168/112mmHg.,ex-smoker 20 42,

Transcription

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2 /112mmHg,ex-smoker 2042,

3 ,168/112mmHg,HR89/min,RR18/min,97%RA 163cm,101kg,BMI38.0 Cushing,, Cre0.68mg/dl,K2.8mEq/L,TSH0.862μIU/ml 1+,WBC1-4/HF,RBC1/HF

4 10 Hypertension ;71:

5 Clinical Question

6 *1 *2 5-15% >30% STOP-BANG % 2-10% Cre % % CTAMRA % 6-23% ARRPAC 1-2% 1-3% TSH Cushing 0.5% <1.0% 0.2~0.5% <1.0% <1% <1% CTA:computed tomographic angiography MRAmagnetic resonance angiography ARRaldosterone renin ratio PACplasma aldosterone concentration 4Common *1, European Heart Journal (2014) 35,

7 2 Common %, %, %,, % 65 17%,,Cushing, Am Fam Physician. 2010;82:

8 Clinical Question

9 , choosing wisely,

10 K,,, Hypertension ;71: J Clin Endocrinol Metab.2016;101: J Clin Endocrinol Metab. 2014;99: Circulation.2006;113:e463-e654 J Clin Endocrinol Metab.2008;93:

11 3BP>130/80 and/or /

12 NSAIDs SNRIMAO VEGF VEGF- Drug VEGFvascular endothelial growth factor

13 MEN2,VHL,NF1 40 MEN2:multiple endocrine neoplasia type2 VHL:von Hippel Lindau NF1neulofibromatosis type1

14 40cm Cushing,,,,,, 20mmHg Cushing

15 Clinical Question

16 CPAP Apnea Hypopnea IndexAHI 20 AHI 40 CPAP sbp2.6mmhg,dbp2.0mmhg QOL, Int J Hypertens. 2017;2017: JAMA ; 318: Chest. 2014; 145: Chest. 2017;151: Sleep.2010; 33:

17 STOP-BANG 3 Epworth Sleepiness scale 11 or (PSG) AHI () 5+AHI () 15 (Respiratory disturbance index:rdi) =(AHI+)/()AHI PSG PSG AHIapnea hypopnea index RDIrespiratory disturbance index J Clin Sleep Med Mar 15;13(3):

18 STOP-BANG questionnaire Snoring Tiredness Observed apenas blood-pressure BMI >35 Age 50 Neck circumference 40cm Gender 3Cut off AHIRDI 5 88%,42% AHIRDI 15 90%,36% AHIRDI 30 93%,35% STOP-BANGvariation Sleep Med Rev. 2017;36:57-70

19 Epworth Sleepiness scaleess 1,, 11 AHI and/or RDI 5 54%,65% AHI and/or RDI 15 47%,62% AHI and/or RDI 30 58%,60% ESSvariationJESS; Japanese version of ESS Sleep Med Rev. 2017;36:57-70

20 55 ACEIARBCre50 1.5cm USCTAMRA 2014US Circulation. 2006;113:e463-e654

21 US PSV PSV PSV RAR RARPSV/PSV RAR PSV AT AT PSVpeak systolic velocity RARrenal aortic ratio AT: acceleration time c/m sec Gefasschirurgie. 2016; 21: 4 13.

22 US gold standard PSV> cm/s 85% 92% RAR> % 89% Acceleration time> s PSV (peak systolic velocity, RAR (Renal Aortic Ratio,-PSV/PSV 80% 88% USPSV AJR Am J Roentgenol.2007;188:

23 USCTAMRA gold standard US CTA MRA 75% 94% 90% 89% 93% 94% Renal Failure.2007;29: MRA MRA 94% 97% 85% 93% Clin Radiol Jul;57(7): USCTAMRA CTAMRA

24 513%, ( ARR>200 ARR>200PAC>120 ARRaldosterone renin ratio PACplasma aldosterone concentration odds ratio Lancet Diabetes Endocrinol Jan;6(1): J Clin Endocrinol Metab, May 2016, 101(5):

25 40 ARR PACpg/ml/PRAng/ml/h 200, 200 J Clin Endocrinol Metab.2016;101:

26 ARR J Clin Endocrinol Metab, May 2016, 101(5): K4.0mEq/L, or ARRβNSAIDs ARRACEiARB CCB K

27 MEN2,VHL,NF1 2* * J Clin Endocrinol Metab. 2014;99: MNNMN 1.0μg/mgCre 97.6% 100% NMN or MN 0.5μg/mgCre 100% 100% MNmetanephrine NMNnormetanephrine World J Surg Jul;22(7):684-8.,

28 3 24 1mg 1mg J Clin Endocrinol Metab.2008;93: ,

29 Cushing,,,, 1mg 5μg/dL 238 5μg/dL 85% 95% 1.8μg/dL 95%,80% J Clin Endocrinol Metab.2008;93:

30 CBC,Cre,Na,K,,,TSH Hypertension ;71:

31 Cushing MEN2,VHL,NF ACEIARBCre50,1.5cm STOP-BANG 3,ESS 11 US PSV>180cm/s CTAMRA PSG AHIRDI 5+ AHIRDI 15 PACPRA ARR>200PAC>120 MNNMN 1.0μg/mgCre NMN or MN 0.5μg/mgCre 1mg 5μg/dL Cushing

32 ,, STOP BANG5/8 PAC=214pg/ml,PRA=0.9ng/ml/hr ARR= AHI=47 40CPAP,

33 Take home message 10%,,,,,, common