高血压-李勇

Hypertensionclinical management update,Li Yong, MDProfessor of MedicineDepartment of Cardiology, Huashan HospitalFudan University, Shanghai 200040,思考题,Antihypertensive management means pharmaceutical therapies?抗高血压治疗就是药物治疗？The benefits of antihypertensive drugs depend on the reduction of BP? 降压幅度是抗高血压治疗临床获益的主要来源？,Sources: WHO World Health Report 2000, CVD infobase,18,000,000 from high-income countries 42,000,000 from low-income countries,Importance of Hypertension and CVD,60,000,000 HTN patients have the risk to develop to MI, stroke, and heart failure,World Heart Federation,Epidemiology of Hypertension,Prevelence of HTN in USA,JNC-VI. Arch Intern Med. 1997;157:2413-2446.,Prevelence of HTN in China,Gu DF, et al. Hypertension. 2002;40:920-927,1991 National survey: prevelence = 11.26%20002001 InterASIA study：prevelence in age 35-74 = 27.2%，about 13,000,000 patients,Prevelence%,age,20002001 InterASIA study,Gu DF, et al. Hypertension. 2002;40:920-927,Prevelence of HTN in China,BP Control Rates,Trends in awareness, treatment, and control of high blood pressure in adults ages 1874,Sources: Unpublished data for 19992000 computed by M. Wolz, National Heart, Lung, and Blood Institute; JNC 6.,中国高血压治疗现状,2004年发布的中国居民营养与健康现状调查结果显示：,Chin J hyper vol 12 No.6 487-489,Chin J hyper vol 12 No.6 487-489,中国高血压治疗现状,Risk of hypertension (%),Residual lifetime risk of developing hypertension among people with blood pressure 135 or DBP 85 mm Hg),Ambulatory Measurement,Ambulatory monitoring can provide:readings throughout day during usual activitiesreadings during sleep to assess nocturnal changesmeasures of SBP and DBP loadAmbulatory readings are usually lower than in clinic (hypertension is defined as SBP 135 or DBP 85 mm Hg),Recommendations for Followup Based on Initial Measurements,Evaluation Objectives,To identify known causes To assess presence or absence of target organ damage and cardiovascular diseaseTo identify other risk factors or disorders that may guide treatment,Evaluation Components,Medical historyPhysical examinationRoutine laboratory testsOptional tests,Medical History,Duration and classification of hypertensionPatient history of cardiovascular diseaseFamily historySymptoms suggesting causes of hypertensionLifestyle factorsCurrent and previous medications,Physical Examination,Blood pressure readings (2 or more)Verification in contralateral armHeight, weight, and waist circumferenceFunduscopic examinationExamination of the neck, heart, lungs, abdomen, and extremitiesNeurological assessment,Laboratory Tests and Other Diagnostic Procedures,Determine presence of target organ damage and other risk factorsSeek specific causes of hypertension,Laboratory Tests Recommended Before Initiating Therapy,UrinalysisComplete blood countBlood chemistry (potassium, sodium, creatinine, and fasting glucose)Lipid profile (total cholesterol and HDL cholesterol) 12-lead electrocardiogram,Optional Tests and Procedures,Creatinine clearanceMicroalbuminuria24-hour urinary proteinSerum calciumSerum uric acidFasting triglyceridesLDL cholesterolGlycosolated hemoglobin,Thyroid-stimulating hormonePlasma renin activity/ urinary sodium determinationLimited echocardiographyUltrasonographyMeasurement of ankle/arm index,Examples of IdentifiableCauses of Hypertension,Renovascular diseaseRenal parenchymal disease Polycystic kidneysAortic coarctation,PheochromocytomaPrimary aldosteronismCushing syndromeHyperparathyroidismExogenous causes,Components of Cardiovascular Risk in Patients With Hypertension,Major Risk Factors: SmokingDyslipidemiaDiabetes mellitusAge older than 60 yearsSex (men or postmenopausal women)Family history of cardiovascular disease,CVD Risk,HTN prevalence 50 million people in the United States.The BP relationship to risk of CVD is continuous, consistent, and independent of other risk factors.Each increment of 20/10 mmHg doubles the risk of CVD across the entire BP range starting from 115/75 mmHg.Prehypertension signals the need for increased education to reduce BP in order to prevent hypertension.,Clinical Risk Factors forStratification of Patients With Hypertension,Heart diseasesStroke or transient ischemic attackNephropathyPeripheral arterial diseaseRetinopathy,Risk Stratification,Risk Stratification,Treatment Strategies andRisk Stratification,Primary Prevention,Primary prevention offers an opportunity to interrupt the costly cycle of managing hypertension.A population-wide approach can reduce morbidity and mortality.Most patients with hypertension do not sufficiently change their lifestyle or adhere to drug therapy enough to achieve control.Blood pressure rise with age is not inevitable.Lifestyle modifications have been shown to lower blood pressure.,Goal of HypertensionPrevention and