canadian recommendations for the management of hypertension ...课件

Canadian Recommendations for the Management of Hypertension Prepared by Lianne Tile MD FRCPC September 2003,Hypertension: Part II,Pharmacological Management,References,Feldman RD, Campbell NRC, Larochelle P et al. 1999 Canadian recommendations for the management of hypertension. CMAJ 1999; 161 (supp 12):1-17. Feldman R et al. The Canadian Hypertension Education Program Recommendations: whats new, whats old but still important in 2003. Journal of Hypertension 2003. August, P. Initial Treatment of Hypertension. NEJM 2003; 348;7 610-17.,Outline,At the end of this seminiar you will be familiar with: Indications for drug treatment Which drugs should be prescribed as first-line therapy? Subsequent therapy? Goals of treatment Individualization of therapy,Levels of Evidence,A - the recommendation was based on 1 or more studies at level I (RCT or equivalent with a significant result) B - the best evidence available is at level II (RCT that does not meet level I criteria) C - the best evidence available is at level III (nonrandomized trial) D - the best evidence available was lower than level III (i.e. case series) and included expert opinion,Case,Mrs. X, our 54-year old, moderately obese but otherwise healthy patient, is seen in follow up. Remember: Both her father and her mother are hypertensive. Her father had a stroke at the age of 64. There is no target organ damage, and lipids, glucose, and EKG are normal. Her blood pressure is now 155/95 over 5 visits and at home, despite lifestyle changes. What (if any) antihypertensive medication would you start? What is the target BP?,Lifestyle Modifications,They can work! In selected patients, these can lower BP similar to a single antihypertensive medication Intervention Targeted change SBP/DBP Sodium reduction 100 mmol/day -5.8 / -2.5 Weight loss -4.5 kg -7.2 / -5.9 Alcohol reduction 2.7 drinks/day -4.6 / -2.3 Exercise 3 times/week -10.3 / -7.5 Dietary DASH diet -11.4 / -5.5,Indications for drug treatment: adults 60 y.o.,sustained diastolic blood pressure of 90 mm Hg or higher, especially with cardiovascular disease or risk factors, or target-organ damage (grade A) diastolic BP of 100 mm Hg or higher even when no other cardiovascular risk factors are present (grade A) medication should be considered in isolated systolic hypertension (systolic BP 160 mm Hg), particularly in those with target-organ damage or cardiovascular risk factors (grade D),Indications for drug treatment: adults 60 y.o.,drug therapy should be prescribed for systolic BP 160 mmHg (grade A) NOTE: 2001 guidelines have removed age as a guide to choice of therapy; those over 60 should be treated as those under 60,Choice of medication: hypertension w.out other compelling indications,Initial therapy should be monotherapy with low-dose thiazide (ALLHAT), beta-blocker, ACE-inhibitor, ARB or long acting dihydropyridine CCB (grade A). Beta-blockers are not recommended as first-line therapy in patients over 60 y.o. (grade A). Thiazide, ARB, or long acting dihydropyridine CCB recommended for isolated systolic HTN (grade A).,Combination therapy is recommended (and often needed) if goals not reached with monotherapy (grade A). Useful Antihypertensive Drug Combinations For additive hypotensive effect in dual therapy, combine an agent from Column 1 with any in Column 2. Column 1 Column 2 * Thiazide diuretic * Beta-blocker * Long-acting dihydropyridine * ACE Inhibitor calcium channel blocker * ARB,Choice of medication: hypertension w.out other compelling indications,Centrally acting agents and alpha-adrenergic antagonists are effective in decreasing BP and reducing cardiovascular events (grade B), but should not be used as initial therapy or in the elderly due to: Cognitive impairment (methyldopa) Postural hypotension (alpha-antagonists) Drowsiness, depression (reserpine) ACEI are not recommended in blacks,Goals of treatment,Uncomplicated hypertension: Diastolic BP 1g/24hrs: BP 125/75 mm Hg,Individualization of antihypertensive therapy,Diabetes Mellitus Coronary Artery Disease Heart Failure Stroke/TIA Renal Disease Left Ventricular Hypertrophy Peripheral Vascular Disease Dyslipidemia Gout,Diabetes,Target blood pressure 130/80 mm Hg Hypertensives without nephropathy: Initial therapy: ACE-I or ARB low dose thiazide an alternative second line: addition of beta-blockers or long-acting dihydropyridine CCB combination of above medications,Diabetes,Hypertensives with nephropathy: Initial therapy: ACE-I or ARB second line: addition of thiazide, beta-blockers, long acting dihydropyridine CCBs, or ACEI/ARB combination if renal impairment and volume overload, add loop diuretic (grade C),Coronary Artery Disease,Stable angina: Beta-blocker (grade D), consider ACE-I alternatively: Long-acting CCB (grade B) Prior MI: Beta-blocker, ACE-I or both (grade A),Heart Failure,Systolic dysfunction: ACE-I (grade A) thiazide or loop diuretics, beta-blockers (metoprolol or carvedilol), or spironolactone as additional therapy (grade A) alternatively: combination of hydralazine and isosorbide dinitrate (grade A) or ARB If still hypertensive: amlodipine (grade A) or felodipine (Grade B),Stroke/TIA,Blood pressure reduction recommended after the acute phase, even in normotensive patients Initial therapy: diuretic/ACE-I combinations,Renal disease,Target BP: 1 g/day 125/75 mm Hg (grade C) Preferred agent: ACE-I (grade A) add diuretic if necessary (grade D) Dihydropyridine CCB is an alternative in nondiabetic renal disease (grade B) Avoid ACE-I in suspected renal artery stenosis,Left ventricular hypertrophy,Initial therapy: ACE-I, ARB, dihydropyridine CCBs or diuretics Beta-blockers for age55 hydralazine and minoxidil should be avoided,Peripheral vascular disease,Same recommendations as for uncomplicated hypertension, but: Avoid beta-blockers in severe disease Raynauds: Use vasodilators such as CCB, ACE-I, ARB, alpha-blocker (grade B),Dyslipidemia,At present there is insufficient evidence to base therapy on reported effects of specific drugs on lipid profile,Hyperuricemia and gout,Asymptomatic hyperuricemia is not a contraindication to diuretic use (grade D) Avoid diuretics in patients with a history of gout, or significant risk factors. If diuretics are essential for BP control, consider allopurinol (grade D).,Response to Therapy,If BP still uncontrolled, consider reasons: Non-adherence Secondary causes Diet Other medications To Improve Adherence: Simplify medication regimens to once daily dosing Tailor pill-taking to fit patients daily habits Encourage greater patient responsibility in BP management (including home BP monitoring) Educate patients and families about