高血压英文ppt精品课件towardsan evidence based treatment strategy in

Towards an Evidence Based Treatment Strategy in Hypertension Tony Woolley M.D. Park Nicollet Clinic Clinical Associate Professor of Medicine, University of Minnesota W My First Lesson In Hypertension CIRCA 1980, first Internal Med clinical rotation Begin Treatment if BP140/90 Start thiazide diuretic, 50mg qd Towards an Evidence Based Treatment Strategy in Hypertension What should our goal BP be, especially for special populations ( Diabetes, Renal disease, Coronary disease, other high risk populations)? What medication strategies are best supported by evidence, especially for special populations? How does the gap between clinical practice and clinical evidence grow? ( Analysis of Bias) Evidence Based Practice Major Principles Hierarchy of Evidence Level 1 evidence= Systematic Reviews or Meta-analysis of RCTs or Single high quality RCTs (like ALLHAT or ACCORD) Tempered by Clinical Judgment and Patient Preferences Evidence Hierarchy More of This And less of This Towards an Evidence Based Treatment Strategy in Hypertension What should our goal BP be, especially for special populations ( Diabetes, Renal disease, Coronary disease, other high risk populations)? Current Recommendations for BP Goals JNC 7 (Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood) Pressure Goal BP 10% ADA DM 10% Evidence Level 5 (Expert Opinion) Framingham Risk Calculation, Ex. Age: 65 Gender: male Total Cholesterol: 200 mg/dL HDL Cholesterol: 40 mg/dL Smoker: No Systolic Blood Pressure: 140 mm/Hg On medication for HBP: Yes Risk Score* 19% * The risk score shown was derived on the basis of an equation. Other NCEP materials, such as ATP III print products, use a point-based system to calculate a risk score that approximates the equation-based one. ATP III Executive Summary and ATP III At-a-Glance. Hypertension in Coronary Artery Disease and “High Risk” Groups No Intent to Treat RCT addresses this Lower Achieved BP has been associated with no benefit or worsened outcomes in post hoc analysis of trials INVEST DM and CAD ONTARGET Vascular disease or DM NEJM 358:1547-1559 I-PRESERVE Diastolic CHF JAMA July 7,2010;304(1)61-68, NEJM 358:1547-1559 N Engl J Med 2008;359:245667 Hypertension in Coronary Artery Disease and “High Risk” Groups AHA/ACC Guidelines say: Treat to 10% Evidence says: No renal or cardiovascular benefit demonstrated in this overall group 2010 ICSI guideline: 80) Epidemiologic population studies show better survival with higher BP STOP-2 Worse survival in treated hypertensives with SBP3g/24h proteinuria had renal outcome benefit Hypertension in CKD Relevant clinical trials: AASK 2002 RCT 1094 African American patients with hypertensive nephropathy assigned to MAP300mg/dl) New ICSI guideline: 140/90 Start thiazide , Break it in half Selected References ICSI Hypertension Guideline 2010 revision /guidelines_and_more/. Treatment Blood Pressure Targets for Hypertension: Cochrane Review 2009 /o/cochrane/clsysrev/articles/CD004349/frame. html ACCORD BP Study, March 14 2010 The Effects of Intensive Blood Pressire Control in Type 2 Diabetes Mellitus /doi/pdf/10.1056/NEJMoa1001286 INVEST Diabetes Subgroup Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients with Diabetes and Coronary Artery Disease JAMA, Vol 304, 1, 61-67 Selected References Hypertension in the Very Elderly Trial (HYVET) 2008 N Engl J Med 2008; 358(18):1887-98. Pharmacotherapy of Hypertension in the Elderly: Cochrane Review 2010 /o/cochrane/clsysrev/articles/CD000028/frame. html AASK 10 year follow up 2010 Intensive Blood-Pressure Control in Hypertensive Chronic Kidney Disease N Engl J Med 2010; 363:918-929 First Line Drugs for Hypertension: Cochrane Review 2009 /o/cochrane/clsysrev/articles/CD001841/frame. html Additional Slides, Treatment These will not be discussed in the presentation Drug Rx for HTN Where is the evidence pointing us? Drug Rx for HTN JNC 7 Thiazides for most Other First line drugs ACE/ARB Beta Blockers CCB Cochrane Review, Drugs for HTN 57 trials, n=58,040 Conclusion: Low dose thiazides reduce all morbidity and mortality outcomes. ACEI and Calcium blockers may be similarly effective but the evidence is less robust. Beta blockers and high dose thiazides are inferior to low dose thiazides Cochrane Review, Drugs for HTN #RCT Mortality Stroke CHD CV events Thiazides 19 .89 .63 .84 .70 low dose 8 .72 high dose 11 1.01 ns Blocker 5 .96 ns .83 .90 ns .89 ACEI 3 .83 .65 .81 .76 CCB 1 .86 ns .58 .77 ns .71 The Cochrane Library 2009, issue 3. http/ Years to CHD Event 0 1 2 3 4 5 6 7 Cumulative CHD Event Rate 0 .04 .08 .12 .16 .2 Cumulative Event Rates for the Primary Outcome (Fatal CHD or Nonfatal MI) by ALLHAT Treatment Group RR (95% CI) p value A/C 0.98 (0.90-1.07) 0.65 L/C 0.99 (0.91-1.08) 0.81 ALLHAT Chlorthalidone Amlodipine Lisinopril Nonfatal MI + CHD Death Subgroup Comparisons RR (95% CI) Amlodipine Better Chlorthalidone Better 0.50 1 2 Non-Diabetic 0.97 (0.86, 1.09) Diabetic 0.99 (0.87, 1.13) Non-Black 0.97 (0.87, 1.08) Black 1.01 (0.86, 1.18) Women 0.99 (0.85, 1.15) Men 0.98 (0.87, 1.09) Age=65 0.97 (0.88, 1.08) Age = 65 1.01 (0.91, 1.12) Age 160 Step 2 If close to goal increase thiazide to 25mg (Lisinipril 20/25) Otherwise add second drug (Lisinopril 20mg, amlodipine 2.5-5mg) Step 3 Add 3rd drug Step 4 Titrate Amlodipine to 10-20 mg Big 3 Add-ons Spironolactone 25 mg “Aldactazide 25/25” if already on HCTZ Monitor K+, especially with ACE/ARB Beta Blockers ?Advantage of vasodilating drugs like labetalol, carvedilol, nebivolol Central