Management,To reduce morbidity and mortality by the least intrusive means possible. This may be accomplished by achieving and maintaining:SBP 140 mm HgDBP 90 mm Hgcontrolling other cardiovascular risk factors,CHD Incidence Rate /1000 Person Years,Historical Lessons About Hypertension,Cumulative Fatal & Nonfatal Endpoints,THE FRAMINGHAM STUDY,THE VET. ADM. STUDY II,Ann Intern Med. 1961;55:33-50,JAMA. 1970;213:1143-1152,Hypertension IncreasesMorbidity and Mortality,Treatment Decreases Morbidity and Mortality,Goals of Therapy for HTN,Reduce CVD and renal morbidity and mortality. Treat to BP 140/90 mmHg or BP 50 years of age.,Benefits of Lowering BP,Average Percent ReductionStroke incidence 3540% Myocardial infarction 2025% Heart failure50%,单纯收缩压升高,(%),(%),脑卒中,冠心病,总死亡,心血管死亡,非心血管死亡,致死和致残事件,死亡率,收缩压和舒张压均升高,脑卒中,冠心病,总死亡,心血管死亡,非心血管死亡,致死和致残事件,死亡率,降压治疗的临床获益,ESH-ESC Hypertension Guidelines. J Hypertens. 2003.,0.01,0.01,0.001,NS,0.001,0.001,0.02,0.01,NS,0.001,血压控制目标值,高血压患者 140/90 mmHg糖尿病患者 130/80 mmHg肾功受损：蛋白尿1g/日 1g/日 125/75 mmHg老年人： SBP150mmHg,2004年中国高血压防治指南,Lifestyle Modifications,For Prevention and ManagementLose weight if overweight.Limit alcohol intake.Increase aerobic physical activity.Reduce sodium intake.Maintain adequate intake of potassium.,For Overall and Cardiovascular HealthMaintain adequate intake of calcium and magnesium. Stop smoking. Reduce dietary saturated fat and cholesterol.,Lifestyle Modification,Pharmacologic Treatment,Decreases cardiovascular morbidity and mortality based on randomized controlled trials.Protects against stroke, coronary events, heart failure, progression of renal disease, progression to more severe hypertension, and all-cause mortality.,Special Considerationsin Selecting Drug Therapy,DemographicsCoexisting diseases and therapiesQuality of lifePhysiological and biochemical measurementsDrug interactionsEconomic considerations,Drug Therapy,A low dose of initial drug should be used, slowly titrating upward.Optimal formulation should provide 24-hour efficacy with once-daily dose with at least 50% of peak effect remaining at end of 24 hours.Combination therapies may provide additional efficacy with fewer adverse effects.,Classes ofAntihypertensive Drugs,ACE inhibitorsAdrenergic inhibitorsAngiotensin II receptor blockers Calcium antagonistsDirect vasodilatorsDiuretics,Initial Drug Choices,Algorithm for Treatment of Hypertension (continued),Not at Goal Blood Pressure ( 140/90 mm Hg) lower goals for patients with diabetes or renal disease,Begin or Continue Lifestyle Modifications,Not at Goal Blood Pressure,Initial Drug Choices,Uncomplicated,Compelling Indications,Not at Goal Blood Pressure,Algorithm for Treatment of Hypertension (continued),Start at low dose and titrate upward. Low-dose combinations may be appropriate.,Specific Indications,Initial Drug Choices*,Uncomplicated Diuretics -blockers,Algorithm for Treatment ofHypertension (continued),*Based on randomized controlled trials.,Initial Drug Choices*,Algorithm for Treatment of Hypertension (continued),Compelling Indications Heart failure ACE inhibitorsDiureticsMyocardial infarction-blockers (non-ISA)ACE inhibitors (with systolic dysfunction)Diabetes mellitus (type 1) with proteinuriaACE inhibitorsIsolated systolic hypertension (older persons) Diuretics preferredLong-acting dihydropyridine calcium antagonists,*Based on randomized controlled trials.,Initial Drug Choices,Specific indications for the following drugs:,Algorithm for Treatment ofHypertension (continued),ACE inhibitors Angiotensin II receptor blockers -blockers,-blockers -blockers Calcium antagonists Diuretics,Specific Drug Indications,Angina -blockers Calcium antagonistsAtrial tachycardia and fibrillation -blockers Nondihydropyridine calcium antagonists,Some antihypertensive drugs may have favorable effects on comorbid conditions:,Heart failureCarvedilolLosartanMyocardial infarctionDiltiazemVerapamil,Specific Indications (continued),Cyclosporine-induced hypertensionCalcium antagonistsDiabetes mellitus (1 and 2) with proteinuriaACE inhibitors (preferred)Calcium antagonistsDiabetes mellitus (type 2)Low-dose diuretics,Dyslipidemia-blockersProstatism (benign prostatic hyperplasia)-blockersRenal insufficiency (caution in renovascular hypertension and creatinine 3 mg/dL 265.2 mol/L)ACE inhibitors,Some antihypertensive drugs may have favorable effects on comorbid conditions:,Specific Indications (continued),Essential tremorNoncardioselective -blockersHyperthyroidism -blockersMigraine Noncardioselective -blockers Nondihydropyridine calcium antagonists,Osteoporosis ThiazidesPerioperative hypertension -blockers,Some antihypertensive drugs may have favorable effects on comorbid conditions:,Not at Goal Blood Pressure ( 140/90 mm Hg),No response or