高血压英文ppt精品课件hypertensionin

Hypertension in CKD Michael J Casey, MD Wake Nephrology Associates Hypertension Stats HTN affects approximately 1 billion worldwide $500 billion in direct costs Continuous, consistent and independent relationship between BP and Cads For those age 40-70, each increased increment of 20/10 mmHg in BP doubles the risk of CVD across the entire BP range of 115/75 to 185/115. Only 35% of hypertensive patients on treatment are under control. Hypertension as Defined by JNC VII 120/80 - normal; “optimal” 121-139/80-89 - “pre-hypertension” Controversial More a health policy statement 140-160/90-100 - Stage 1 Hypertension 160/100 - Stage 2 Hypertension Evaluation of the Hypertensive Pt Age and rapidity of HBP onset Accurate measurement of BP Medication review Family History H/O CVD or kidney disease EtOH and tobacco Sleep history Evaluation of the Hypertensive Pt Evidence of Volume status Edema Heart & lung exam for CHF End Organ Damage Albuminuria/Proteinuria (MACR, 24 hr urine) LVH (ECG, Echo) CKD Measurement of Blood Pressure Seated position with arm supported ideal Allow patient to settle for several minutes Proper sized cuff Bladder to encircle 80 100% arm Bladder width 40-50% of arm Confirm 2 readings 5 minutes apart in both arms for initial diagnosis If taken in wrist or legs, the cuff must be at the level of the heart BP Measurement Home BP Monitoring Self readings or continuous ambulatory monitoring Helpful adjunct to office readings More readings in patients usual environment Better correlated with cardiovascular outcomes Improves patient compliance Helps clarify symptoms Defines masked and white coat hypertension Home BP Monitoring Patients need to be taught proper methods No wrist cuffs Semi-automated electronic cuffs Cuff needs to be checked against office readings Frequency of monitoring can vary All current outcome data/guidelines/trails are from office readings Ambulatory BP Monitoring Ambulatory BP Monitoring Ambulatory BP Monitoring More reproducible than office measurements Helpful in early diagnosis Unexplained microalbuminuria or LVH White Coat Hypertension Resistant Hypertension No long term studies yet Prevalence of HTN in CKD Hypertension in CKD 80% of patients with CKD have HBP Most start with essential hypertension As GFR decreases it is more dependent on salt/water retention from decreased GFR CKD patients also have derangements in the Renin/Angiotensin/Aldosterone system Treatment of Hypertension Goal depends on disease state 25mg Ineffective at GFR 50 Can boost efficacy of loop diuretics Loop Diuretics Necessary to maintain volume status in GFR 50 Furosemide is classic but short half life so poor for HBP Bumetanide is same but better absorbed Torsemide has much longer half-life and is my choice now that it is generic Titrate to increase UOP then increase frequency Low potassium is main issue, especially with thiazides (metolazone) Beta Blockers Selective Beta Blockers Atenolol, metoprolol, bisoprolol, nebivolol Non selective Beta Blockers Propranolol Alpha Beta Blockers Labetolol, carvedolol Beta Blockers Next class in CKD patients Reduces HR, SV and also renin Reduces incidence of sudden cardiac death and arrhythmias Reduces CV events in CHF, post-MI Counter-acts reflex increase in HR/CO induced by vasodilators and diuretics Beta Blockers Carvedolol, labetolol are better for HBP Atenolol, metoprolol better for CHF, HR reduction and arrhythmia Propranolol for ascites/cirrhosis, anxiety Bradycardia and fatigue are main side effects Central Adrenergic Agents Clonidine is predominant drug Probably same benefits as b blockers No studies and never will be Synergy with b blockers debatable Dry mouth, fatigue, t.i.d., bradycardia Good for acute HBP/prn use Patch available Methyldopa for HBP in pregnancy Dihydropyridine Calcium Channel Blockers Nifedipine, amlodipine, felodipine Direct vasodilators Very effective prob 4th drug of choice Can cause peripheral edema especially in females No effect on HR, CHF Increase GFR, proteinuria Glomerular Perfusion Non-Dihydropyridine CCBs Diltiazem and Verapamil Reduce HR and Lower BP Arrhythmia control Reduction in proteinuria but no renal outcomes Edema, bradycardia, gingival hyperplasia, CyP450 interactions Other Vasodilators Alpha blockers doxazosin, terazosin, prazosin Help with BHP Once daily Orthostatic hypertension, tachycardia, CHF Hydralazine Improved outcomes in AA with CHF BID or TID Lupus syndrome Moderately effective Minoxidil Most potent antihypertensive agent Severe rebound tachycardia and edema Need beta blocker and loop diuretic Hair growth Pericarditis Inexpensive Hypertension in ESRD Great area of debate RAAS Agents and Beta blockers may improve outcomes in non-RCTs What is correct measurement? Pre-HD BP Post-HD BP Home BP When to take/hold BP Meds Hypertension in ESRD Hypertension in ESRD Hypertension in ESRD Hypertension in ESRD J-shaped curve of survival vs BP in ESRD Better survival with moderate HBP Only compared to other ESRD ? Skewed by young patients ? Skewed by cardiomyopathy Most HBP is due to inadequate volume control Decrease interdialytic weight gain Challenge weight Longer HD times (daily, nocturnal, PD) Treatment of HBP in ESRD Gradually challenge weight each HD No edema Cramping Low BP Management of intradialytic HBP UF profiling Na+ modeling Lower dialysate temperature Carnitene levels Treatment of HBP in ESRD Do not hold Beta blockers / Clonidine before dialysis (MY OPINION) Short acting meds Increase risk rebound HBP, Tachycardia Take once daily meds at bedtime for consistency from day to day Wean off meds without cardiovascular benefits Treatment of HBP in ESRD Treatment of HBP in ESRD Treatme