高血压病伴糖尿病的处理

1、中国医科大学一院心内科中国医科大学一院心内科 齐国先齐国先 重庆重庆 2008 12 13Steno-2 Study 2003, 2008RCT of 160 T2DM pts with microalbuminuria强化干预 vs 常规干预 SBP: 130 mm Hg Total cholesterol 175 mg% HbA1c: 6.5%NEJM 2003; 348:383 NEJM 2008; 358:580Intensive GroupConventional GroupSystolic BP 15 mm Hg (146 131) 3 mm Hg (149 146)LDL-C 5

2、0 mg% (133 83) 11 mg% (137 126)HbA1c 0.5% (8.4 7.9) 0.2% (8.8 9.0)NEJM 2008; 358:580% Reduction in Complications With Intensive Rx at 13.3yTotal Mortality 40% (50% vs 30%)Cardiovascular events 59% (65% vs 30%)Proliferative retinopathy 55% -Nephropathy 56% - 共同土壤学说: “Metabolic Syndrome”HTN vs No HTND

3、M vs No DM2.4x in DM2.0 x in HTNNEJM 2000; 342:905 Diabetes Care 2005; 28:310% with BP 140/90All U.S. adults30%Diabetic U.S. adults60% Type 1 DM - Normoalbuminuria30% - Microalbuminuria40% - Macroalbuminuria80% Type 2 DM - At Dx50% - Microalbuminuria80% - Macroalbuminuria95%NEJM 2000; 342:905 Diabet

4、es Care 2005; 28:310 Am J Kid Dis 2007; 49 (Suppl 2):S74J Cardiometab Syndr 2006; 1:95(86% 130/80)Relative Risk of ComplicationsDiabetes vs No Diabetes: CVD2.0 4.0 ESRD7.0Diabetes BP vs Diabetes CHD3.0 Stroke4.0 Retinopathy2.0 Nephropathy2.0 Neuropathy1.6 Mortality2.075% die from CVDJAMA 2004; 292:2

5、495 Kid Internat 2000; 59:703 NEJM 2005; 352:341 Stronger predictor of risk than diastolic BP:Cardiovascular diseaseRenal dysfunction 65% of DM hypertensives have isolated systolic hypertension Systolic hypertension more difficult to controlDiabetes Care 1994; 17:1247Lancet 2002; 360:1903Hypertensio

6、n 2003; 42:1206% With BP 130/80NHANES, 2003-200435%VA, 2001-200223%Community 1 care, 2002-200431-35%Academic medicine, 200233%GEMINI RCT, 200468%Arch Int Med 2007; 167:2394JAMA 2004; 292:2227 疾病本身的原因疾病本身的原因 Most DM pts need 3-4 drugs to control BPActivation of RAA systemVolume overload, especially i

7、f CKDSleep apnea from associated obesityVascular damageJ Hypertens 2005; 23:2305Hypertension 2000; 35:1038 Am J Hypertens 2004; 17:915J Cardiometab Syn 2007; 2:114用药依从性低用药依从性低 Cost adherence 62%/30% Inadequate pt education BP 7/3 mm Hg Side effects refills 25% Complex regimens SBP 6 mm Hg - QD dosin

8、g Fixed-dose combo pills adherence 10-20%Arch Int Med 2006; 166:332, 1836Am J Therap 2005; 12:605J Gen Intern Med 2008; 23:588 Ann Intern Med 2006; 145:165 Int J Clin Prac 2006; 51:441 Educate patients: goal BP, etc Control cost Dose QD, fixed-combo pills Address side effects ADHERENCE! Decrease cli

9、nician therapeutic 惰性惰性 - Q 1mo FU, Rx until BP goal BP: 1st reading higher 3 readings, 1 min apart “Alerting response” Discard 1st, average last 2 Recommended for all HTN pts by AHA, 2008Best predictor of CVD eventsDetects “white coat” and “masked” HTN 非诊室非诊室 BP goals 诊室诊室 BP goal Equivalent Goal B

