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Yimaitong organizes reports, please do not reprint without authorization.
Introduction: On April 23, 2021, the "Twelfth National Symposium on Progress in Diagnosis and Treatment of Endocrine and Metabolic Diseases" was held in Baoding.
I had a wonderful academic sharing on the topic of "common" diseases that were ignored.
Professor Yiming Mu made a detailed combing of endocrine hypertension, which is mainly divided into: ➤Adrenal origin: pheochromocytoma and parasympathetic ganglioma, primary aldosteronism, deoxycorticosterone, etc.
➤Extrinsic adrenal glands: pituitary origin (Cushing disease, acromegaly), sleep apnea syndrome, parathyroid origin, thyroid origin, etc.
The expert introduced Professor Mu Yiming, the director of the Endocrinology Department of PLA General Hospital, chief physician, professor, doctoral supervisor, professor and doctoral supervisor of Tsinghua University and Nankai University School of Medicine.
He is also the chairman of the Tenth Committee of the Endocrinology Branch of the Chinese Medical Association, the president-elect of the Endocrinology and Metabolism Physician Branch of the Chinese Medical Doctor Association, the chairman of the Endocrinology Professional Committee of the Chinese Medical Association and the chairman of the Endocrinology Branch of the Beijing Medical Association.
The large number of hypertensive patients in my country According to foreign data, the prevalence of hypertension in the United States is 28.
6%, of which 15% are secondary hypertension, and more than 50% of adolescent hypertension are secondary hypertension, <40 years old hypertension 30% of the patients had secondary hypertension.
Domestic data show that the crude prevalence rate of hypertension in my country's adult population is 27.
9%, and the standardized rate is 23.
2%.
It is estimated that about half of the population in my country has high blood pressure.A variety of endocrine diseases start with hypertension, and attention needs to be paid to Endocrine Reviews, Volume 38, Issue 2, April 2017, published the latest scientific statement on endocrine hypertension screening by the American Endocrine Society, stating that there are at least 15 endocrine diseases The onset may be high blood pressure, which needs to be cured by surgery and medication.
The causes of endocrine-related hypertension are shown in the table below.
The main reasons include adrenal origin (protoaldehyde, pheochromocytoma, etc.
), pituitary origin (Cushing disease, acromegaly), sleep apnea syndrome, parathyroid origin Sexual (hyperparathyroidism), thyroid origin (hyperthyroidism, hypothyroidism) and other causes.
It is recommended that patients with refractory hypertension be screened: When a patient has symptoms of hypertension, how to determine whether it is endocrine hypertension through various examinations is a huge challenge for physicians.
The 2013 ESH/ESC related guidelines recommend simple secondary hypertension screening for all hypertensive populations; China's 2020 version of the Protoaldehyde Consensus expands the screening targets for Protoaldehyde disease-newly diagnosed hypertensive patients are included in the screening range .
Out of considerations such as cost and feasibility, it is recommended to screen key populations.
Adrenal hypertension 1.
Pheochromocytoma and parasympathetic ganglioma (PPGLs) Pheochromocytoma and parasympathetic ganglioma are collectively referred to as PPGLs.
Pheochromocytoma is a rare neuroendocrine tumor, often caused by pheochromocytoma It is caused by excessive release of catecholamines, and its characteristics include: ➤It originates from the chromaffin tissues of the adrenal medulla, sympathetic ganglia or other parts; ➤Continuous or intermittent release of large amounts of catecholamines, causing persistent or paroxysmal hypertension and multiple organ functions Metabolic disorders; ➤10% are malignant tumors.
Screening objects: ➤Paroxysmal symptoms (typical triad of headache, sweating, and palpitations); ➤Von Hippel-Lindau syndrome (VHLS) or multiple endocrine tumors (MEN-2) family history; ➤adrenal accident Tumor; ➤ unstable or refractory hypertension; ➤ orthostatic hypotension.
Screening method: Diagnosis and treatment path: 2.
