高血压病伴糖尿病的处理.pptx

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,#,高血压病伴糖尿病的处理,中国医科大学一院心内科,齐国先,重庆,2008 12 13,多重危险因素的共同控制,Steno-2 Study 2003,2008,RCT of 160 T2DM pts with microalbuminuria,强化干预,vs,常规干预,SBP:130 mm Hg,Total cholesterol 175 mg%,HbA1c:6.5%,Initial FU:7.8y,Extended FU:13.3y,NEJM,2003;348:383,NEJM,2008;358:580,STENO-2 STUDY:,危险因素的控制,Intensive Group,Conventional Group,Systolic BP,15 mm Hg,(146,131),3 mm Hg,(149,146),LDL-C,50 mg%,(133,83),11 mg%,(137,126),HbA1c,0.5%,(8.4,7.9),0.2%,(8.8,9.0),NEJM,2008;358:580,STENO-2 STUDY:,强化治疗的效果,%Reduction in Complications,With Intensive Rx at 13.3y,Total Mortality,40%(50%,vs,30%),Cardiovascular events,59%(65%,vs,30%),Proliferative retinopathy,55%-,Nephropathy,56%-,NEJM,2008;358:580,HYPERTENSION AND DIABETES:,PARTNERS IN CRIME!,共同土壤学说,:“Metabolic Syndrome”,HTN,vs,No HTNDM,vs,No DM,2.4x,in DM2.0 x in HTN,NEJM,2000;342:905,Diabetes,Care,2005;28:310,高血压的发病率,IN DIABETES,%with BP,140/90,All U.S.adults,30%,Diabetic U.S.adults,60%,Type 1 DM,-Normoalbuminuria,30%,-Microalbuminuria,40%,-Macroalbuminuria,80%,Type 2 DM,-At Dx,50%,-Microalbuminuria,80%,-Macroalbuminuria,95%,NEJM,2000;342:905,Diabetes,Care,2005;28:310,Am,J,Kid,Dis,2007;49(Suppl 2):S74,J,Cardiometab,Syndr,2006;1:95,(86%,130/80),高血压增加糖尿病病人的并发症,Relative Risk of Complications,Diabetes,vs,No Diabetes:,CVD,2.0 4.0,ESRD,7.0,Diabetes,BP,vs,Diabetes,CHD,3.0,Stroke,4.0,Retinopathy,2.0,Nephropathy,2.0,Neuropathy,1.6,Mortality,2.0,75%die from CVD,JAMA,2004;292:2495,Kid,Internat,2000;59:703,NEJM,2005;352:341,关注焦点“,SYSTOLIC BP”,Stronger predictor of risk than diastolic BP:,Cardiovascular disease,Renal dysfunction,65%of DM hypertensives have isolated systolic hypertension,Systolic hypertension more difficult to control,Diabetes,Care,1994;17:1247,Lancet,2002;360:1903,Hypertension,2003;42:1206,糖尿病伴高血压病的控制达标现状,%With BP 130/80,NHANES,2003-2004,35%,VA,2001-2002,23%,Community 1,care,2002-2004,31-35%,Academic medicine,2002,33%,GEMINI RCT,2004,68%,Arch,Int,Med,2007;167:2394,JAMA,2004;292:2227,Ann,Fam,Med,2006;4:23,J,Gen,Intern,Med,2006;21:1050,控制不理想的原因何在？,疾病本身的原因,Most DM pts need 3-4 drugs to control BP,Activation of RAA system,Volume overload,especially if CKD,Sleep apnea from associated obesity,Vascular damage,J,Hypertens,2005;23:2305,Hypertension,2000;35:1038,Am,J,Hypertens,2004;17:915,J,Cardiometab,Syn,2007;2:114,控制不理想的原因何在？,用药依从性低,Cost,adherence 62%/30%,Inadequate pt education,BP 7/3 mm Hg,Side effects,refills 25%,Complex regimens,SBP 6 mm Hg,-QD dosing,Fixed-dose combo pills,adherence 10-20%,Arch,Int,Med,2006;166:332,1836,Am,J,Therap,2005;12:605,J,Gen,Intern,Med,2008;23:588,Ann,Intern,Med,2006;145:165,Int,J,Clin,Prac,2006;51:441,改善的策略,IN DM-HTN CONTROL,Educate patients:goal BP,etc,Control cost,Dose QD,fixed-combo pills,Address side effects,ADHERENCE!,Decrease clinician therapeutic,惰性,-Q 1mo FU,Rx until BP goal BP:,1,st,reading higher,3 readings,1 min apart,“,Alerting response”,Discard 1,st,average last 2,Hypertension,2005;45:142,J,Hypertens,2005;23:697,Can,J,Card,2007;23:529,非诊室,BP MEASUREMENT,Recommended for,all,HTN pts by AHA,2008,Best predictor of CVD events,Detects“white coat”and“masked”HTN,非诊室,BP goals,诊室,BP goal,Equivalent Goal BP,Office BP 130/80,Home BP 125/75,24-h ABPM study:,Daytime awake BP 125/75,Full 24-h BP 120/70,AHA Hypertension Primer,2008;p.343,血压类型,IN DM,DAYTIMEOUT-OF-OFFICE BP,125/75,130/80,OFFICE BP,NORMOTENSION:,Office BP 130/80,Day ABPM 125/75,Home BP 125/75,WHITE-COAT