高血压李勇.pptx

slide 1思考题思考题Antihypertensive management means pharmaceutical therapies?抗高血压治疗就是药物治疗？The benefits of antihypertensive drugs depend on the reduction of BP?降压幅度是抗高血压治疗临床获益的主要来源？slide 2Sources:WHO World Health Report 2000,CVD infobase 18,000,000 from high-income countries 42,000,000 from low-income countriesImportance of Hypertension and CVD60,000,000 HTN patients have the risk to develop to MI,stroke,and heart failureWorld Heart FederationEpidemiology of Hypertensionslide 3Prevelence of HTN in USAJNC-VI.Arch Intern Med.1997;157:2413-2446.NHANES III BP 140/90 mmHg or on therapiesPercent hypertensive18-2930-3940-4950-5960-6970-7980+Age3%9%18%38%51%66%72%020406080slide 4Prevelence of HTN in ChinaGu DF,et al.Hypertension.2002;40:920-927010203040506030354045505560657075男性男性女性女性1991 National survey:prevelence=11.26%1991 National survey:prevelence=11.26%200020002001 InterASIA study2001 InterASIA study：prevelence in age 35-74=27.2%prevelence in age 35-74=27.2%，about about 13,000,000 patients13,000,000 patientsPrevelence%ageslide 5200020002001 InterASIA study2001 InterASIA studyGu DF,et al.Hypertension.2002;40:920-927Prevelence of HTN in Chinaslide 6BP Control RatesTrendsinawareness,treatment,andcontrolofhighbloodpressureinadultsages1874National Health and Nutrition Examination Survey,PercentII197680II(Phase 1)198891II(Phase 2)19919419992000Awareness51736870Treatment31555459Control10292734Sources:Unpublisheddatafor19992000computedbyM.Wolz,NationalHeart,Lung,andBloodInstitute;JNC6.slide 7中国高血压治疗现状中国高血压治疗现状知晓率治疗率控制率200230.2%24.7%6.1%199126.6%12.2%2.9%2004年发布的中国居民营养与健康现状调查结果显示：Chin J hyper vol 12 No.6 487-489slide 8Chin J hyper vol 12 No.6 487-489患病率患病率患病人数患病人数高血压高血压18.8%1.6亿亿糖尿病糖尿病2.6%2000万万糖耐量异常糖耐量异常1.90%2000万万超重超重22.80%2亿亿肥胖肥胖7.10%6000万万高高TC(5.72mmol/L)2.90%1.6亿人次亿人次高高TG(1.7mmol/L)11.90%低低HDL(0.91mmol/L)7.40%中国高血压治疗现状中国高血压治疗现状slide 9Risk of hypertension(%)Residual lifetime risk of developing hypertension among people with blood pressure 135 or DBP 85 mm Hg)slide 47Ambulatory MeasurementAmbulatory monitoring can provide:readings throughout day during usual activitiesreadings during sleep to assess nocturnal changesmeasures of SBP and DBP loadAmbulatory readings are usually lower than in clinic(hypertension is defined as SBP 135 or DBP 85 mm Hg)slide 48Recommendations for Followup Based on Initial Measurementsslide 49Evaluation ObjectivesTo identify known causes To assess presence or absence of target organ damage and cardiovascular diseaseTo identify other risk factors or disorders that may guide treatmentslide 50Evaluation ComponentsMedical historyPhysical examinationRoutine laboratory testsOptional testsslide 51Medical HistoryDuration and classification of hypertensionPatient history of cardiovascular diseaseFamily historySymptoms suggesting causes of hypertensionLifestyle factorsCurrent and previous medicationsslide 52Physical ExaminationBlood pressure readings(2 or more)Verification in contralateral armHeight,weight,and waist circumferenceFunduscopic examinationExamination of the neck,heart,lungs,abdomen,and extremitiesNeurological assessmentslide 53Laboratory Tests and Other Diagnostic ProceduresDetermine presence of target organ damage and other risk factorsSeek specific causes of hypertensionslide 54Laboratory Tests Recommended Before Initiating TherapyUrinalysisComplete blood countBlood chemistry(potassium,sodium,creatinine,and fasting glucose)Lipid profile(total cholesterol and HDL cholesterol)12-lead electrocardiogramslide 55Optional Tests and ProceduresCreatinine clearanceMicroalbuminuria24-hour urinary proteinSerum calciumSerum uric acidFasting triglyceridesLDL