Primary aldosteronism (PA) PA is the most common (5%-10% of people with hypertension) and curable endocrine hypertension.
Among those with refractory hypertension, The prevalence of PA is nearly 20%. PA is due to increased secretion of aldosterone exceeding human needs, leading to increased reabsorption of sodium ions in the distal renal tubules, causing hypertension and angiotensin II inhibition, and is not dependent on the renin-angiotensin II system.
Screening objects: ➤Continuous increase in blood pressure (≥150mmHg and /100mmHg); using 3 kinds of antihypertensive drugs still can not be controlled (BP>140/90mmHg); ➤hypertension with spontaneous or diuretic-induced hypokalemia ➤High blood pressure with incidental adrenal tumors; ➤Family history of early-onset hypertension (<20 years old) or stroke (<40 years old); ➤Hypertensive patients with PA in first-degree relatives.
Screening methods: ➤Serum potassium: As a small number of PAs will have hypokalemia, the detection of serum potassium as a screening method lacks sensitivity.
When hypokalemia occurs, the blood potassium level is a valuable clue to the diagnosis of PA.
➤Aldosterone/renin ratio: When PRA is inhibited (<1.
0ng/ml/h), PAC increases (>10ng/dl), and it is positive; when PRA is inhibited (<1.
0ng/ml/h), PAC increases (> 15ng/dl) + ARR≥20 is positive.
Note: When detecting ARRs, diuretics should be stopped for 4 weeks and other influential drugs for more than 2 weeks, and other antihypertensive drugs with less impact (such as verapamil sustained-release agent, prazosin) can be used.
When stopping the drug, the effects of the drug must be taken into account (see the table below).
3.
Deoxycorticosterone.
Excessive mineralocorticoid effects are caused by deoxycorticosterone or cortisol.
Hypertension patients with hypokalemia, low aldosterone, and low renin should be considered.
Common types: ➤Congenital adrenal hyperplasia (CAH): 11β-hydroxylase deficiency, 17α-hydroxylase deficiency; ➤Deoxycorticosterone (DOC)-producing tumor; ➤primary cortisol resistance; ➤ Apparent mineralocorticoid excess syndrome (AME); ➤Liddle syndrome: abnormal renal tubular ion transport.
Secondary hyperaldosteronism and renovascular hypertension Renovascular hypertension (RVH) refers to high blood pressure caused by reduced blood flow in the kidneys.
Secondary hyperaldosteronism refers to the activation of the renin-angiotensin axis caused by various factors, leading to a pathological increase in aldosterone levels.
Renal vascular hypertension is one example of secondary hyperaldosteronism.
Renal vascular disease, renal infarction, circulatory failure with or without diuretics, renal hypoperfusion related to heart failure or liver failure, parabulbar cell tumors (rarely) resulting in excessive renin production can be caused.
Clinical features: The activation of the RASS system caused by renal vascular occlusive disease can produce a series of clinical manifestations: ➤Accelerated/malignant stage hypertension; ➤Impaired cardiac function; ➤Circulatory congestion (acute pulmonary edema"); ➤Impaired renal parenchyma Irreversible damage to renal function.
Screening objects: ➤New-onset hypertension younger than 30 years old; ➤ Progressive, stubborn, and malignant hypertension; ➤Deterioration of renal function after treatment with ACEl or ARB (creatinine rises higher than before treatment Level 30%); ➤ New-onset hypertension (with atherosclerotic renal artery stenosis) aged> 50 years; ➤ Acute pulmonary edema of unknown cause; ➤ Rapid decline in renal function, progressive increase in blood pressure, and acute pulmonary edema Patients should be screened based on specific conditions.
Screening method: pituitary endocrine hypertension 1.
