老年高血压患者的治疗

1、Management of hypertension in the elderly Jiguang WANG, MD, PhD Shanghai Institute of Hypertension, Ruijin Hospital, Shanghai, China nSize of the problem: hypertension nCareful selection of antihypertensive drugs to potentiate the huge benefit and to avoid the potential harm nRoadmap to control bloo

2、d pressure in resistant hypertensive patients Awareness, treatment and control rates of hypertension in China PrevalenceNumber of patients Awareness TreatedControlled 1991 (15 y) 11.394 million26.645.5% (12.1) 23.1% (2.8) 2002 (18 y） 18.8160 million30.281.8% (24.7) 25.0% (6.1) 2002 (60 y） 49.170 mil

3、lion37.696.3% (36.2) 24.1% (7.6) Chin J Hypertens 1995;3(suppl):14 -18; Li Liming, et al. ChinJ E pidemiol 2005;26:,478-484. nSize of the problem: hypertension nCareful selection of antihypertensive drugs to potentiate the huge benefit and to avoid the potential harm nRoadmap to control blood pressu

4、re in resistant hypertensive patients Relative risk reductions by antihypertensive treatment in early trials Progression to severe HT CHFStrokeCHD Total mortality CV mortality -94* -53%* -40%* -16%* -13% -21%* *P0.05 Collins R et al. Br Med Bull 1994;50:272-298. BPLTTC. Lancet 2003;362:1527-45. 0 -5

5、 -10 -15 -20 -25 -30 StrokeCHD CHF Total mortality -23% -15% -16% -14% 4/3 mmHgN20 888 Major CV events -15% Relative risk reductions by antihypertensive treatment in recent trials 指南推荐指南推荐 o利尿剂利尿剂 o 阻滞剂阻滞剂 o钙离子拮抗剂钙离子拮抗剂 o转换酶抑制剂转换酶抑制剂 o血管紧张素受体拮抗剂血管紧张素受体拮抗剂 J Hypertens 2007;25:1105-87. INTERMAP: Urina

6、ry electrolytes in men Zhou BF et al. J Hum Hypertens 2003;17:623630. JapanChinaUKUSA Urinary Na(mg/day)4843563337024202 Urinary Na(mmol/day)211245161183 Urinary K(mg/day)1920150629122512 Urinary K(mmol/day)49.238.674.764.4 Urinary Na/K(mmol/mmol)4.56.82.33.1 INTERMAP: Urinary electrolytes in women

7、Zhou BF et al. J Hum Hypertens 2003;17:623630. JapanChinaUKUSA Urinary Na(mg/day)4278483929293272 Urinary Na(mmol/day)186210127142 Urinary K(mg/day)1891147523781982 Urinary K(mmol/day)48.537.961.050.8 Urinary Na/K(mmol/mmol)4.16.02.23.1 HYVET: Serum concentrations of cholesterol, sodium and potassiu

8、m Liu LS et al. Chin Med J 2008; 121:1509-1512. MenWomen Characteristic (mmol/L) China Other countries China Other countries Total cholesterol4.691.05.451.15.021.15.601.1 HDL cholesterol 1.370.36 1.290.391.430.361.330.43 Sodium 1404.1 1424.11404.1 1424.3 Potassium 4.250.47 4.420.404.260.494.380.40 S

9、HEP: New-onset diabetes mellitus Shafi T et al. Hypertension 2008;52:1022-9. 45% per 0.5 mmol/L in K+ nSize of the problem: hypertension nCareful selection of antihypertensive drugs to potentiate the huge benefit and to avoid the potential harm nRoadmap to control blood pressure in resistant hyperte

10、nsive patients Hypertension 2008 Pharmacologic recommendations for the treatment of resistant hypertension (1) Use of a long-acting thiazide diuretic, preferably chlorthalidone Combine agents with different mechanisms of action Recommended triple regimen of - ACE inhibitor or ARB - Calcium channel b