cholesterolGlycosolated hemoglobinThyroid-stimulating hormonePlasma renin activity/urinary sodium determinationLimited echocardiographyUltrasonographyMeasurement of ankle/arm indexslide 56Examples of IdentifiableCauses of HypertensionRenovascular diseaseRenal parenchymal disease Polycystic kidneysAortic coarctationPheochromocytomaPrimary aldosteronismCushing syndromeHyperparathyroidismExogenous causesslide 57Components of Cardiovascular Risk in Patients With HypertensionMajor Risk Factors:SmokingDyslipidemiaDiabetes mellitusAge older than 60 yearsSex(men or postmenopausal women)Family history of cardiovascular diseaseslide 58CVD RiskHTNprevalence50millionpeopleintheUnitedStates.TheBPrelationshiptoriskofCVDiscontinuous,consistent,andindependentofotherriskfactors.Eachincrementof20/10mmHgdoublestheriskofCVDacrosstheentireBPrangestartingfrom115/75mmHg.PrehypertensionsignalstheneedforincreasededucationtoreduceBPinordertopreventhypertension.slide 59Clinical Risk Factors forStratification of Patients With HypertensionHeart diseasesStroke or transient ischemic attackNephropathyPeripheral arterial diseaseRetinopathyslide 60Risk Stratificationslide 61Risk Stratificationslide 62Treatment Strategies andRisk Stratificationslide 63Primary PreventionPrimary prevention offers an opportunity to interrupt the costly cycle of managing hypertension.A population-wide approach can reduce morbidity and mortality.Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control.Blood pressure rise with age is not inevitable.Lifestyle modifications have been shown to lower blood pressure.slide 64Goal of HypertensionPrevention and ManagementTo reduce morbidity and mortality by the least intrusive means possible.This may be accomplished by achieving and maintaining:SBP 140 mm HgDBP 90 mm Hgcontrolling other cardiovascular risk factors CHD Incidence Rate/1000 Person YearsHistorical Lessons About HypertensionHistorical Lessons About HypertensionCumulative Fatal&Nonfatal EndpointsTHE FRAMINGHAM STUDYTHE VET.ADM.STUDY IIAnn Intern Med.1961;55:33-50JAMA.1970;213:1143-1152Hypertension IncreasesMorbidity and MortalityTreatment Decreases Morbidity and Mortalityslide 66Goals of Therapy for HTNReduceCVDandrenalmorbidityandmortality.TreattoBP140/90mmHgorBP50yearsofage.slide 67Benefits of Lowering BPAverage Percent ReductionStrokeincidence3540%Myocardialinfarction2025%Heartfailure50%单纯收缩压升高单纯收缩压升高(%)0102030405001020304050(%)脑卒中脑卒中脑卒中脑卒中 冠心病冠心病冠心病冠心病总死亡总死亡总死亡总死亡心血管心血管心血管心血管死亡死亡死亡死亡非心血管非心血管非心血管非心血管死亡死亡死亡死亡致死和致残事件致死和致残事件致死和致残事件致死和致残事件死亡率死亡率死亡率死亡率收缩压和舒张压均升高收缩压和舒张压均升高脑卒中脑卒中脑卒中脑卒中冠心病冠心病冠心病冠心病总死亡总死亡总死亡总死亡心血管心血管心血管心血管死亡死亡死亡死亡非心血管非心血管非心血管非心血管死亡死亡死亡死亡致死和致残事件致死和致残事件致死和致残事件致死和致残事件死亡率死亡率死亡率死亡率降压治疗的临床获益降压治疗的临床获益ESH-ESC Hypertension Guidelines.J Hypertens.2003.0.010.010.010.010.0010.001NSNS0.0010.0010.0010.0010.020.020.010.01NSNS0.0010.001slide 69血压控制目标值血压控制目标值q高血压患者高血压患者 140/90 mmHgq糖尿病患者糖尿病患者 130/80 mmHgq肾功受损：蛋白尿肾功受损：蛋白尿1g/1g/日日 1g/1g/日日 125/75 mmHgq老年人：老年人：SBP150mmHg2004年中国高血压防治指南年中国高血压防治指南 slide 70Lifestyle ModificationsFor Prevention and ManagementLose weight if overweight.Limit alcohol intake.Increase aerobic physical activity.Reduce sodium intake.Maintain adequate intake of potassium.For Overall and Cardiovascular HealthMaintain adequate intake of calcium and magnesium.Stop smoking.Reduce dietary saturated fat and cholesterol.slide 71Lifestyle ModificationModificationApproximate SBP reduction(range)Weight reduction 520mmHg/10 kg weight lossAdopt DASH eating plan 814 mmHgDietary sodium reduction 28 mmHgPhysical activity 49 mmHgModeration of alcohol consumption 24 mmHgslide 72Pharmacologic TreatmentDecreases cardiovascular morbidity and mortality based on randomized controlled trials.Protects against stroke,coronary events,heart failure,progression of renal disease,progression to more severe hypertension,and all-cause mortality.slide 73Special Considerationsin Selecting Drug TherapyDemographicsCoexisting diseases and therapiesQuality of lifePhysiological and biochemical measurementsDrug interactionsEconomic considerationsslide 74Drug TherapyA low dose of initial drug should be used,slowly titrating upward.Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50%of peak effect remaining at end of 24 hours.Combination therapies may provide additional efficacy with fewer adverse effects.slide 75Classes ofAntihypertensive DrugsACE inhibitorsAdrenergic inhibitorsAngiotensin II receptor blockers Calcium antagonistsDirect vasodilatorsDiureticsslide 76Initial Drug ChoicesAlgorithm for Treatment of Hypertension(continued)Not at Goal Blood Pressure(140/90 mm Hg)lower goals for patients with diabetes or renal diseaseBegin or Continue Lifestyle Modificationsslide 77Not at Goal Blood PressureInitial Drug ChoicesUncomplicatedCompelling IndicationsNot at Goal Blood PressureAlgorithm for Treatment of Hypertension(continued)Start at low dose and titrate upward.Low-dose combinations may be appropriate.Specific Indicationsslide 78Initial Drug Choices*Uncomplicated Diuretics-blockersAlgorithm for Treatment ofHypertension(continued)*Based on randomized controlled trials.slide 79Initial Drug Choices*Algorithm for Treatment of Hypertension(continued)Compelling Indications Heart failure ACE inhibitorsDiureticsMyocardial infarction-blockers(non-ISA)ACE inhibitors(with systolic dysfunction)Diabetes mellitus(type 1)with proteinuriaACE inhibitorsIsolated systolic hypertension(older persons)Diuretics preferredLong-acting dihydropyridine calcium antagonists*Based on randomized controlled trials.slide 80Initial Drug ChoicesSpecific indications for the following drugs:Algorithm for Treatment ofHypertension(continued)ACE inhibitors Angiotensin II receptor blockers-blockers-blockers-blockers Calcium antagonists Diureticsslide 81Specific Drug IndicationsAngina -blockers Calcium antagonistsAtrial tachycardia and fibrillation -blockers Nondihydropyridine calcium antagonistsSome antihypertensive drugs may have favorable effects on comorbid conditions:Heart failureCarvedilolLosartanMyocardial infarctionDiltiazemVerapamilslide 82Specific Indications(continued)Cyclosporine-induced hypertensionCalcium antagonistsDiabetes mellitus(1 and 2)with proteinuriaACE inhibitors(preferred)Calcium antagonistsDiabetes mellitus(type 2)Low-dose diureticsDyslipidemia-blockersProstatism(benign prostatic hyperplasia)-blockersRenal insufficiency(caution in renovascular hypertension and creatinine 3 mg/dL 265.2 mol/L)ACE inhibitorsSome antihypertensive drugs may have favorable effects on comorbid conditions:slide 83Specific Indications(continued)Essential tremorNoncardioselective -blockersHyperthyroidism -blockersMigraine Noncardioselective -blockers Nondihydropyridine calcium antagonistsOsteoporosis ThiazidesPerioperative hypertension -blockersSome antihypertensive drugs may have favorable effects on comorbid conditions:slide 84Not at Goal Blood Pressure(140/90 mm Hg)No response or troublesome side effectsInadequate response but well toleratedSubstitute another drug from different classAdd second agent from different class(diuretic if not already used)Not at Goal Blood Pressure(140/90 mmHg)Initial Drug ChoicesAlgorithm for Treatment ofHypertension(continued)slide 85Not at Goal Blood Pressure(140/90 mm Hg)Continue adding agents from other