Cushing disease ➤ Iatrogenic Cushing’s syndrome is more common in clinical practice; ➤ The mechanism of hypertension: increased DOC production, the endogenous Sexual vasoconstrictors (such as epinephrine, angiotensin II) increase the pressure sensitivity, increase cardiac output, increase the liver's production of angiotensinogen to activate RAAS, and cortisol activates the mineralocorticoid receptor; ➤ screening methods : The detection of endogenous cortisol overdose includes an overnight 1mg dexamethasone suppression test, measuring midnight saliva cortisol and 24-hour urine free cortisol.
2.
Acromegaly ➤20%-40% of patients with hypertension, and sodium Retention is related to the expansion of extracellular volume; Screening method: measurement of serum insulin-like growth factor 1 (IGF-1).
Sleep apnea syndrome (OSA) causes endocrine hypertension ➤50% OSA suffers from hypertension, 30%-40 % Hypertension suffers from OSA, and the level of aldosterone is positively correlated with the severity of OSA; Screening method: The diagnosis of OSA needs to be assessed by polysomnography.
Endocrine hypertension of parathyroid origin (hyperparathyroidism) ➤Hypercalcemia is associated with an increase in the frequency of hypertension.
The incidence of hypertension in patients with primary hyperparathyroidism is 10%-60%; ➤ the mechanism is not clear; ➤ screening method: by measuring serum parathyroid hormone (PTH) and 24-hour urinary calcium excretion, it can be Confirm that hyperparathyroidism is the cause of hypercalcemia.
The mechanism of thyroid-derived (hyperthyroidism, hypothyroidism) endocrine hypertension and hypertension: ➤Hyperthyroidism: When excess thyroid hormone in the circulation interacts with thyroid hormone receptors in peripheral tissues, both metabolic activity and sensitivity to circulating catecholamines increase ➤Hypothyroidism: The systemic vascular resistance increases and the extracellular volume expands.
Screening method: Thyroid function.
Summary Finally, Professor Mu Yiming concluded: “The core of correct diagnosis and treatment of endocrine hypertension is to carefully understand the underlying mechanism.
In addition, in order to reduce the possibility of missed or misdiagnosed The sensitivity of the concept of "sexual hypertension.
"
Introduction: On April 23, 2021, the "Twelfth National Symposium on Progress in Diagnosis and Treatment of Endocrine and Metabolic Diseases" was held in Baoding.
I had a wonderful academic sharing on the topic of "common" diseases that were ignored.
Professor Yiming Mu made a detailed combing of endocrine hypertension, which is mainly divided into: ➤Adrenal origin: pheochromocytoma and parasympathetic ganglioma, primary aldosteronism, deoxycorticosterone, etc.
➤Extrinsic adrenal glands: pituitary origin (Cushing disease, acromegaly), sleep apnea syndrome, parathyroid origin, thyroid origin, etc.
The expert introduced Professor Mu Yiming, the director of the Endocrinology Department of PLA General Hospital, chief physician, professor, doctoral supervisor, professor and doctoral supervisor of Tsinghua University and Nankai University School of Medicine.
He is also the chairman of the Tenth Committee of the Endocrinology Branch of the Chinese Medical Association, the president-elect of the Endocrinology and Metabolism Physician Branch of the Chinese Medical Doctor Association, the chairman of the Endocrinology Professional Committee of the Chinese Medical Association and the chairman of the Endocrinology Branch of the Beijing Medical Association.
The large number of hypertensive patients in my country According to foreign data, the prevalence of hypertension in the United States is 28.
6%, of which 15% are secondary hypertension, and more than 50% of adolescent hypertension are secondary hypertension, <40 years old hypertension 30% of the patients had secondary hypertension.
Domestic data show that the crude prevalence rate of hypertension in my country's adult population is 27.
9%, and the standardized rate is 23.
2%.
It is estimated that about half of the population in my country has high blood pressure.A variety of endocrine diseases start with hypertension, and attention needs to be paid to Endocrine Reviews, Volume 38, Issue 2, April 2017, published the latest scientific statement on endocrine hypertension screening by the American Endocrine Society, stating that there are at least 15 endocrine diseases The onset may be high blood pressure, which needs to be cured by surgery and medication.
