【高血压精品英文课件】高血压心脏病 hypertensive heart disease

HypertensiveHeartDisease RickyM Kirby FNP BC LopezInternalMedicineAssociates4250LakesideDrive Suite204Jacksonville FL32210 904 598 1888rickkirby References JNC7FullReport NIHPublicationNo 04 5203 http hin nhlbi nih gov nhbpep slds menu htm hbpch1 JNC7Express NIHPub No 03 5233December2003 JNC7Quickreferencecard NIHPub No 03 5231 JNC7 FullReport Comprehensivejustificationandrationale 87pages NIHPub No 04 5203 Express Succinctevidence basedrecommendations PublishedinJAMAMay21 2003 andasaGovernmentPrintingOfficepublication 52pages NIHPub No 03 5233 ReferenceCard Quickreferencecard 2pages NIHPub No 03 5231 Overview ClassificationofBPCVDRiskBenefitsofLoweringBPBPMeasurementTechniquesIn officeAmbulatoryBPMonitoringSelf measurementCVDRiskFactorsCausesofHTNTargetOrganDamageLaboratory DiagnosticTests TreatmentGoalsofTherapyLifeStyleModificationAlgorithmforTreatmentofHypertensionManagementofBPinAdultsMinorityPopulationsHTNintheElderlyCaseStudy Factoids Forpersonsoverage50 SBPisamoreimportantthanDBPasCVDriskfactor Startingat115 75mmHg CVDriskdoubleswitheachincrementof20 10mmHgthroughouttheBPrange Personswhoarenormotensiveatage55havea90 lifetimeriskfordevelopingHTN ThosewithSBP120 139mmHgorDBP80 89mmHgshouldbeconsideredprehypertensivewhorequirehealth promotinglifestylemodificationstopreventCVD Factoids Thiazide typediuretics eitheraloneorcombination shouldbeconsideredforinitialdrugtherapy High riskconditionsareacompellingreasontostartotherdrugclasses MostpatientswillrequiretwoormoreantihypertensivedrugstoachievegoalBP IfBPis 20 10mmHgabovegoal initiatetherapywithtwoagents oneusuallyshouldbeathiazide typediuretic Factoids HypertensionisthemostcommonprimarydiagnosisinAmerica 35millionofficevisitsastheprimarydiagnosis ThemosteffectivetherapyprescribedbyacarefulclinicianwillcontrolHTNONLYifpatientsaremotivated Motivationimproveswhenpatientshavepositiveexperienceswith andtrustin theclinicianandthemedication Thecliniciansjudgmentremainsparamountindetermininginitialandcontinuingtherapy BloodPressureClassifications CVDRisk HTNprevalence 50millionpeopleintheUnitedStates TheBPrelationshiptoriskofCVDiscontinuous consistent andindependentofotherriskfactors Eachincrementof20 10mmHgdoublestheriskofCVDacrosstheentireBPrangestartingfrom115 75mmHg PrehypertensionsignalstheneedforincreasededucationtoreduceBPinordertopreventhypertensionandthereforereducetheriskofCVD BenefitsofLoweringBP Instage1HTNachievingasustained12mmHgreductioninSBPover10yearswillprevent1deathforevery11patientstreated InthepresenceofCVDortargetorgandamage only9patientswouldrequiresuchBPreductiontopreventadeath Inclinicaltrials antihypertensivetherapyhasbeenassociatedwithreductionsinstrokeincidenceaveraging35 40percent myocardialinfarction 20 25percent andheartfailure morethan50percent BPMeasurementTechniques OfficeBPMeasurement Useauscultatorymethodwithaproperlycalibratedandvalidatedinstrument Patientshouldbeseatedquietlyfor5minutesinachair notonanexamtable