高血压英文ppt精品课件cardiovascular diseasepreventive

CardiovascularDisease PreventiveMedicine2005 DavidR Rudy M D M P H ProfessorandChairmanFamilyandPreventiveMedicineChicagoMedicalSchool RUMS AtheroscleroticVascularDisease RiskFactors ScreeningtoPrevent AtheroscleroticDisease Coronaryarterydisease CAD CerebrovasculardiseaseCVD Peripheralvasculardisease PVD Reno vasculardis andrenalfailure CRF hypertension CoronaryArteryDisease CAD 1 5millionmyocardialinfarctions MI year US 700 142deathsfromCAD15 casefatalityw acuteMI 30 casefatalityw acuteMIsasfirstindicationofCAD Risks highBP dyslipidemia physicalinactivity diabetesmellitus age obesity SmokingGenetics ScreeningversusPrevention 1 ScreeningforCADingeneralpopulationisimpractical e g screeningEKGs stresstesting coronaryangiograms RestingEKGsnotsensitiveenough EKGstresstestingnotsensitiveenoughinhighriskpopulations Thalliumstress EKGtoosensitiveinlowriskpopulations Coronaryangiogramstooriskyandtooexpensiveforscreening ScreeningversusPrevention 2 Primary andsecondary preventionofCADthroughcontrolofcontrollableriskfactors Screeningisforriskfactors imperfectbutcosteffectiveandtolerable RiskfactorsforCAD andotherathero scleroticvasculardis Controllable Hypertension diabetes dyslipidemia smoking C reactiveprotein emotionalstress Uncontrollable inheritance Riskfactorstendtowardclusters hypertension diabetes dyslipidemia MetabolicsyndromeXandinsulinresistance strongassoc w obesity stronglyfamilialbutremediable MetabolicSyndromeX Insulinresistance hyperinsulinemia incipientdiabetestypeIIHypertensionDyslipidemia TC LDLC TGs HDLC CriteriaformetabolicsyndromeX any3 5 1 Abdominalobesity waistmeasurement 102cm 40in inmen 88 35in cminwomen 2 Hypertrigyceridemia 150mg dL 1 69mmol L 3 LowHDLcholesterol 40mg dL 1 04mmol L 50mg dLforwomen4 High bloodpressure 130 85mmHgorhypertensionundertreatment5 Highfastingbloodglucose 110mg dL 6 1mmol L ortakingRxforD MExecutiveSummaryoftheThirdReportoftheNCEPetc ATPIII JAMA2001 285 2486 2496 Relationshipbetweendiabetesandhypertension Diabeticshavea50 prevalenceofhypertension compareto15 20 ofUSpopulation evenwhencorrectedforweightHypertensiveshaveprevalenceofglucoseintolerance abnBSpatterns 15 18 compareto5 6 ofadultUSpop wD M asignificantlylargerpercentageisassumedtohaveinsulinresistancew oglucoseintolerance Obesity diabetes hypertensionanddyslipidemia 80 90 oftypeIIdiabeticsareobesePrevalenceofobesityandofdiabetestypeIIhaveriseninparallelsince1980 33 increaseinprevalenceofD Mbetween1990and1998 CAD electrocardiogram restingEKGasscreen STdepression Twaveinversion Qwaves LVHmaydiagnoseCAD However seldomCADpresentsw osymptoms soEKGpoorscreen E g inCADoccursin1 4 ofmiddleagedmenw osympts ofthose 3 15 developedsymptomaticCADover5 15years CAD electrocardiogram restingEKGasscreen 2 1 4 ofmiddleagedmenhaveCADw osymptoms angiographicproof ofthose 3 15 developedsymptomaticCADover5 15years Thus atmost prevalenceofCADinasymptomaticmales 0 6 ofmiddleagedmen CADscreeningandEKG 3 EKGisneitherverysensitive only29 ofangiogramprovendiseasehadST Torvoltagechanges Norspecific NonspecificT commonRestingEKGmostusefulforbaselineandfuturecomparison CADscreeningandEKG 4 Stresstesting EKGonly moresensitiveandspecificthanrestingEKG butmanyfalse notspecificenoughStill only1 11 w abnormalitiessufferedacuteMIorsuddendeathwhenfollowedover4 13yearsAdditionofthalliumscintigraphyscanprovesmoresensitivebutlessspecificinlowriskpopulation CADscreeningandEKG 5 Only1 11 w abnormalitiessufferedacuteMIorsuddendeathwhenfollowedover13years0 045 4 10 000 ofrestingEKGswilldiagnoseasymptomaticCAD CADscreeningand EKG 7 StresstestingOKinhigherriskstates e g outofshapemiddleagedex athletesbeforeembarkingonexerciseprogram usuallyEKGw o e g thalliumAtypicalchestpainw dyslipidemia Obesityand orhypertension w thalliumEKGismostusefulintheacutesituation BestapplicationforScannedStressTesting Diagnosisofchestpain I e notascreeningsituation CriteriaforCADScreeningI Theconditionsmusthaveasignificanteffectonthequalityorquantityoflife YES Acceptablemethodsoftreatmentmustbeavailableforthecondition YES Theconditionmusthaveanasymptomaticperiodduringwhichdetectionandtreatmentsignificantlyreducemorbidityormortality YES Treatmentintheasymptomaticphasemustyieldatherapeuticresultsuperiortothatobtainedbydelayingtreatmentuntilsymptomsappear notsettled CriteriaforScreeningII Teststhatareacceptabletopatientsmustbeavailableatreasonablecosttodetecttheconditionintheasymptomaticperiod Corollary