【高血压英文课件】-Getting-Blood-Pressure-to-Goal

GettingBloodPressuretoGoalRulesofThree:3drugs3months3behaviors(Activity-Diet-ControlofTobaccoandAlcohol)3Partners(Patient–Family–Provider)ThisprogramwassponsoredbytheNationalKidneyFoundationofMichigan(NKFM)andtheMichiganDepartmentofCommunityHealth(MDCH).FundingwasprovidedbyagenerousgrantfromNKFMandMDCHandvariouspharmacompanies.ContinuingMedicalEducationcreditisprovidedbyWayneStateUniversitySchoolofMedicineTheprogramwasdevelopedandpreparedby:

DianeLevine,MDWayneStateUniversitySilasNorman,MD,UniversityofMichiganRosalindPeters,PhD,RN,WayneStateUniversitySusanSteigerwalt,MD,St.JohnHospitalWithinputfromtheHypertensionExpertGroupofNKFMandtheexpertiseandcreativityofitsmemberswithspecialthankstoVelmaTheisenandLindaSmithWheelockACSW,MSBAConflictofInterestIndividualSpeakerstoAddtheirinformationpriortopresenting

MajorityofUSHypertensivePatientsNotatSBPGoalof<140mmHgUnacceptableBPControlRatesRequireIncreasedAwareness,MoreAggressiveTreatmentSignificanceofHBPProblem50%ofhypertensivesareuncontrolled.UptohalfarenotreceivingpharmacologictreatmentAntihypertensivetherapycanStroke–30%CHF–40-50%CAD–10-20%CADEvents-~55%Mortality–10%~$1Billionindirectmedicalcosts/yearCardiovascularMortalityRiskDoublesWithEach20/10mmHgBPIncrement*CV-RelatedMortalityRatesAreHigherinAfricanAmericansCardiovascularEventsinTreatedHypertensiveDiabeticPatientsPreventingKidneyFailureAfricanAmericansinMichiganhavepoorerbloodpressurecontrolthanCaucasiansAfricanAmericansareatfivetimesgreaterriskofprogressiontoendstagerenaldiseaseBetterbloodpressurecontrolSLOWSPROGRESSIONofrenaldiseaseBPcontrolreducestheriskofstroke,MI,andCHFFactorsContributingtoPoorBPControlPatientFactorsAgeRace/ethnicityObesityAccessNonadherenceKnowledgeCostComplextreatmentPt/ProviderCommunicationSecondaryHTNProviderFactorsMeasurementissuesLackofknowledge/DisagreementwithguidelinesConcernforsideeffectsNon-advancingofdrugsinasymptomaticpatientsResponsetopatientsconcernsovercomplexityoftreatmentLackoftimeMeasurementAccuracyAccuracyofofficemeasurementsManual–RegularlycalibratedWhite-CoatSyndromeHomeMonitoring

OmronHealthcareArm(notwrist)monitorGoalreadings<135/85

MeasurementAccuracy*

PatientPosition:BacksupportedFeetonthefloorArmattheleveloftheheartNotalkingCuffSize–Mostadultsneedalargecuff(SeeCDandAHAwebsitefordetails)TaketwiceCheckorthostaticbloodpressure*CDprovidedtosupportreviewandstandardizationofBPmeasurementMeasurementAccuracy:

OrthostaticHypotension20%prevalenceincommunitydwellingadultsoverage65IncreaseswithagePresentinyoungerpatientswithdiabetesorautonomicdysfunction“Iforthostasiscannotbecorrected,usestandingBPtoassessgoalBP”(JNC-7)JNC7:NewBPClassificationsJNC7RecommendedBPGoals<140and<90mmHg

Patientswithmostconditions<130and<80mmHgDiabetesMellitusCKDAlbuminuria>300mg/24hror>200mg/gurinarycreatinineeGFR<60ml/min/1.73m2SerumcreatininelevelsaloneoverestimatekidneyfunctionAssessandaddressothercardiovascularriskfactorsChobanianAVetal.JAMA.2003;289:2560-2572.JNC7:ManagementofHypertensionbyBPClassificationCommonProviderConcernswithGuidelineGoals

NonAcceptanceofBPgoalsResistancetoacceptSBPthresholdsNottreatingunlessSBP>160mmHgConcernsofincreasedcardiovascularriskwithexcessiveloweringofDBP(J-Curve)BelievethatmoretimeisneededtoreachgoalVALUE,

LANCET,2004:363:2022-2031Ruleof3

“MDBP”3

Months3

Drugs3

Behaviors

(activity-diet-alcoholandtobaccocontrol)3

Partners

(Patient–Family–Provider)

ItMightTake3MonthsGettingBPtogoalin3monthsRequiresmultiplevisitsGettingtoGoalvisitschedule:MonthlyuntilgoalisreachedIncreasevisitfrequencyifStage2Increasevisitfrequencywithcomorbidconditions

Atgoal–followupvisitscheduleEvery3-6monthsdependingoncomorbiditiesCheckK+andCreatinine1-2x/year