feetonthefloor andarmsupportedatheartlevel Appropriate sizedcuffshouldbeusedtoensureaccuracy Atleasttwomeasurementsshouldbemade Cliniciansshouldprovidetopatients verballyandinwriting specificBPnumbersandBPgoals AmbulatoryBPMonitoring ABPMiswarrantedforevaluationof white coat HTNintheabsenceoftargetorganinjury AmbulatoryBPvaluesareusuallylowerthanclinicreadings Awake individualswithhypertensionhaveanaverageBPof 135 85mmHgandduringsleep 120 75mmHg IfBPdoesnotdropby10to20 duringthenightitmayindicateapossibleincreasedriskofcardiovascularevents Self MeasurementofBP Providesinformationon ResponsetoantihypertensivetherapyImprovingadherencewiththerapyEvaluatingwhite coatHTNHomemeasurementof 135 85mmHgisgenerallyconsideredtobehypertensive Homemeasurementdevicesshouldbecheckedregularly CVDRiskFactors HypertensionCigarettesmokingObesity BMI 30kg m2 PhysicalinactivityDyslipidemiaDiabetesmellitusMicroalbuminuriaorestimatedGFR 60ml minAge olderthan55formen 65forwomen FamilyhistoryofprematureCVD menunderage55orwomenunderage65 CausesofHypertension SomecausesofhypertensionSleepapneaDrug inducedorrelatedcausesChronickidneydiseasePrimaryaldosteronismRenovasculardiseaseChronicsteroidtherapyandCushing ssyndromePheochromocytomaCoarctationoftheaortaThyroidorparathyroiddisease TargetOrganDamage HeartLeftventricularhypertrophyAnginaHeartfailureBrainStrokeortransientischemicattackChronickidneydiseasePeripheralarterialdiseaseRetinopathy Laboratory DiagnosticTests RoutineTestsElectrocardiogramUrinalysisBloodglucose andhematocritSerumpotassium creatinine orthecorrespondingestimatedGFRLipidprofile after9 to12 hourfast thatincludeshigh densityandlow densitylipoproteincholesterol andtriglyceridesMeasurementofurinaryalbuminexcretionoralbumin creatinineratio Laboratory DiagnosticTests MoreextensivetestingforidentifiablecausesisnotgenerallyindicatedunlessBPcontrolisnotachieved Treatment GoalsoftherapyLifestylemodificationPharmacologictreatmentAlgorithmfortreatmentofhypertension GoalsofTherapy ReduceCVDandrenalmorbidityandmortality TreattoBP50yearsofage LifestyleModification AlgorithmforTreatmentofHypertension ManagementofBPforadults Initialcombinedtherapyshouldbeusedcautiouslyinthoseatriskfororthostatichypotension TreatpatientswithchronickidneydiseaseordiabetestoBPgoalof 130 80mmHg MinorityPopulations Ingeneral treatmentsimilarforalldemographicgroups SocioeconomicfactorsandlifestyleimportantbarrierstoBPcontrol Prevalence severityofHTNincreasedinAfricanAmericans AfricanAmericansdemonstratesomewhatreducedBPresponsestomonotherapywithBBs ACEIs orARBscomparedtodiureticsorCCBs Thesedifferencesusuallyeliminatedbyaddingadequatedosesofadiuretic HypertensioninOlderPersons Morethantwo thirdsofpeopleover65haveHTN ThispopulationhasthelowestratesofBPcontrol Treatment includingthosewhowithisolatedsystolicHTN shouldfollowsameprinciplesoutlinedforgeneralcareofHTN Lowerinitialdrugdosesmaybeindicatedtoavoidsymptoms standarddosesandmultipledrugswillbeneededtoreachBPtargets CaseStudy 1 Mr M 64y