1、高 血 压 (Hypertension) 南方医科大学基础医学院病理学系 周洁,Case Report,张某，男，62岁，突然昏迷2小时入院。10年前发现高血压，近来常感心悸，以体力活动为甚，近半月觉头晕、眼花、乏力，四肢麻木，今晨上厕所时突然跌倒，不省人事，左侧上下肢不能活动并有小便失禁。 给予吸氧、降压等治疗，疗效不显，昏迷 加深，呼吸不规则，呼吸心跳停止死亡。,Autopsy results,Cerebral Infarction (Stroke),HaemorrhagicNecrosis,Whats hypertension?,在安静休息状态下体循环血压持续增高,收缩压140mmHg和
2、/或舒张压90mmHgHypertension is elevated levels of blood pressure(High Blood Pressure)Sustained increase in blood pressure. Systolic 140, Diastolic 90 mmHg,Causes of hypertension(HT),原发性(primary HT) 95% 特发性(Idiopathic HT) 高血压病继发性(secondary HT) 5% 症状性(symptomatic HT),Types of primary hypertension(分型),良性(b
3、enign) 缓进型(Chronic)95-98%恶性(malignant)急进型(Accelerated) 2-5%，进展迅速, 病变严重,1-2y死亡,1. 良性高血压 benign (Chronic) hypertension,(1)机能紊乱期(functional phase)细小A痉挛(spasm)血压波动无器质性变化(without organ damage)dizziness, headache, and visual difficulties,Stages of Chronic hypertension,(2)动脉系统病变期 (arteries change phase)细A(
4、1mm)玻璃变细A硬化(Arteriolosclerosis)肌型A内膜胶原弹力纤维增生,内弹力膜分裂中膜增厚,管腔狭窄BP持续增高, 舒张压100mmHg左心室轻度肥大,Arteriolosclerosis,Stages of Chronic hypertension,(3)内脏病变期（visceral change phase） a. 心(heart)外周阻力左室代偿肥大(厚1.5-2.0cm)向心性肥大(concentric):心腔不扩张离心性肥大(eccentric): 肌原性扩张高血压性心脏病(hypertensive heart disease),正常心脏与高血压心脏(Hypert
5、ensive heart disease),Left Ventricular Hypertrophy,Left Ventricular Hypertrophy,b.肾(kidney)原发性颗粒性固缩肾(essential granular atrophic kidney)Gross morphology 弥漫性对称性缩小，变硬,表面细颗粒状,皮质变薄2mm（3-5mm),Leathery Granularity due to minute scarring,颗粒性固缩肾和正常肾比较,Essential granular atrophic kidney,入球小A玻璃样变肌型小A纤维化肾小球纤维化
6、 玻璃样变肾小管萎缩肾小球代偿性增生、肥大,Microscopic: essential granular atrophic kidney,Hyaline Arteriolosclerosis,（3）脑(brain),高血压脑病 （hypertensive encephalopathy）中枢N功能障碍征候群: 颅内高压,头痛,呕吐,视力障碍及意识模糊病变 脑水肿，点状出血,脑软化(Cerebral Infarction) （softening of the brain） 微梗死灶( microinfarct）/梗死灶液化性坏死: 淡染、疏松网状周围胶质细胞胶质疤痕,Cerebral Infar
7、ction,脑出血(cerebral hemorrhage)部位 基底节,内囊,大脑白质，脑干原因 细小A痉挛,脑组织缺血性坏死 形成微A瘤破裂出血 豆纹A大脑中A直角分出,高压冲击,脑出血(Cerebral hemorrhage),破入脑室突然昏迷，肢体驰缓，反射消失，二便失禁, 死亡内囊偏瘫 左脑出血失语桥脑出血面瘫,对侧上下肢瘫血肿占位颅内高压,脑疝,Subarachnoid Haemorrhage:,Cerebral Blood vesselsSpecial features:Thin walled*End arteries*Micro-aneurisms,高血压危象（hyperten
8、sive crisis）,短期内血压急剧升高，舒张压超过120或130mmHg并伴一系列严重症状，危及生命的临床现象,高血压脑病 颅内出血蛛网膜下腔出血 急性脑梗死急性左心衰竭 不稳定型心绞痛急性心肌梗死 急性肾衰竭,级 视网膜动脉变细级 视网膜动脉狭窄，动脉交叉压迫；级 眼底出血或棉絮状渗出；级 出血或渗出物伴有视神经乳头水肿,(4)眼(eyes),Normal Retina,Hypertensive Retinopathy,Fundoscopy,2.恶性高血压 Malignant(Accelerated) hypertension,中青年(Middle & young ages)BP,舒张
