夜間血壓窘境夜間血壓的窘境第1頁(yè)100s:Riva-RocciandKorotkoff,conventionalbloodpressuremonitoring.40s:ABPM,itisgenerallyacceptedthatABPMestimates‘‘true’’meanBPandhasbettercorrelationwithend-organdamageandcardiovascularoutcomes.(NewEnglandJournalofMedicine)24:ThedippingphenomenonwasfirstcoinedbyO’Brienandcolleagues.Nondippinghasbeenconsideredanabnormaldiurnalrhythm,whichisassociatedwithgreatercardiovascularandcerebrovasculardiseases.(lancet)IntroductionThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第2頁(yè):NBPlevelsratherthancircadianBPpatternaremoreaccurateinpredictingmortalityandmorbidityrelatedtoBP,independentofmeanBPanddaytimeBPlevels.:isolatednocturnalhypertensionasapotentiallynovelclinicalentityderivedfromaChinesepopulationstudywasexaminedbyLiandcolleagues.10.5%IntroductionThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第3頁(yè)Introduction指南更新指南問(wèn)世臨床研究個(gè)人經(jīng)驗(yàn)100SCBPM40SABPM24dippingphenomenon07INHThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第4頁(yè)1.MethodsformonitoringNBP;2.Accurateperiodofnocturnaltime;3.DiagnosticthresholdsofabnormalNBP;4.whethertocontrolabnormalNBP;5.howtomanageabnormalNBP.DilemmaThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第5頁(yè)MethodsformonitoringNBPABPMprovidesthefollowingthreetypesofinformationMeanBPlevel;ThediurnalrhythmofBP;BPvariability.Thisfullyautomaticandtheoreticalnon-sleepdisturbancetechniqueisalsoanidealmethodtomonitorNBP.agoldenstandardforNBPmeasurement()ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第6頁(yè)MethodsformonitoringNBPABPMhasitsownvitallimitations:Sonorousstimuli:disturbsleep,thecorrelationbetweenNBPandTODABPMisnotcommonlyemployedinroutineclinicalpracticeforevaluatingNBPThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第7頁(yè)MethodsformonitoringNBPFullyautomatichomeBPdevicesManualBPdeviceItisimportanttorecognizethatanexactandpracticalmethodforthemeasurementofNBPisessential.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第8頁(yè)AccurateperiodofnocturnaltimeTherehasbeennoconfirmedperiodofnocturnaltimeforNBP.Patients’diaryentries:noobjectivelyArbitraryfixedtime:1AMto6AM11PMto7AMNocturnal≠SleepNBPisgenerallyregardedastheaverageofBPreadingrecordedduringtheperiodmostlikelycoincidingwithsleeptime.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第9頁(yè)DiagnosticthresholdsofabnormalNBPTherelationshipbetweencardiovascularriskandBPiscontinuous.120?70mmHg(ESH?ESC)125?75mmHg(AHA)itsdistributioninnormalreferencepopulations.outcome-driventhresholds(IDACO)standardofnocturnalhypotensionMoreattentionshouldalsobepaidtotheexcessiveNBPdippingthatisassociatedwithcardiacandcerebrovascularrisks.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第10頁(yè)Althoughthereisnoconsistentdefinitionofnocturnaltimeintheguidelines,thereexistsaseeminglyuniformthresholdfornocturnalhypertension.DilemmaThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第11頁(yè)ManagementofNBPNBPhasbeendemonstratedtobetterreflectcardiovascularriskanddeaththandaytimeBPinhypertensivepatientsandpopulationstudies.Therefore,managementofabnormalNBPmayhavepositivepotentialimpactoncardiacandcerebrovascularoutcomes.however,thegoaloflowlimitsofNBPhasneverbeenwidelyandgenerallydetermined.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第12頁(yè)WhichlevelofNBPisgoodforanindividualpatient?

‘‘thelower,thebetter’’vs‘‘J-shaped.ManagementofNBPThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第13頁(yè)DifferentkindsofrelatedeventsmayrequirediverselevelsofNBP.NBPwasnotassociatedwithhemorrhagicstrokebutischemiccardiacandcerebrovascularevents.(Ohasamastudy)Althoughbothall-causemortalityandcause-specificcardiovasculareventsaresignificantlypredictedbyNBP,knowledgeaboutparticularlycerebraleventsissparse.ManagementofNBPThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第14頁(yè)CertainpopulationsmayrequireparticularlevelsofNBP.

Nocturnaldippingisanormalphenomenoninhealthyyoungerpersons;however,itmaybeharmfulforelderlypatientsleadingtocerebralhypoperfusionandevencerebralevents.Intheelderly,failureofcerebralautoregulationhasshownthatevenminorfallsinBPmayleadtocerebraldysfunction,whichmeansthatmanagementofNBPintheelderlyshouldbeprudent,especiallyinpatientswithischemicorhemorrhagiccerebralevents.ManagementofNBPThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第15頁(yè)NocturnalHypertensionLoweringhighNBPcansignificantlydecreasemortalityandmorbidity.sympatheticnervoussystemreninangiotensinsystemAtenolollowereddaytimeBPbuthadnosignificanteffectonNBPPerindoprilloweredNBPmorethandaytimeBP.SympatheticnervoussystemlikelymakeslittlecontributiontoNBP.ACEinhibitorsconferagreaterdropinNBPthanindaytimeBP.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第16頁(yè)NocturnalHypertensionThereisnogeneralconsistencyinthemanagementofNocturnalHypertension,letalonedifferentdrugsefficacies.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第17頁(yè)NocturnalHypotensionExcessivelowNBPalsoincreasescardiacandcerebrovascularrisks,theeye.Studiesonwhethernocturnalhypotensionisassociatedwithvisuallossfromglaucoma,however,hasyieldedcontroversialresults.ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第18頁(yè)TimeofDosingandMorningBPSurgeWhyshouldantihypertensivedrugsbeadministeredinthemorningafterrising?ThefirstaffiliatedhospitalofSTUMC夜間血壓的窘境第19頁(yè)TimeofDosingandMorningBPSurgeWhyshouldantihypertensivedrugsbeadministeredinthemorningafterrising?BPvaluessurgerapidly.Timingofcardiacandcerebrovascular