高血压病伴糖尿病的处理

高血压病伴糖尿病的处理 中国医科大学一院心内科齐国先重庆20081213 多重危险因素的共同控制 Steno 2Study2003 2008RCTof160T2DMptswithmicroalbuminuria强化干预vs常规干预SBP 130mmHgTotalcholesterol 175mg HbA1c 6 5 InitialFU 7 8yExtendedFU 13 3yNEJM2003 348 383NEJM2008 358 580 STENO 2STUDY 危险因素的控制 STENO 2STUDY 强化治疗的效果 HYPERTENSIONANDDIABETES PARTNERSINCRIME 共同土壤学说 MetabolicSyndrome HTNvsNoHTNDMvsNoDM2 4x inDM2 0 x inHTNNEJM2000 342 905DiabetesCare2005 28 310 高血压的发病率INDIABETES 86 130 80 高血压增加糖尿病病人的并发症 关注焦点 SYSTOLICBP StrongerpredictorofriskthandiastolicBP CardiovasculardiseaseRenaldysfunction 65 ofDMhypertensiveshaveisolatedsystolichypertension Systolichypertensionmoredifficulttocontrol DiabetesCare1994 17 1247Lancet2002 360 1903Hypertension2003 42 1206 糖尿病伴高血压病的控制达标现状 控制不理想的原因何在 疾病本身的原因MostDMptsneed3 4drugstocontrolBPActivationofRAA systemVolumeoverload especiallyifCKDSleepapneafromassociatedobesityVasculardamageJHypertens2005 23 2305Hypertension2000 35 1038AmJHypertens2004 17 915JCardiometabSyn2007 2 114 控制不理想的原因何在 改善的策略INDM HTNCONTROL Educatepatients goalBP etc Controlcost DoseQD fixed combopills Addresssideeffects ADHERENCE Decreasecliniciantherapeutic惰性 Q1moFU RxuntilBP 130 80 Teamcare homeBPmonitoring 诊断INHTNINDIABETES AccurateofficeBPmeasurementOut of officeBPmeasurementforsomeHomeBPmeasurement24 hourambulatoryBPmonitorstudy 诊室血压测量 KEYTECHNIQUES 非诊室BPMEASUREMENT RecommendedforallHTNptsbyAHA 2008BestpredictorofCVDeventsDetects whitecoat and masked HTN非诊室BPgoals 诊室BPgoalEquivalentGoalBPOfficeBP130 80HomeBP125 7524 hABPMstudy DaytimeawakeBP125 75Full24 hBP120 70AHAHypertensionPrimer 2008 p 343 血压类型INDM DAYTIMEOUT OF OFFICEBP 125 75 130 80 OFFICEBP NORMOTENSION OfficeBP 130 80 DayABPM 125 75 HomeBP 125 75 WHITE COATHTN OfficeBP 130 80 DayABPM 125 75 HomeBP 125 75 MASKEDHTN OfficeBP 130 80 DayABPM 125 75 HomeBP 125 75 SUSTAINEDHTN OfficeBP 130 80 DayABPM 135 85 HomeBP 135 85 评价OFHYPERTENSIONINDM BPqvisit Propertechnique BP 120 129 70 79 BP 130 80on2visits 1moapart BP 120 70 FUBPqvisit ConsiderOut of officeBP HomeBP 24hrABPM RiskStratifyforRx 125 75 125 75 危险分层 初始治疗 LowerCVDriskInitiallifestyleRxHigherCVDriskInitialdrugRx LifestyleRxDiabetesCare2008 31 Supple1 S24 OfficeBP 130 80on2visits 1monthapartorHomeBPordaytimeawakeBPby24 hrABPM 125 75 HigherRiskDM5 BP 140 90 or Albuminuria or CVDorLVH LowerRiskDM5 BP 130 139 80 89 NoTOD PharmacologicRx Lifestylemodification Lifestylemodificationfor3motrial Modifiedfrom DiabetesCare2007 29 Suppl S4CanJCardiol2007 23 529 BP 130 80 生活方式干预 资料很少 BPmmHgWeightloss Kg1 1 LowNa 2 4g d5 3 DASHDiet11 5 plantprotein monosatfat8 4 ETOH 2drinks d4 2 Briskwalking 150min wk5 4 JHypertens2006 24 269Hypertension2006 47 296CanJCardiol2007 23 529 www nhlbi nih gov health public heart hbp hbp low hbp low pdf 降压药的选择INDIABETES Optimaldrug s forCVDoutcomes 75 ofDMptsdiefromCVDOptimaldrug s forrenaloutcomes 10 20 ofDMptsdevelopnephropathy 心血管病的预防INDIABETES Meta analysesofRCTsforDM HTN CHD Stroke CVDevents D ACE I ARB CCBAlpha blockers BBs age 60y lesseffectiveCHF CCBslesseffectiveforprevention ARBs diureticsmoreeffective ACEIeffectiveArchInternMed2005 165 1410AnnInternMed2006 144 272 BBsvsOTHERANTI HTNAGENTS BBsFORHTN NEWGUIDELINES Not1st lineRxunlessHF post MI angina AHA 2007NICE BHS 2006CHEP 2008andESC ESH 2007Carvedilolpossiblyfavoredovermetoprolol Greater inmicroalbuminuriaLesser inwt TG HbA1cCirculation2007 115 2761CanJCard2007 23 529EurHeartJ2007 28 1462Hypertension2005 46 1309KidInternat2006 70 1905 LESSEFFECTIVEBPDRUGS ALPHA BLOCKERS Doxazosin Terazosin PHARM RXOFHTNINDM BP 130 80SingledrugRx BPby10 5mmHgBeginlow dose2 drugRxifBP 150 902 drugRx ACE I ARB DiureticvsACE I ARB CCBMostDMptsrequire 3 drugRxStandardregimen ACE I ARB Diuretic CCB PHARM RXOFHTNINDM Adjustdiuretic eGFRwww kidney org professionals kdoqi gfr calculator cfmeGFR 30 50ml min 1 73m2 thiazideChlorthalidone 25mg dpreferredifneed 3drugseGFR 30 50ml min 1 73m2 loopdiureticFurosemideorbumetamidebidTorsemideqdTitratedoseto4 5lbwtloss PHARM RXOFHTNINDIABETES AccurateDxofHTN BP 130 80inoffice and or BP 125 75out of office ACE IorARB Lifestyle s IfBP 150 90 ACE IorARB Diuretic orCCB AddDiuretic Thiazideformostpatients LoopdiureticifeGFR 30 50 Cr 1 6 1 9mg BIDfurosemide bumetanideorQDtorsemide AmJKidDis2007 49 Suppl2 S74DiabetesCare2007 30 Suppl1 S4 BP 130 80after1mo PHARM RXOFHTNINDIABETES ACE IorARB Diuretic Addnon DHPCCB VerapamilorDiltiazem AddaldosteroneblockerIFeGFR 50 Cr 1 5mg andK 4 5 Spironolactoneoramiloride MonitorK carefully AmJKidDis2007 49 Suppl2 S74DiabetesCare2007 30 Suppl1 S4 BP 130 80after1mo AddDHPCCB amlodipineorother StopNon DHPCCB Add DHPCCB amlodipineorother BB esp carvedilol BP 130 80after1mo Consultation BP 130 80after1mo ACE I ARB LIMITEDUTILIT