高血压病伴糖尿病的处理策略.pptx

高血压病伴糖尿病的处理策略高血压病伴糖尿病的处理策略中国医科大学一院心内科中国医科大学一院心内科 齐国先齐国先 沈阳沈阳 2009 06 27HTN伴DM的流行病学HTN伴DM的危害HTN伴DM的控制多重危险因素的共同控制多重危险因素的共同控制生活方式的改善降压目标和降压药物的选择主要内容流行病学高血压和糖尿病高血压和糖尿病PARTNERS IN CRIME!共同土壤学说:“MetabolicSyndrome”HTNvsNoHTNDMvsNoDM2.4xinDM2.0 xinHTNNEJM2000;342:905DiabetesCare2005;28:310SyndromeXorMetabolicsynd.LDLHDLCentralobesityType2DMAtherosclerosisMacrovasculardiseaseHypertensionInsulinresistance(insulin)美国糖尿病患者高血压的发病率%with BP 140/90All U.S.adults30%Diabetic U.S.adults60%Type 1 DM -Normoalbuminuria30%-Microalbuminuria40%-Macroalbuminuria80%Type 2 DM -At Dx50%-Microalbuminuria80%-Macroalbuminuria95%NEJM 2000;342:905 Diabetes Care 2005;28:310 Am J Kid Dis 2007;49(Suppl 2):S74J Cardiometab Syndr 2006;1:95(86%130/80)Data from King H et al.Diabetes Care.1998;21:1414-1431.TopThreeCountriesforDiabetesHTN伴DM的危害高血压增加糖尿病病人的并发症Relative Risk of ComplicationsDiabetes vs No Diabetes:CVD2.0 4.0 ESRD7.0Diabetes BP vs Diabetes CHD3.0 Stroke4.0 Retinopathy2.0 Nephropathy2.0 Neuropathy1.6 Mortality2.075%die from CVDJAMA 2004;292:2495 Kid Internat 2000;59:703 NEJM 2005;352:341AssociationofSBPandCVMortalityinMenWithType2Diabetes250200150100500120120-139140-159160-179180-199SBP(mmHg)CVmortalityrate/10,000person-yrNondiabeticDiabeticCV,cardiovascular;SBP,systolicbloodpressure.StamlerJetal.Diabetes Care.1993;16:434-444.200NephropathyhistoryinDMHTN伴DM的控制多重危险因素的共同控制多重危险因素的共同控制Steno-2Study2003,2008RCTof160T2DMptswithmicroalbuminuria强化干预vs常规干预SBP:130mmHgTotalcholesterol175mg%HbA1c:50yearsDiabetesfor10yearsTakingtreatmentforHTNEvidenceoftarget-organdamageorestablishedcardiovasculardiseaseAtrialfibrillationLipid-loweringtherapy-indicationsinDMAllpeoplewithestablishedCVDAllpeople40yearsAllpeople9%)需要治疗的血压升高总胆固醇6mmol/l代谢综合征直系亲属中有早发心血管疾病的家族史改善生活方式改善生活方式规律的有氧运动，每周3-5次，每次30-60分钟推荐适量的酒精摄入限盐，3.6克/天控制体重控制体重限制咖啡（或其他含咖啡因的饮料）,5杯/天 BP mm Hg控制体重（Kg）1/1低盐 Na 2.4 g/d5/3健康饮食 11/5饮酒 4/2步行,150 min/wk5/4J Hypertens 2006;24:269 Hypertension 2006;47:296 Can J Cardiol 2007;23:529www.nhlbi.nih.gov/health/public/heart/hbp/hbp_low/hbp_low.pdfDECREASE in CORONARY ATTACK in 2 YEARS,%CIGARETTES PER DAYMENWOMEN10(1/2 pack)192420(1 pack)344040(2 packs)5764高血压患者戒烟后的获益情况降压目标和降压药物的选择IdealBPTargets130/80forpeoplewithoutproteinuria125/75forpeoplewithproteinuria糖尿病伴高血压病的控制达标现状%With BP 130/80NHANES,2003-200435%VA,2001-200223%Community 1 care,2002-200431-35%Academic medicine,200233%GEMINI RCT,200468%Arch Int Med 2007;167:2394JAMA 2004;292:2227Ann Fam Med 2006;4:23J Gen Intern Med 2006;21:1050控制不理想的原因疾病本身的原因疾病本身的原因MostDMptsneed3-4drugstocontrolBPActivationofRAAsystemVolumeoverload,especiallyifCKDSleepapneafromassociatedobesityVasculardamageJ Hypertens 2005;23:2305Hypertension 2000;35:1038 Am J Hypertens 2004;17:915J Cardiometab Syn 2007;2:114控制不理想的原因用药依从性低用药依从性低 药品价格药品价格 adherence 30%患者教育患者教育 BP 7/3 mm Hg 药物副作用药物副作用 换药 25%用药方法用药方法 SBP 6 mm Hg -QD dosing -Fixed-dose combo pills adherence 10-20%Arch Int Med 2006;166:332,1836Am J Therap 2005;12:605J Gen Intern Med 2008;23:588 Ann Intern Med 2006;145:165 Int J Clin Prac 2006;51:441改善用药依从性用药依从性的策略INDM-HTN 教育教育:goal BP,etc控制花费控制花费改善剂型改善剂型-长效、复方制剂长效、复方制剂关注药物副作用关注药物副作用降低医生用药的降低医生用药的 惰惰性性糖尿病伴高血压诊断中注意的问题诊室血压测定的准确性。