid disease 1 ~ 2% 1 ~ 3% Pheochromocytoma 0.2 ~ 0.5% < 1% Coarctation of the aorta < 1% < 1% 資料來源 : 參考資料 2 133
圖一診斷續發性高血壓流程 資料來源 : 參考資料 2 (verapamil, hydralazine, doxazosin) aldosterone/renin (sodium loading test) aldosterone spironolactone 罕見原因 1. (Cushing's syndrome) [7] 24 cortisol dexamethasone ACTH cortisol adrenal enzyme inhibitor 2. / (hyper-/ hypothyroidism) TSH 3. (pheochromocytoma) MEN2 24 catecholamine free metanephrines / 134
4. (coarctation of the aorta) (ligamentum arteriosum) / (percutaneous balloon angioplasty) 結論 參考資料 1. UptoDate: Evaluation of secondary hypertension evaluationof-secondary hypertension?source=search_ result&search=evaluation%20of%20 secondary%20hypertension&selectedtit le=1~150 Accessed September 25, 2017. 2. Secondary arterial hypertension: when, who, and how to screen? EHJ. 2014: 35:1245 54. 3. UptoDate: Management of obstructive sleep apnea in adults management-of-obstructive-sleepapnea-in-adults?source=search_ result&search=management%20of%20 obstructive%20sleep%20apnea%20in%20 adults&selectedtitle=1~150 Accessed September 25, 2017. 4. UptoDate: Treatment of unilateral atherosclerotic renal artery stenosis treatment-of-unilateral-atheroscleroticrenal-artery-stenosis?source=search_ result&search=treatment%20of%20 unilateral%20atherosclerotic%20renal%20 artery%20stenosis&selectedtitle=1~150 Accessed September 25, 2017. 5. UptoDate: Clinical manifestations and diagnosis of fibromuscular dysplasia clinicalmanifestations-and-diagnosis-of-fibromusculardysplasia?source=search_result&search=clinic al+manifestations+and+diagnosis+of+fibromus cular+dysplasia&selectedtitle=1~46 Accessed September 25, 2017. 6. UptoDate: Treatment of primary aldosteronism treatment-ofprimary-aldosteronism?source=search_result&se arch=treatment+of+primary+aldosteronism&sel ectedtitle=1~81 Accessed September 25, 2017. 7. UptoDate: Epidemiology and clinical manifestations of Cushing's syndrome epidemiology-and-clinical-manifestations-ofcushings-syndrome?source=search_result&searc h=epidemiology+and+clinical+manifestations+o f+cushing%27s+syndrome&selectedtitle=1~150 Accessed September 25, 2017. 8. UptoDate: Overview of the treatment of Cushing's syndrome overview-of-the-treatment-of-cushingssyndrome?source=search_result&search=overv iew+of+the+treatment+of+cushing%27s+syndr ome&selectedtitle=1~150 Accessed September 25, 2017. 9. Drug induced hypertension https://dhammacitta.org/forum/index. php?topic=6962.0 Accessed September 25, 2017. 135