The causes of endocrine-related hypertension are shown in the table below.
The main reasons include adrenal origin (protoaldehyde, pheochromocytoma, etc.
), pituitary origin (Cushing disease, acromegaly), sleep apnea syndrome, parathyroid origin Sexual (hyperparathyroidism), thyroid origin (hyperthyroidism, hypothyroidism) and other causes.
It is recommended that patients with refractory hypertension be screened: When a patient has symptoms of hypertension, how to determine whether it is endocrine hypertension through various examinations is a huge challenge for physicians.
The 2013 ESH/ESC related guidelines recommend simple secondary hypertension screening for all hypertensive populations; China's 2020 version of the Protoaldehyde Consensus expands the screening targets for Protoaldehyde disease-newly diagnosed hypertensive patients are included in the screening range .
Out of considerations such as cost and feasibility, it is recommended to screen key populations.
Adrenal hypertension 1.
Pheochromocytoma and parasympathetic ganglioma (PPGLs) Pheochromocytoma and parasympathetic ganglioma are collectively referred to as PPGLs.
Pheochromocytoma is a rare neuroendocrine tumor, often caused by pheochromocytoma It is caused by excessive release of catecholamines, and its characteristics include: ➤It originates from the chromaffin tissues of the adrenal medulla, sympathetic ganglia or other parts; ➤Continuous or intermittent release of large amounts of catecholamines, causing persistent or paroxysmal hypertension and multiple organ functions Metabolic disorders; ➤10% are malignant tumors.
Screening objects: ➤Paroxysmal symptoms (typical triad of headache, sweating, and palpitations); ➤Von Hippel-Lindau syndrome (VHLS) or multiple endocrine tumors (MEN-2) family history; ➤adrenal accident Tumor; ➤ unstable or refractory hypertension; ➤ orthostatic hypotension.
Screening method: Diagnosis and treatment path: 2.
Primary aldosteronism (PA) PA is the most common (5%-10% of people with hypertension) and curable endocrine hypertension.
Among those with refractory hypertension, The prevalence of PA is nearly 20%. PA is due to increased secretion of aldosterone exceeding human needs, leading to increased reabsorption of sodium ions in the distal renal tubules, causing hypertension and angiotensin II inhibition, and is not dependent on the renin-angiotensin II system.
Screening objects: ➤Continuous increase in blood pressure (≥150mmHg and /100mmHg); using 3 kinds of antihypertensive drugs still can not be controlled (BP>140/90mmHg); ➤hypertension with spontaneous or diuretic-induced hypokalemia ➤High blood pressure with incidental adrenal tumors; ➤Family history of early-onset hypertension (<20 years old) or stroke (<40 years old); ➤Hypertensive patients with PA in first-degree relatives.
Screening methods: ➤Serum potassium: As a small number of PAs will have hypokalemia, the detection of serum potassium as a screening method lacks sensitivity.
When hypokalemia occurs, the blood potassium level is a valuable clue to the diagnosis of PA.
➤Aldosterone/renin ratio: When PRA is inhibited (<1.
0ng/ml/h), PAC increases (>10ng/dl), and it is positive; when PRA is inhibited (<1.
0ng/ml/h), PAC increases (> 15ng/dl) + ARR≥20 is positive.
Note: When detecting ARRs, diuretics should be stopped for 4 weeks and other influential drugs for more than 2 weeks, and other antihypertensive drugs with less impact (such as verapamil sustained-release agent, prazosin) can be used.
When stopping the drug, the effects of the drug must be taken into account (see the table below).
3.
Deoxycorticosterone.
Excessive mineralocorticoid effects are caused by deoxycorticosterone or cortisol.
Hypertension patients with hypokalemia, low aldosterone, and low renin should be considered.