非诊室血压测定的HomeBPmeasurement24-hourambulatoryBP诊室血压测量需要注意的问题 BP(mm Hg)休息休息 5 min 12/6坐位,back supported 6/8袖带的水平 at midsternal 2/inch袖带大小袖带大小 6-18/4-13放气的速度 2 mm Hg/sec SBP/DBP测定测定3次，间隔次，间隔:1 min 1st reading higher Discard 1st,average last 2Hypertension 2005;45:142 J Hypertens 2005;23:697 Can J Card 2007;23:529 非诊室血压的测定Recommended for all HTN pts by AHA,2008BestpredictorofCVDeventsDetects“whitecoat”and“masked”HTN非诊室非诊室 BP goals 诊室诊室 BP goal EquivalentGoalBPOfficeBP130/80 HomeBP125/7524-hABPMstudy:DaytimeawakeBP125/75Full24-hBP120/70AHAHypertensionPrimer,2008;p.343糖尿病患者的血压类型非诊室非诊室血压血压125/75130/80诊室血室血压正常血正常血压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75白大衣高血白大衣高血压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75隐蔽性高血蔽性高血压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75 高血高血压 Office BP 130/80 Day ABPM 135/85 Home BP 135/85糖尿病患者高血压的评价流程首次血压测量 Proper techniqueBP=120/129/70-79BP 130/80 on 2 visits 1 mo apartBP 120/70FU BP Consider Out-of-office BP:Home BP 24 hr ABPMRisk Stratify60y)lesseffective CHF:ACE-I，diureticsmoreeffectiveCCBslesseffectiveforprevention?ARBseffective?ArchInternMed2005;165:1410AnnInternMed2006;144:272BBsvsOTHERANTI-HTNAGENTSMeta-analyses:#RCTsHazard Ratio For StrokeLindholm,2005131.16(1.04-1.30)Bangalore,2007121.15(1.01-1.30)Khan,2006:Age 60y71.18(1.07-1.30)Age 60y50.99(0.67-1.44)15-18%stroke risk with BB -Especially in elderly 60y Equally(not more)protective for MI,deathAm J Card 2007;100:1254J Am Coll Card 2007;50:563BBsFORHTN:NEWGUIDELINESNot 1st-line Rx unless HF,post-MI,angina:AHA,2007NICE/BHS,2006CHEP,2008andESC/ESH,2007Carvedilol possibly favored over metoprolol:Greater in microalbuminuriaLesser in wt,TG,HbA1cCirculation2007;115:2761CanJCard2007;23:529EurHeartJ2007;28:1462Hypertension2005;46:1309KidInternat2006;70:1905LESSEFFECTIVEBPDRUGS:ALPHA-BLOCKERS(Doxazosin,Terazosin)ALLHAT:-blocker vs diuretic,8749 DM patientsDoxazosin vs ChlorthalidoneFatal/non-fatal CHDNo differenceCombined CVD events 22%by diureticCHF 85%by diuretic Limit -blockers to 4th Step RxJ Clin Hypertens 2004;6:116糖尿病患者的药物治疗BP 130/80Single drug Rx BP by 10/5 mm HgBeginlow-dose2-drugRxifBP150/902-drug联合应用:ACE-I(ARB)DiureticvsACE-I(ARB)CCBMost DM pts require 3-drug Rx标准方案ACE-I(ARB)DiureticCCB糖尿病患者的药物治疗Adjust diuretic（eGFR）-eGFR 30-50 ml/min/1.73m2 thiazideChlorthalidone,25mg/difneed3drugseGFR 30-50 ml/min/1.73m2 loop diureticFurosemidebidTorsemideqdUncertainty about optimal 4th drugAssessforcausesofresistantHTN糖尿病患者的药物治疗流程准确诊断: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）ACE-IorARBDiureticCCB Loop diuretic if eGFR 30-50(Cr 1.6-1.9 mg%)Am J Kid Dis 2007;49(Suppl 2):S74 Diabetes Care 2007;30(Suppl 1):S4BP 130/80 after 1 moACE-IorARBDiureticCCB BBsor-blockersor检查原因BP 130/80 after 1 mo