troublesome side effects,Inadequate response but well tolerated,Substitute another drug from different class,Add second agent from different class (diuretic if not already used),Not at Goal Blood Pressure (140/90 mmHg),Initial Drug Choices,Algorithm for Treatment ofHypertension (continued),Not at Goal Blood Pressure ( 140/90 mm Hg),Continue adding agents from other classes.Consider referral to a hypertension specialist.,Substitute drug from different class,Add second agent from different class,Algorithm for Treatment of Hypertension (continued),血压,直接机制(自动调节),肾上腺素能机制(，),盐机制(氯化钠),体液/激素机制(血管紧张素II、去甲肾上腺素、内皮素),维持血压的主要机制,Direct,Adrenergic,Salt,Hormones,快速强效，控制血压,Combination Therapies,-adrenergic blockers and diureticsACE inhibitors and diureticsAngiotensin II receptor antagonists and diureticsCalcium antagonists and ACE inhibitorsOther combinations,Combination Therapies,Followup,Follow up within 1-2 months after initiating therapy.Recognize that high-risk patients often require high dose or combination therapies and shorter intervals between changes in medications.Consider reasons for lack of responsiveness if blood pressure is uncontrolled after reaching full dose.Consider reducing dose and number of agents after1 year at or below goal.,Causes for InadequateResponse to Drug Therapy,PseudoresistanceNonadherence to therapyVolume overloadDrug-related causesAssociated conditionsIdentifiable causes of hypertension,Guidelines for ImprovingAdherence to Therapy,Be aware of signs of nonadherence.Establish goal of therapy.Encourage a positive attitude about achieving goals.Educate patients about the disease and therapy.Maintain contact with patients.Encourage lifestyle modifications.Keep care inexpensive and simple.,Guidelines for ImprovingAdherence to Therapy (continued),Integrate therapy into daily routine.Prescribe long-acting drugs.Adjust therapy to minimize adverse affects.Continue to add drugs systematically to meet goal.Consider using nurse case management.Utilize other health professionals.Try a new approach if current regime is inadequate.,Hypertensive Emergencies and Urgencies,Emergencies require immediate blood pressure reduction to prevent or limit target organ damage.Urgencies benefit from reducing blood pressure within a few hours.Elevated blood pressure alone rarely requires emergency therapy.Fast-acting drugs are available.,Drugs Available forHypertensive Emergencies,VasodilatorsNitroprussideNicardipineFenoldopamNitroglycerinEnalaprilatHydralazine,Adrenergic InhibitorsLabetalolEsmololPhentolamine,For persons over age 50, SBP is a more important than DBP as CVD risk factor.Starting at 115/75 mmHg, CVD risk doubles with each increment of 20/10 mmHg throughout the BP range. Persons who are normotensive at age 55 have a 90% lifetime risk for developing HTN.Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promoting lifestyle modifications to prevent CVD.,New Features and Key Messages,Key Messages (Continued),The most effective therapy prescribed by the careful clinician will control HTN only if patients are motivated.Motivation improves when patients have positive experiences with, and trust in, the clinician.Empathy builds trust and is a potent motivator.The responsible physicians judgment remains paramount.,思考题,Antihypertensive management means pharmaceutical therapies?抗高血压治疗就是药物治疗？The benefits of antihypertensive drugs depend on the reduction of BP? 降压幅度是抗高血压治疗临床获益的主要来源？,Pregnant Women,Chronic hypertension is high blood pressure present before pregnancy or diagnosed before 20th week of gestation.Preeclampsia is increased blood pressure that occurs in pregnancy (generally after the 20th week) and is accompanied by edema, proteinuria, or both.ACE inhibitors and angiotensin II receptor blockers are contraindicated for pregnant women. Methyldopa is recommended for women diagnosed during pregnancy.,Antihypertensive Drugs Used in Pregnancy,Antihypertensive Drugs Used in Pregnancy (continued),Older Persons,Hypertension is common.SBP is better predictor of events than DBP.Pseudohypertension and “white-coat hypertension” may indicate need for readings outside office.Primary hypertension is most common cause, but common identifiable causes (e.g., renovascular hypertension) should be considered.,Older Persons (continued),Therapy should begin with lifestyle modifications.Starting doses for drug therapy should be lower than those used in younger adults.Goal of therapy is the same ( 140/90 mm Hg) although an interim goal of SBP 160 mm Hg may be necessary.,Special Situations,Cardiovascular diseasesRenal diseaseDiabetes mellitusDyslipidemia,Sleep apneaBronchial asthmaGoutSurgeryVarious chemical agents,Cardiovascular Diseases,Cerebrovascular diseaseIndication for treatment, except im