HTN:,Office BP 130/80,Day ABPM 125/75,Home BP 125/75,MASKED HTN:,Office BP 130/80,Day ABPM 125/75,Home BP 125/75,SUSTAINED HTN:,Office BP 130/80,Day ABPM 135/85,Home BP 135/85,评价,OF HYPERTENSION IN DM,BP q visit,Proper technique,BP=120/129/70-79,BP 130/80 on 2 visits 1 mo apart,BP 120/70,FU BP q visit,Consider,Out-of-office BP:,Home BP,24 hr ABPM,Risk Stratify for Rx,125/75,125/75,危险分层,-,初始治疗,Lower CVD riskInitial lifestyle Rx,Higher CVD riskInitial drug Rx,Lifestyle Rx,Diabetes,Care,2008;31(Supple 1):S24,Office BP 130/80 on 2 visits 1 month apart,or,Home BP or daytime awake BP by 24-hr ABPM 125/75,Higher Risk DM,5,:,BP,140/90,or,Albuminuria,or,CVD or LVH,Lower Risk DM,5,:,BP=,130-139/80-89,No TOD,Pharmacologic Rx,Lifestyle modification,Lifestyle modification,for 3 mo trial,Modified from:,Diabetes,Care,2007;29(Suppl):S4,Can,J,Cardiol,2007;23:529,BP,130/80,生活方式干预（资料很少）,BP mm Hg,Weight loss/Kg1/1,Low Na 60y)less effective,CHF:,CCBs less effective for prevention,?ARBs,diuretics more effective?,ACEI effective,Arch,Intern,Med,2005;165:1410,Ann,Intern,Med,2006;144:272,BBs,vs,OTHER ANTI-HTN AGENTS,Meta-analyses:,#RCTs,Hazard Ratio For Stroke,Lindholm,2005,13,1.16,(1.04-1.30),Bangalore,2007,12,1.15,(1.01-1.30),Khan,2006:,Age 60y,7,1.18,(1.07-1.30),Age 60y,5,0.99,(0.67-1.44),15-18%,stroke risk with BB,-Especially in elderly 60y,Equally(not more)protective for MI,death,Am,J,Card,2007;100:1254,J,Am,Coll,Card 2007;50:563,BBs FOR HTN:NEW GUIDELINES,Not,1,st,-line Rx unless HF,post-MI,angina:,AHA,2007,NICE/BHS,2006,CHEP,2008 and ESC/ESH,2007,Carvedilol possibly favored over metoprolol:,Greater,in microalbuminuria,Lesser in wt,TG,HbA1c,Circulation,2007;115:2761,Can,J,Card,2007;23:529,Eur,Heart,J,2007;28:1462,Hypertension,2005;46:1309,Kid,Internat,2006;70:1905,LESS EFFECTIVE BP DRUGS:ALPHA-BLOCKERS,(Doxazosin,Terazosin),ALLHAT:,-blocker,vs,diuretic,8749 DM patients,Doxazosin vs Chlorthalidone,Fatal/non-fatal CHD,No difference,Combined CVD events,22%by diuretic,CHF,85%by diuretic,Limit,-blockers to 4,th,Step Rx,J,Clin,Hypertens,2004;6:116,PHARM-RX OF HTN IN DM,BP 130/80,Single drug Rx,BP by 10/5 mm Hg,Begin,low-dose,2-drug Rx if BP 150/90,2-drug Rx:,ACE-I(ARB)Diuretic,vs,ACE-I(ARB)CCB,Most DM pts require 3-drug Rx,Standard regimen:,ACE-I(ARB)Diuretic CCB,PHARM-RX OF HTN IN DM,Adjust diuretic,eGFR,www.kidney.org/professionals/kdoqi/gfr_calculator.cfm,eGFR 30-50 ml/min/1.73m,2,thiazide,Chlorthalidone,25 mg/d preferred if need 3 drugs,eGFR 30-50 ml/min/1.73m,2,loop diuretic,Furosemide or bumetamide,bid,Torsemide,qd,Titrate dose to 4-5 lb wt loss,PHARM-RX OF HTN IN DIABETES,Accurate Dx of HTN:,BP 130/80 in office,and,/,or,BP 125/75 out-of-office,ACE-I,or,ARB,Lifestyle,s,If BP 150/90:,-ACE-I,or,ARB,Diuretic(or CCB?),Add Diuretic,Thiazide for most patients,Loop diuretic if eGFR 50(Cr 1.5 mg%)and K,+,4.5,Spironolactone,or,amiloride,Monitor K,+,carefully,Am,J,Kid,Dis,2007;49(Suppl 2):S74,Diabetes,Care,2007;30(Suppl 1):S4,BP,130/80 after 1 mo,Add DHP CCB(amlodipine or other),Stop Non-DHP CCB,Add:,-DHP CCB,(amlodipine,or,other),-BB(esp.,carvedilol),BP,130/80 after 1 mo,Consultation,BP,130/80 after 1 mo,ACE-I,ARB:LIMITED UTILITY,Theoretically attractive:more complete RAAS blockade,Limited BP,and CVD events,vs,ACE-I at max dose,ONTARGET RCT:25,620 with CVD Stroke DM,Ramipril,vs,Telmisartan,vs,RT,Minimal,BP:2.4/1.4 mm Hg,No,CVD events,More,side effects,NEJM,2008;358:1547,Am,J,Kid,Dis,2007;49(Suppl 2):S74,谢谢！,