Common types: ➤Congenital adrenal hyperplasia (CAH): 11β-hydroxylase deficiency, 17α-hydroxylase deficiency; ➤Deoxycorticosterone (DOC)-producing tumor; ➤primary cortisol resistance; ➤ Apparent mineralocorticoid excess syndrome (AME); ➤Liddle syndrome: abnormal renal tubular ion transport.
Secondary hyperaldosteronism and renovascular hypertension Renovascular hypertension (RVH) refers to high blood pressure caused by reduced blood flow in the kidneys.
Secondary hyperaldosteronism refers to the activation of the renin-angiotensin axis caused by various factors, leading to a pathological increase in aldosterone levels.
Renal vascular hypertension is one example of secondary hyperaldosteronism.
Renal vascular disease, renal infarction, circulatory failure with or without diuretics, renal hypoperfusion related to heart failure or liver failure, parabulbar cell tumors (rarely) resulting in excessive renin production can be caused.
Clinical features: The activation of the RASS system caused by renal vascular occlusive disease can produce a series of clinical manifestations: ➤Accelerated/malignant stage hypertension; ➤Impaired cardiac function; ➤Circulatory congestion (acute pulmonary edema"); ➤Impaired renal parenchyma Irreversible damage to renal function.
Screening objects: ➤New-onset hypertension younger than 30 years old; ➤ Progressive, stubborn, and malignant hypertension; ➤Deterioration of renal function after treatment with ACEl or ARB (creatinine rises higher than before treatment Level 30%); ➤ New-onset hypertension (with atherosclerotic renal artery stenosis) aged> 50 years; ➤ Acute pulmonary edema of unknown cause; ➤ Rapid decline in renal function, progressive increase in blood pressure, and acute pulmonary edema Patients should be screened based on specific conditions.
Screening method: pituitary endocrine hypertension 1.
Cushing disease ➤ Iatrogenic Cushing’s syndrome is more common in clinical practice; ➤ The mechanism of hypertension: increased DOC production, the endogenous Sexual vasoconstrictors (such as epinephrine, angiotensin II) increase the pressure sensitivity, increase cardiac output, increase the liver's production of angiotensinogen to activate RAAS, and cortisol activates the mineralocorticoid receptor; ➤ screening methods : The detection of endogenous cortisol overdose includes an overnight 1mg dexamethasone suppression test, measuring midnight saliva cortisol and 24-hour urine free cortisol.
2.
Acromegaly ➤20%-40% of patients with hypertension, and sodium Retention is related to the expansion of extracellular volume; Screening method: measurement of serum insulin-like growth factor 1 (IGF-1).
Sleep apnea syndrome (OSA) causes endocrine hypertension ➤50% OSA suffers from hypertension, 30%-40 % Hypertension suffers from OSA, and the level of aldosterone is positively correlated with the severity of OSA; Screening method: The diagnosis of OSA needs to be assessed by polysomnography.
Endocrine hypertension of parathyroid origin (hyperparathyroidism) ➤Hypercalcemia is associated with an increase in the frequency of hypertension.
The incidence of hypertension in patients with primary hyperparathyroidism is 10%-60%; ➤ the mechanism is not clear; ➤ screening method: by measuring serum parathyroid hormone (PTH) and 24-hour urinary calcium excretion, it can be Confirm that hyperparathyroidism is the cause of hypercalcemia.
The mechanism of thyroid-derived (hyperthyroidism, hypothyroidism) endocrine hypertension and hypertension: ➤Hyperthyroidism: When excess thyroid hormone in the circulation interacts with thyroid hormone receptors in peripheral tissues, both metabolic activity and sensitivity to circulating catecholamines increase ➤Hypothyroidism: The systemic vascular resistance increases and the extracellular volume expands.
Screening method: Thyroid function.
Summary Finally, Professor Mu Yiming concluded: “The core of correct diagnosis and treatment of endocrine hypertension is to carefully understand the underlying mechanism.
In addition, in order to reduce the possibility of missed or misdiagnosed The sensitivity of the concept of "sexual hypertension.
"
