高血压英文ppt精品课件_4

Pharmacotherapy: A Pathophysiologic Approach The McGraw-Hill Companies Abbreviations ACE: angiotensin-converting enzyme ARB: angiotensin II receptor blocker AHA: American Heart Association BP: blood pressure CCB: calcium channel blocker CV: cardiovascular DBP: diastolic blood pressure GFR: glomerular filtration rate HF: heart failure ISA: intrinsic sympathomimetic activity JNC 7: Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure MI: myocardial infarction RAAS: renin-angiotensin aldosterone system SBP: systolic blood pressure 2 Overview Definition, classification of hypertension (HTN) Goals of therapy Compelling indications Lifestyle modifications Hypertension in pregnancy Treatment Orthostatic hypotension Hypertensive crisis Monitoring antihypertensive drug therapy 3 Hypertension Persistent elevation of arterial blood pressure (BP) National Guideline 7th Report of the Joint National Committee on the Detection, Evaluation, and Treatment of High Blood Pressure (JNC7) 72 million Americans (31%) have BP 140/90 mmHg Most patients asymptomatic Cardiovascular morbidity antihypertensive drug therapy reduces cardiovascular 42(6):12061252. Target-Organ Damage Brain: stroke, transient ischemic attack, dementia Eyes: retinopathy Heart: left ventricular hypertrophy, angina Kidney: chronic kidney disease Peripheral Vasculature: peripheral arterial disease 5 6 Etiology Essential hypertension: 90% of cases hereditary component Secondary hypertension: 160 or 100 17Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42(6):12061252. Clinical Controversy White coat hypertension: elevated BP in clinic followed by normal BP reading at home Aggressive treatment of white coat hypertension is controversial Patients with white coat hypertension may have increased CV risk compared to those without such BP changes 18 Classification for Adults Classification based on average of 2 properly measured seated BP measurements from 2 clinical encounters If systolic 288(23):29812997. JNC7 Recommendations Thiazide-like diuretics preferred 1st line therapy based on clinical trials showing morbidity 42(6):12061252. Clinical Controversy Avoiding Cardiovascular Events through COMbination Therapy in Patients LIving with Systolic Hypertension (ACCOMPLISH) Endpoint: composite of death from CV causes, hospitalization for angina, nonfatal MI or stroke, coronary revascularization, 359(23):2417-2428. Compelling Indications Heart Failure Post Myocardial Infarction High Coronary Disease Risk Diabetes Mellitus Chronic Kidney Disease Recurrent Stroke Prevention 27 Recommendations cohort or case-controlled analytic studies; dramatic results from uncontrolled experiments or subgroup analyses 3: opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert communities 28 29 ACE: angiotensin-converting enzyme; ARB: angiotensin receptor blocker; CCB: calcium channel blocker; DBP: diastolic blood pressure; SBP: systolic blood pressure 3030 Lifestyle Modifications Modification Recommendation Approximate Systolic Blood Pressure Reduction (mm Hg)a Weight loss Maintain normal body weight (body mass index 18.524.9 kg/m2) 520 per 10-kg weight loss DASH-type dietary patterns Consume a diet rich in fruits, vegetables, and low-fat dairy products with a reduced content of saturated and total fat 814 Reduced salt intake Reduce daily dietary sodium intake as much as possible, ideally to 65 mmol/day (1.5 g/day sodium, or 3.8 g/day sodium chloride) 28 Physical activity Regular aerobic physical activity (at least 30 min/day, most days of the week) 49 Moderation of alcohol intake Limit consumption to 2 drinks/day in men and 1 drink/day in women and lighter- weight persons 24 31 DASH, Dietary Approaches to Stop Hypertension. a Effects of implementing these modifications are time and dose dependent and could be greater for some patients. DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM: Pharmacotherapy:A Pathophysiologic Approach, 7th Edition: / Clinical Controversy Prehypertension: patients do not have HTN but at risk for developing it Trial of Preventing Hypertension (TROPHY) showed treating prehypertension with candesartan decreased progression to stage 1 hypertension Unknown whether managing prehypertension with drug therapy and lifestyle modifications decreases CV events or if this approach is cost-effective 32Julius S, Nesbitt SD, Egan BM, et al. Feasibility of treating prehypertension with an angiotensin-receptor blocker. N Engl J Med 2006;354(16):16851697. Hypertension in Pregnancy Important to differentiate preeclampsia from chronic, transient, no increase in major teratogenicity with exposure Diuretics Not first-line, probably safe in low doses ACE inhibitors, ARBs Pregnancy category C in 1st trimester, category D in 2nd 372:547-543. Renin Inhibitor 1st agent FDA approved in 2007: aliskiren Inhibits angiotensinogen to angiotensin I conversion FDA approved as monotherapy tachyphylaxis can cause loss of antihypertensive effect counteract with concurrent -blocker clonidine if -blocker contraindicated 72 Direct Arterial Vasodilators Adverse effects: sodium/water retention angina Hydralazine can cause lupus-like syndrome Minoxidil can cause hypertrichosis 73 Reserpine Peripheral adrenergic antagonist depletes norephinephrine from sympathetic nerve endings; blocks norephinephrine transport into storage granules reduces norephinephrine release into synapse following nerve stimulation reduced sympathetic tone peripheral vascular resistance reduction decreased BP depletes catecholamines from brain caution with high intracranial pressure, azotemia, or in chronic kidney disease Nicardipine hydrochloride 515 mg/h intravenous 510 1530; may exceed 240 Tachycardia, headache, flushing, local phlebitis Most hypertensive emergencies except acute heart failure; caution with coronary ischemia Clevidipine butyrate 1-2 mg/h intravenous infusion; may double dose every 90 sec initially; maximum: 32 mg/h; typical maintenance dose: 4 to 6 mg/h 2-4 5-15 Headache, syncope, dyspnea, nausea, vomiting Most hypertensive