11、locker - Thiazide diuretic oConsider addition of mineralocorticoid receptor antagonist. oUse of loop diuretic may be necessary in patients with CKD (creatinine clearance 30 mL/min). Pharmacologic recommendations for the treatment of resistant hypertension (2) Number No. drugs 2 drugs ALLHAT42,4241.8

12、40% ANBP26083 2.050% ASCOT19,2572.378% CONVINCE16,6021.840% INVEST22,5763.085% LIFE91932.046% VALUE15,2452.054% Number of drugs in recent large HT trials Achieved 135/76 147/82 136/77 136/79 131/76 144/81 138/78 Catheter-Based Renal Sympathetic Denervation for the Management of Resistant Hypertensio

13、n Henry Krum MBBS PhD FRACP Centre of Cardiovascular Research Alfred Heart Centre, The Alfred Hospital, Melbourne, Australia Treatments Catheter-Based Renal Sympathetic Denervation for the Management of Resistant Hypertension Henry Krum MBBS PhD FRACP Centre of Cardiovascular Research Alfred Heart C

14、entre, The Alfred Hospital, Melbourne, Australia Results: Blood Pressure Reduction 87% had a reduction in SBP 10 mmHg P0.001 except for DBP at 12 months (P=0.02) Conclusions Therapeutic renal sympathetic denervation produced predictable, significant, and sustained reductions in BP in patients with r

15、esistant hypertension. The brief and simple procedure was performed without significant complications to either the renal artery or the kidney. Results appear both to confirm the important role of renal sympathetic nerves in resistant hypertension and to suggest that renal sympathetic denervation co

16、uld be of therapeutic benefit in this patient population. Prospective randomized clinical trials examining the treatment of hypertension are beginning in 2009, and trials in heart failure and chronic kidney disease are anticipated. 因为知晓率低、用药后血压控制率低，我国因为知晓率低、用药后血压控制率低，我国90%以上的高血压患以上的高血压患 者的血压未得到有效控制者

17、的血压未得到有效控制(140/90 mm Hg)，在广大农村该比例，在广大农村该比例 甚至高达甚至高达96.5%。因此，必需大幅度提高高血压检出率与治疗控。因此，必需大幅度提高高血压检出率与治疗控 制率。制率。 指南推荐使用的指南推荐使用的5大类降压药物均可在大类降压药物均可在50%以上的患者中发挥降以上的患者中发挥降 压作用。在关注降压达标的同时，应尽可能减少降压药物的不良压作用。在关注降压达标的同时，应尽可能减少降压药物的不良 反应，降低降压治疗的代价。反应，降低降压治疗的代价。 联合降压治疗，特别联合使用联合降压治疗，特别联合使用3个以上药物时，不仅可以提高降个以上药物时，不仅可以提高降

18、 压达标的比例，很可能还可更有效地降低心脑血管并发症的风险压达标的比例，很可能还可更有效地降低心脑血管并发症的风险 。但即便使用多个降压药物，仍会有比例很低，但绝对数量巨大。但即便使用多个降压药物，仍会有比例很低，但绝对数量巨大 的高血压患者，可能需要寻求药物以外的治疗手段，不管是外科的高血压患者，可能需要寻求药物以外的治疗手段，不管是外科 手术治疗，还是介入治疗方法。手术治疗，还是介入治疗方法。 Thank you very much Thank you very much ！ nSize of the problem: hypertension nCareful selection of

19、antihypertensive drugs to potentiate the huge benefit and to avoid the potential harm nRoadmap to control blood pressure in resistant hypertensive patients Relative risk reductions by antihypertensive treatment in early trials Progression to severe HT CHFStrokeCHD Total mortality CV mortality -94* -53%* -40%* -16%* -13% -21%* *P0.05 Collins R et al. Br Med Bull 1994;50:272-298. BPLTTC. Lancet 2003;362:1527-45. 0 -5 -10 -15 -2