9、压130 mmHg快速进展(Rapidly progressive)较早出现肾衰(Early renal failure)高血压脑病(Hypertensive encephalopathy) 死于尿毒症(Uraemia)、脑出血、心衰,Pathology: Accelerated hypertension,增生性小动脉硬化hyperplastic arteriolosclerosis 同心性排列,葱皮样坏死性细动脉炎necrotizing arteriolitis 纤维素样坏死,小出血微血栓,微梗死Intravascular thrombosis & infarction,Hyperplast
10、ic Arteriolosclerosis,Onion Skin ThickeningOf arterioles.,Narrow Lumen,Necrotizing arteriolitis,Fibrinoid Necrosis,Thrombosis,3.病因与发病机理 (etiology& pathogenesis),Regulation of BP:,BP = Cardiac Output x Peripheral ResistanceEndocrine FactorsRenin, Angiotensin, ADH, Aldosterone.Neural FactorsSympatheti
11、c & ParasympatheticBlood VolumeSodium, MineralocorticoidsCardiac FactorsHeart rate & Contractility.,Hypertension:etiology & pathogenesis,(1)遗传因素(genetic factor) 血管紧张素（AGT）基因缺陷AGT 遗传性排钠障碍,多基因(2)饮食因素(dietary factor) Heavy Sodium (Na) Intake WHO5g/d(3)社会心理因素(social & mental factor) 应激性生活事件激素平衡,(4)肾因素(r
12、enal factor) 髓质间质细胞分泌前列腺素抗高血压、 肾脏潴留过多钠盐(肾素, 水钠)(5)神经内分泌因素(neuroendocrine factor) 缩血管:神经肽Y(NPY),去甲肾上腺素 扩血管:降钙素基因相关肽（CGRP) P物质 功能失衡交感神经活性增高,Hypertension: etiology & pathogenesis,(6)血管因素(vascular factor)内皮功能异常 内皮细胞生成一氧化氮(Nitric oxide,NO) 减少，内皮素增加。加剧高血压的结构基础 血管壁增厚、血管腔狭窄、小动脉稀少、 血管功能异常,Hypertension：etiolo
13、gy & pathogenesis,减轻体重，BMI24采用合理膳食限制钠盐 每人每日5克减少脂肪 占总热量的30%以下增加蔬菜、水果和鲜奶控制饮酒 每日酒精量1.3, 0.95), 左心室流出道狭窄,肥厚型心肌病Hypertrophic Cardiomyopathy,Hypertrophic Cardiomyopathy: 心肌细胞畸形肥大，排列紊乱,Endocardium thickened and opaqueEndomyocardial fibrosisEosinophils in some case心室充盈受限,室壁顺应性下降(Stiff and inelastic ventricl
14、e which fills with great difficulty),限制型心肌病Restrictive Cardiomyopathies,心肌炎(Myocarditis),Definition: Inflammation resulting in injury to cardiac myocytes.Common types 病毒性心肌炎(viral myocarditis) 细菌性心肌炎(bacterial myocarditis) 孤立性心肌炎(isolated myocarditis),Viral myocarditis: Clinic Features,发病前1-3周有病毒感染史
15、心悸、胸痛、呼吸困难、浮肿心律失常(arrhythmias)心衰(congestive failure), 心源性休克弥漫性收缩幅度减低，左心室增大WBC，C反应蛋白，肌钙蛋白（+）,Viral myocarditis: basic pathology,病毒(Coxsackie virus, ECHO, influenza)直接损伤或免疫介导心肌变性坏死+ 炎细胞浸润心肌收缩力+心律失常,Viral myocarditis: Gross:Cardiac dilation-myocardium flabby, pale, with focal hemorrhages,Viral myocardi
16、tis: -Microscopicedemainflammatory infiltrate of lymphocytes and other mononuclear cellsmyocyte degeneration and/or necrosisviral inclusions may be present,Viral myocarditis,孤立性心肌炎 (isolated myocarditis),特发性巨细胞性心肌炎, Fiedler心肌炎病因不明巨细胞性肉芽肿炎心肌灶状坏死+巨细胞性肉芽肿foci of necrosis + multinucleated giant cells present,缓进型急进型,机能紊乱期动脉系统病变期内脏病变期,高血压病心肌病心肌炎,增生性小动脉硬化坏死性细动脉炎微血栓,微梗死,小结（Summary),思考题1.高血压病与动脉粥样硬化在血管病变有何不同？2. 何为高血压病？其基本病理变化有哪些？,下课,