classes.Consider referral to a hypertension specialist.Substitute drug from different classAdd second agent from different classAlgorithm for Treatment of Hypertension(continued)slide 86血压血压直接机制直接机制直接机制直接机制(自动调节自动调节自动调节自动调节)肾上腺素能机制肾上腺素能机制肾上腺素能机制肾上腺素能机制(，)盐机制盐机制盐机制盐机制(氯化钠氯化钠氯化钠氯化钠)体液体液体液体液/激素机制激素机制激素机制激素机制(血管紧血管紧血管紧血管紧张素张素张素张素IIIIIIII、去甲肾上腺素、去甲肾上腺素、去甲肾上腺素、去甲肾上腺素、内皮素内皮素内皮素内皮素)维持血压的主要机制维持血压的主要机制DirectAdrenergicSaltHormones快速强效，控制血压快速强效，控制血压slide 87Combination Therapies-adrenergic blockers and diureticsACE inhibitors and diureticsAngiotensin II receptor antagonists and diureticsCalcium antagonists and ACE inhibitorsOther combinationsslide 88Combination Therapiesslide 89FollowupFollow up within 1-2 months after initiating therapy.Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications.Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose.Consider reducing dose and number of agents after1 year at or below goal.slide 90Causes for InadequateResponse to Drug Therapy PseudoresistanceNonadherence to therapyVolume overloadDrug-related causesAssociated conditionsIdentifiable causes of hypertensionslide 91Guidelines for ImprovingAdherence to TherapyBe aware of signs of nonadherence.Establish goal of therapy.Encourage a positive attitude about achieving goals.Educate patients about the disease and therapy.Maintain contact with patients.Encourage lifestyle modifications.Keep care inexpensive and simple.slide 92Guidelines for ImprovingAdherence to Therapy(continued)Integrate therapy into daily routine.Prescribe long-acting drugs.Adjust therapy to minimize adverse affects.Continue to add drugs systematically to meet goal.Consider using nurse case management.Utilize other health professionals.Try a new approach if current regime is inadequate.slide 93Hypertensive Emergencies and UrgenciesEmergencies require immediate blood pressure reduction to prevent or limit target organ damage.Urgencies benefit from reducing blood pressure within a few hours.Elevated blood pressure alone rarely requires emergency therapy.Fast-acting drugs are available.slide 94Drugs Available forHypertensive EmergenciesVasodilatorsNitroprussideNicardipineFenoldopamNitroglycerinEnalaprilatHydralazineAdrenergic InhibitorsLabetalolEsmololPhentolamineslide 95For persons over age 50,SBP is a more important than DBP as CVD risk factor.Starting at 115/75 mmHg,CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.Persons who are normotensive at age 55 have a 90%lifetime risk for developing HTN.Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.New Features and Key Messagesslide 96Key Messages(Continued)The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.Motivation improves when patients have positive experiences with,and trust in,the clinician.Empathy builds trust and is a potent motivator.The responsible physicians judgment remains paramount.slide 97思考题思考题Antihypertensive management means pharmaceutical therapies?抗高血压治疗就是药物治疗？The benefits of antihypertensive drugs depend on the reduction of BP?降压幅度是抗高血压治疗临床获益的主要来源？slide 98Pregnant WomenChronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation.Preeclampsia is increased blood pressure that occurs in pregnancy(generally after the 20th week)and is accompanied by edema,proteinuria,or both.ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women.Methyldopa is recommended for women diagnosed during pregnancy.slide 99Antihypertensive Drugs Used in Pregnancyslide 100Antihypertensive Drugs Used in Pregnancy(continued)slide 101Older PersonsHypertension is common.SBP is better predictor of events than DBP.Pseudohypertension and“white-coat hypertension”may indicate n