10、POffice BP 130/80 Home BP 125/7524-h ABPM study:Daytime awake BP 125/75Full 24-h BP 120/70AHA Hypertension Primer, 2008; p.343DAYTIMEOUT-OF-OFFICE BP125/75130/80OFFICE BPNORMOTENSION: Office BP 130/80 Day ABPM 125/75 Home BP 125/75WHITE-COAT HTN: Office BP 130/80 Day ABPM 125/75 Home BP 125/75MASKED

11、 HTN: Office BP 130/80 Day ABPM 125/75 Home BP 125/75 SUSTAINED HTN: Office BP 130/80 Day ABPM 135/85 Home BP 135/85 BP q visit Proper techniqueBP = 120/129/70-79BP 130/80 on 2 visits 1 mo apartBP 120/70FU BP q visitConsider Out-of-office BP: Home BP 24 hr ABPMRisk Stratify for Rx 125/75 125/75 Lowe

12、r CVD riskInitial lifestyle Rx Higher CVD riskInitial drug Rx Lifestyle RxDiabetes Care 2008; 31(Supple 1):S24Office BP 130/80 on 2 visits 1 month apart or Home BP or daytime awake BP by 24-hr ABPM 125/75Higher Risk DM5: BP 140/90, or Albuminuria, or CVD or LVHLower Risk DM5: BP = 130-139/80-89 No T

13、OD Pharmacologic Rx Lifestyle modification Lifestyle modification for 3 mo trialModified from:Diabetes Care 2007; 29(Suppl):S4Can J Cardiol 2007; 23:529BP 130/80 BP mm HgWeight loss/Kg1/1Low Na 60y) less effective CHF:CCBs less effective for prevention? ARBs, diuretics more effective?ACEI effectiveA

14、rch Intern Med 2005; 165:1410Ann Intern Med 2006 ; 144:272Meta-analyses:# RCTsHazard Ratio For StrokeLindholm, 2005131.16 (1.04-1.30)Bangalore, 2007121.15 (1.01-1.30)Khan, 2006: Age 60y71.18 (1.07-1.30) Age 60y50.99 (0.67-1.44) 15-18% stroke risk with BB - Especially in elderly 60y Equally(not more)

15、 protective for MI, deathNot 1st - line Rx unless HF, post-MI, angina:AHA, 2007NICE/BHS, 2006CHEP, 2008 and ESC/ESH, 2007Carvedilol possibly favored over metoprolol: Greater in microalbuminuria Lesser in wt, TG, HbA1cCirculation 2007; 115:2761 Can J Card 2007; 23:529 Eur Heart J 2007; 28:1462Hyperte

16、nsion 2005; 46:1309 Kid Internat 2006; 70:1905ALLHAT: -blocker vs diuretic, 8749 DM patientsDoxazosin vs ChlorthalidoneFatal/non-fatal CHDNo differenceCombined CVD events 22% by diureticCHF 85% by diuretic Limit -blockers to 4th Step RxJ Clin Hypertens 2004; 6:116 BP 130/80 Single drug Rx BP by 10/5

17、 mm HgBegin low-dose 2-drug Rx if BP 150/902-drug Rx:ACE-I (ARB) Diuretic vs ACE-I (ARB) CCB Most DM pts require 3-drug RxStandard regimen:ACE-I (ARB) Diuretic CCB Adjust diuretic eGFR2 thiazide Chlorthalidone, 25 mg/d preferred if need 3 drugs2 loop diuretic Furosemide or bumetamide bid Torsemide q

18、d Titrate dose to 4-5 lb wt lossAccurate Dx of HTN: BP 130/80 in office, and/or BP 125/75 out-of-office ACE-I or ARB Lifestyle s If BP 150/90: - ACE-I or ARB Diuretic (or CCB?)Add Diuretic Thiazide for most patients Loop diuretic if eGFR 50 (Cr 1.5 mg%) and K+ Spironolactone or amiloride Monitor K+ carefullyAm J Kid Dis 2007; 49(Suppl 2):S74Diabetes Care 2007; 30(Suppl 1):S4BP 130/80 after 1 moAdd DHP CCB (amlodipine or other) Stop Non-DHP CCB Add: - DHP CCB (amlodipine or other) - BB (esp., carvedilol)BP 130/80 after 1 moC