oBlackMaleseen10 2003PMH Notseenforsince5 2000forHTN Gout UrinaryfrequencyOtherpertinent married rarecoffee noillegaldrugs noETOH stoppedsmoking1972 youngerbrotherdiedCVACC Insomnia lumbarbackpain wheezingVS BP200 100 T98 9 R20 HGT6 3 WGT291 BMI37PE UnremarkableexceptLumbarpain strain Page1 CaseStudy 1 Tx Plan Clonidine0 1mginoffice BP to170 96after15min StartCardizemLA180QD Samples LABsCMP Lipid Labs Glucose126 Fasting Bun19 Creatinine1 2 Na140 K4 0 allotherswnl TC188 TG79 HDL40 LDL132 3DaysBP200 110 CardizemtoHS 3DaysBP210 100 Cardizemto360HS 1weekBP210 106 ContCardizemstartDiovan80 12 5 Page2 CaseStudy 1 3DaysBP174 96 Diovanto160 12 5AfterthisandbeforeDecemberAtenolol50mg lisinopril20mgbid clonidine0 1mgbidadded BP12 2003150 90inoffice SBPathome140 s ABDMRA Possiblesevereleftcommonproximalarterystenosis ReferraltoNephrologyClonidine to0 2mgbid Page3 CaseStudy 1 NephrologiststoppedDiovan HCTstartedLasix1 2004BP172 100 Cardizemto540mgQD BP to150 s 160 s 3 2004BP164 102 clonidineto0 3bid4 2004BP150 sstopAtenololstartToprolXL50mgQD4 2004thru12 2004BP150 soffice130 sathome Whitecoatsyndrome1 2005 clonidinetoTID4 2005SP130 70 TIA CTHead neuroconsult Plavix Page4 CaseStudy 1 Lastvisit10 2005BP124 62 P78 wgt152 BMI31Medications CardizemCD540mgQD Clonidine0 2mgTID ToprolXL50mgHS Lisinopril20mgBID Lasix20mgQDCo morbidconditions LVHbyecho microproteinuria renalarterystenosis TIA Diabetes1 2005HgbA1C5 9 9 2005HgbA1C9 8 Page5 CaseStudy 2 Mr W 71y oblackmale initialvisit3 2005PMHx noPCPfor3years deniedsignificantPMHx verypoorhistorian Otherpertinent FmHxunk widower deniedtobacco ETOH caffeine druguseCC massleftforearmVS BP202 122 T97 4 P76 R18 Hgt70 WGT267 BMI39 Page1 CaseStudy 2 PE LFAproximaltoelbow7cmfirm non mobile non tender mass Ventralhernia8cm 2 6systolicmurmur4thICSMCL WheezingLbase UA Leukocytes Tx Plan Clonidine0 1mgx1 180 100 startavalide150 12 5 CTAbd MRILFA CXR labs CMP TFT CBC Lipid PSALabs glucose121 Bun38 Creatinine5 5 RBC3 7 Hgb10 4 Hmt31 5MCV85 TFTwnl refusedlipidandPSA Page2 CaseStudy 2 CTabd pelvis morphologysuggestiveofcirrhosis hydronephrosis hydroureter markedurinaryretention leftrenalcyst 1 5mmleftadrenalmass 7days BP150 90 stopavalidestartavapro300mg refertourologist renalultrasound24hoururine creatinine6 1 creatininecl7 HgbA1C4 94 2005 BP162 102 continueavapro startToprolXL25mgWasduetoRTC2weeks Page3 CaseStudy 2 7 2005 hadstoppedAvaprourgedtoseeurologist 1week 180 98 clonidine0 1mg ptrefuseadditionalmedications 1week 182 98 clonidine0 1mg 150 80 startLotrel5 20 creatinine1 4 Bun13 K3 8 1week 176 100 clonidine0 1mg 136 84 startclonidine0 1mgBID RenalUSF Uhydronephrosis Page4 CaseStudy 2 1week 168 90 ptstoppedLotrelonown restartLotrelMedications Clonidine0 1mgbid Lotrel5 20QD Avapro300mgQD FeSO4Labs H H10 1 31 7 MCV85 9 K3 8 Bun13 Creatinine1 4 Page5 CaseStudy 3 Ms S 84y owhitefemaleinitialOV12 2003seenasposthospitalreferral PmHx noPCPforseveralyears asthma malignanthypertension elevatedlipid AVstenosis elevatedlipids GIbleed diver