Sensitivityandspecificitymustbeappropriatefortheriskstatusofthepopulationbeingscreened NOandNO Theincidenceoftheconditionmustbesufficienttojustifythecostofscreening YES Significanceofhypertension PrevalenceUSsaidtobe58million 20 oftheentirepopulation adultsandchildren Leadingriskfactorforstroke Whenneglected presentsashypertensiveheartdisease LVH pulmonaryedema CADLargelyasymptomatic Hypertension Rankingriskfactorforstroke CAD RenalFailure Pathophysiologyofessentialhypertension 35 Caucasiansandmostothergroups hypertensioncharacterizedbysalt waterretention 65 African Americans majorityofelderly10 peripheralvascularresistance PVR renin angiotensin catecholamines 55 mixedPVR saltretention Hyperinsulinemiaassociatedw volumedependenthypertension Hyperinsulinemiaassociatedw mineralo corticoid probablecontributortovolumedependenthypertension Salt waterretentiondrivenhypertensionrespondstodiuretics thiazides loopdiuretics exceptinrisingcreatinine andtosaltrestrictionWhatportionofmostgroups hypertensionhavepuresaltsensitivity 35 WhichportionofAfrican Americanshypertension 67 SaltRestriction opportunityforprimarypreventionofhypertension OthermainstaysofRxofhypertension ACEIsandACERBs Ca channelblockers blockers DefinitionsofHypertension HTN Threereadingsonseparateoccasions 140 90 tomakethediagnosis unlessBPisfoundat 210 120 HtninChildren 95th 99thpercentiles AgegroupNewborns 30dInfants3 5years6 9years10 12years13 15years16 18years SBP DBP mmHg104 109SBP112 117 74 81116 123 76 83122 129 78 85126 133 82 89136 143 86 91142 149 82 97 PhysiologicTypesofHypertension IEssentialorPrimaryHypertension 90 95 ofallcases IISecondaryHypertension 5 10 ofallcases pheo primaryaldosteronism renovascular Zollo ThePortableInternist HanleyandBelfus PhiladelphiaandMoseby St Louis1995 PrimaryandsecondarypreventionHTNw odrugs WeightcontroltopreventHTN andtopreventinsulinresistance Controlsodiumintaketoprevent1 3HTN usefuladjunctinaddtional1 3StressmanagementControlofotheraggravatingriskfactors e g smoking dyslipidemia IsolatedSystolicHypertension ISH SBP 140 CVDriskMorecommoninelderly elderlymorelikelytohaveISH likelytobediureticresponsive FactorsinprimarypreventionofHtninhighriskpeople saltrestriction stressmanagement weightcontrol Implicationsofhypertensionandofdiabetesre kidneys Statusofrenalfunction Majorcausesofchronicrenalfailure notESRD subw Bakris Diabetesmellitus31 0 Hypertension27 0 Glomerulonephritis14 0 Obstructiveuropathy5 7 Polycysticrenaldisease3 6 Others5 7 Unknown13 0 Diabetes TheMostCommonCauseofESRD PrimaryDiagnosisforPatientsWhoStartDialysis Glomerulonephritis 13 Other 10 UnitedStatesRenalDataSystem Annualdatareport 2000 No ofpatients Projection 95 CI 1984 1988 1992 1996 2000 2004 2008 0 100 200 300 400 500 600 700 r2 99 8 243 524 281 355 520 240 No ofdialysispatients thousands PreventionofEndStageRenalDiseasebyBPandBScontrol TightcontrolofbloodsugarandofBPpreventsESRDindiabeticsandhypertensives DiabetesControlandComplicationsTrialResearchGrp DiabetesCare1995UnitedKingdomProspectiveDiabetesStudy1998 RecommendationsforscreeningforHTN USPSTF 1996 Screeningforhypertensionisrecommendedforallchildrenandadults i e BPsonallvisits SecondaryPreventionofComplicationsofD MthroughcontrolofBS insulinresistance UKPDS MetforminasgoodasS U sinBScontrolbutMImortalityreducedby39 w metformin b creducesinsulin HgbA1Ccontrolledto 7 0insteadof7 9 reducedretinopathyby29 nephropathyby33 andneuropathyby40 manynowcutHgbA1C 6 4 Dyslipidemia Preventionandscreening ATPIIIcriteriaforlipidlevels ideal LDLcholesterol 100mg dLTotalcholesterol 200mg dLHDLcholesterol 40mg dL men JAMA 2001 285 2487 2497 Lipidlevels whentoapplydiet Totalcholesterol startdiet 200LDLC dietfor 160mg dLHDLC dietat5 1males 4 1females TG dietfor 150 Dietarygoals Fats30 totalcalas saturatedsimpleFiber20 30gmProtein15 oftotalcaloriesCholesterol 200mg day MoreliberaluseoftheHMGCo enzymeAinhibitors statins Increasinglybelievedthatpeoplew mildtomoderateriskfactorsbenefitfrom statins theforegoingincludesevenwomenandelderly 75y o ThatLDLshouldnotexceed100mg dL Thateveryoneshouldhavealipidprofileevery5years Moreliberaldefinitionofriskstatus FromFraminghamstudy peoplew tworiskfactorsshouldbetreatedasiftheyhavealreadyadiagnosisofCAD Peoplew diabetesalonetobetreatedasiftheyhavealreadyadiagnosisofCAD SignificanceofCRPRidker J A M A 2001 285 2481 2485Ridker NewEnglJMed2004 352 20 8 Markerofoverexuberantinflammatoryresponse relevantinendothelialinjuryandrepair Highestquarti