高血压英文ppt精品课件cardiovascular diseasepreventive

Cardiovascular Disease; Preventive Medicine 2005 David R. Rudy, M.D., M.P.H. Professor and Chairman Family and Preventive Medicine Chicago Medical School, RUMS Atherosclerotic Vascular Disease Risk Factors, Screening to Prevent Atherosclerotic Disease Coronary artery disease (CAD) Cerebrovascular disease CVD) Peripheral vascular disease (PVD) Reno-vascular dis. and renal failure (CRF) hypertension Coronary Artery Disease (CAD) 1.5 million myocardial infarctions (MI)/year/US; 700,142 deaths from CAD 15% case fatality w/ acute MI; 30% case fatality w/ acute MIs as first indication of CAD; Risks=high BP, dyslipidemia, physical inactivity, diabetes mellitus, age. (obesity) Smoking Genetics Screening versus Prevention (1) Screening for CAD in general population is impractical (e.g. screening EKGs, stress testing, coronary angiograms) Resting EKGs not sensitive enough; EKG stress testing not sensitive enough in high risk populations; Thallium stress/EKG too sensitive in low risk populations; Coronary angiograms too risky and too expensive for screening Screening versus Prevention (2) Primary (and secondary) prevention of CAD through control of controllable risk factors: Screening is for risk factors: imperfect but cost effective and tolerable Risk factors for CAD (and other athero- sclerotic vascular dis: Controllable: Hypertension, diabetes, dyslipidemia, smoking, C-reactive protein, (emotional stress); Uncontrollable: inheritance Risk factors tend toward clusters: hypertension, diabetes, dyslipidemia; Metabolic syndrome X and insulin resistance (strong assoc. w/ obesity; strongly familial but remediable) Metabolic Syndrome X Insulin resistance, hyperinsulinemia, incipient diabetes type II Hypertension Dyslipidemia: TC, LDLC, TGs, HDLC Criteria for metabolic syndrome X: any 3/5 1. Abdominal obesity: waist measurement 102 cm (40 in.) in men, 88 (35 in.)cm in women. 2. Hypertrigyceridemia: 150 mg/dL (1.69 mmol/L) 3. Low HDL cholesterol: 40 mg/dL (1.04 mmol/L); CAD Renal Failure Noncardiovascular Disease Coronary Heart Disease Stroke 10 20 30 40 50 1972 1978 1984 1990 Figure 1. Decline in age-adjusted mortality since 1972. Data for 1990 are provisional. Source: National Center for Health Statistics data calculated by the National Heart, Lung, and Blood Institute. Decline in Mortality Pathophysiology of essential hypertension 35 % Caucasians and most other groups hypertension characterized by salt/water retention; 65% African-Americans; majority of elderly 10% peripheral vascular resistance (PVR) (renin/angiotensin, catecholamines) 55% mixed PVR/salt retention) Hyperinsulinemia associated w/ volume dependent hypertension Hyperinsulinemia associated w/ mineralo- corticoid, probable contributor to volume dependent hypertension Salt/water retention driven hypertension responds to diuretics: thiazides loop diuretics (except in rising creatinine)- - and to salt restriction What portion of most groups hypertension have pure salt sensitivity? 35% Which portion of African-Americans hypertension? 67% Salt Restriction: opportunity for primary prevention of hypertension (Other mainstays of Rx of hypertension: ACEIs and ACERBs, Ca+ channel blockers, blockers) Definitions of Hypertension (HTN) Three readings on separate occasions (140/90) to make the diagnosis, unless BP is found at 210/120 Htn in Children: 95th-99th percentiles* Age group Newborns 30 d Infants 3-5 years 6-9 years 10-12 years 13-15 years 16-18 years SBP/DBP, mm Hg 104-109 SBP 112-117/74-81 116-123/76-83 122-129/78-85 126-133/82-89 136-143/86-91 142-149/82-97 Physiologic Types of Hypertension I Essential or Primary Hypertension (90-95% of all cases) II Secondary Hypertension: 5-10% of all cases (pheo, primary aldosteronism, renovascular) (Zollo: The Portable Internist. Hanley and Belfus/Philadelphia and Moseby/St. Louis 1995) Primary and secondary prevention HTN w/o drugs Weight control to prevent HTN (and to prevent insulin resistance) Control sodium intake to prevent 1/3 HTN; useful adjunct in addtional 1/3 Stress management Control of other aggravating risk factors: e.g. smoking, dyslipidemia Isolated Systolic Hypertension (ISH: SBP140): CVD risk More common in elderly; elderly more likely to have ISH; likely to be diuretic responsive. Factors in primary prevention of Htn in high risk people: -salt restriction -stress management -weight control Implications of hypertension and of diabetes re/ kidneys: Status of renal function Major causes of chronic renal failure (not ESRD)* sub w/ Bakris: Diabetes mellitus 31.0% Hypertension 27.0% Glomerulonephritis 14.0% Obstructive uropathy 5.7% Polycystic renal disease 3.6% Others 5.7% Unknown 13.0% Diabetes: The Most Common Cause of ESRD Primary Diagnosis for Patients Who Start Dialysis Diabetes 50.1% Hypertension 27% Glomerulonephritis 13% Other 10% United States Renal Data System. Annual data report. 2000. No. of patients Projection 95% CI 1984 1988 1992 1996 2000 2004 20080 100 200 300 400 500 600 700 r2=99.8% 243,524 281,355 520,240 No. of dialysis patients (thousands) Prevention of End Stage Renal Disease by BP and BS control Tight control of blood sugar and of BP prevents ESRD in diabetics and hypertensives. Diabetes Control and Complications Trial Research Grp. Diabetes Care 1995 United Kingdom Prospective Diabetes Study 1998 Recommendations for screening for HTN (USPSTF, 1996): “Screening for hypertension is recommended for all children and adults”, i.e. BPs on all visits Secondary Prevention of Complications of D/M through control of BS, insulin resistance; UKPDS: Metformin as good as S.U.s in BS control but MI mortality reduced by 39% w/ metformin (b/c reduces insulin) Hgb A1C controlled to 200 LDLC: diet for 160 mg/dL HDLC: diet at 5.1 males, 4.1 females, TG: diet for 150 Dietary goals: Fats 30% total cal as: saturated simple Fiber 20-30 gm Protein 15% of total calories Cholesterol 75 y.o.); That LDL should not exceed 100 mg/dL; That everyone should have a lipid profile every 5 years. More liberal definition of risk status From Framingham study, people w/ two risk factors should be treated as if they have already a diagnosis of CAD. People w/ diabetes alone to be treated as if they have already a diagnosis of CAD. Significance of CRP Ridker : J.A.M.A. 2001; 285:2481-2485 Ridker: New Engl J Med 2004; 352:20-8 Marker of over exuberant inflammatory response, relevant in endothelial injury and repair; Highest quartile of CRP exhibits RR of 1.5 times expected risk for atherosclerotic disease CRP continued AS is a disease of endothelial defectiveness - failure causes rupture of plaques CRP levels, along with Total and Low Density Lipoprotein Cholesterol are reduced by statins Recommendation for lipid screening (USPSTF) USPSTF: Guide to Clinical Preventive Services Second Edition. Williams and Wilkins 1996 “-periodic measurement of cholesterol for all m