DrugTherapyStepApproach:StartwithdiureticifnocontraindicationsAddACEICalciumChannelBlocker(CCB)Betablockers–butcautionMostpatientsrequire

multipledrugstoachievecontrol(average=3.5drugs)Usemultipledrugsif:BP20/10mmHgabovegoal(Stage22drugs)StandingBPabovegoalinpatientsoverage65orDMNotatgoalafter3monthsMultipleAntihypertensiveAgentsAreNeededtoAchieveTargetBloodPressureDrugTreatment:DiureticsIfnocompellingindications(CHF,diabetes,CKD)Chlorthalidone(orotherthiazides)firstThenACEIorARBRememberBetaBlockersARENOTforprimarypreventionandareinferiortodiureticsasmonotherapyVigilantlypreventhypokalemiaSpironolactone/HCTZisagreatcombination!BringpatientsbackinoneweektocheckfordiureticinducedhypokalemiaWatchforhyponatremiaDrugTreatment:ACEinhibitorsCheckElectrolytes,BUN,andCreatininepriortostartingRecheckK+andCreatinine1weekafterinitiationoftherapyGenericavailableBIDDosing:enalapril(5mgbid-20mgbid)captopril(12.5mgbid-50mgbid)DailyDosinglisinopril(5-40mgdaily)Sideeffects:Cough-switchtoARBifaffordableHyperkalemiaandacuterenalfailureAngioedemaWhatHaveWeLearned?

TreatmentTreatmentoftheveryelderlydecreases strokeandCADbutdoesnotprolongsurvival(Lancet1999:353:793)Bestdrugsinrankorder:ChlorthalidoneACEinhibitorHCTZ(Hypertension2004;44:800)CCB

WhatHaveWeLearned?

TreatmentACEIandARBdecreasenewonsetofdiabetesby25%comparedtobetablockers(LIFE);23%comparedtoCCBs(VALUEtrial)NewonsetofdiabeteswhileundergoingtreatmentforhypertensionconfersthesameexcessCVriskaspreexistingdiabetes(Hypertension(2004)43p.963)WhatHaveWeLearned?

TreatmentMonotherapywithatenololisNOTasefficaciousasotherantihypertensivesfordecreasingCVriskdespiteequivalentBPcontrol(Lancet:2004:364:1684)BetablockersareinferiortodiureticsforbloodpressurecontrolandCVriskprotection(stroke,CHF)inolderpatients(MRCtrial,1990;JAMA

1998;279:1903-1907;INVEST:JAMA290:2805-2816;ASCOTTrial)CombinationTreatmentsLogical/additivecombinationsDiuretic+ACEIorARBDiuretic+BetaBlockerorsympatholyticsCCB+ACEIorARBDiuretic+BetaBlocker+vasodilatorDiuretic+CCBCombinationTreatmentsCombinationswithNOadditiveeffectBetaBlocker+ACEIVasodilators+CCBCombinationwithadditivesideeffectsBetaBlocker+clonidineorguanfacineBetaBlocker+verapamilordiltiazemClonidine/guanfacine+verapamilordiltiazemWhenadding

Indifficulttocontrolpatients

ItTakes3DRUGS!ChoosealogicalADDITIVEcombinations:Diuretic+ACEI+CCBDiuretic+BBlocker+vasodilatorDiuretic+clonidine+vasodilatorSpecialPopulationsDiabetesACEIorARBDiureticsareimportantadjuncttherapyBScontrolassociatedwithBPcontrolCKDACEIorARBareimportanttopreserverenalfunctionIfeGFR<50starttorsemideorfurosemidebidPostMIBetablockersACEIorARBCheckK+andCreatininepriortoinitiatingand1weekafterinitiatingACE

ItMightTake3MonthsButifnotatgoalby6monthsconsider:PatientreasonsfornonadherenceSleepApneaAlcoholoveruseDiabetesChronicKidneyDiseaseSecondarycausesConsultwithorrefertoHypertensionSpecialist

VALUE,LANCET,2004:363:2022-2031SleepApneaUpto60%maleswithresistanthypertension(alsocommoninpostmenopausalfemales)Suspectdiagnosis-screenandreferPathophysiologyofhypertensionlikelySNSactivation

Lifestyle:ItTakes3BEHAVIORSExerciseDietControloftobaccoandalcoholLifestyle:Exercise4-9mmHgSBPreduction30-45minutes/day/5-7days/weekAerobicactivity(e.g.briskwalking)WriteaprescriptionFavoritePatientSig40minutesofwalking5X/wk BPMD3333Lifestyle:DietWeightControl

5-20mmHgSBPreduction/10kgLowSodium(<2.4g)

2-8mmHgSBPreductionDASH8-14mmHgSBPreductionControlofTobaccoandAlcoholSmokingCessationWriteprescriptionAlcoholModeration<2alcoholicdrinks/day–men<1alcoholicdrink/day–women2-4mmHgreductioninSBPAccessforothersubstancesPartners:Ittakes3PartnersPatientFamilyProviderProvider/PatientRelationshipKeyThePatient:Participationiscrucial

Describethejourney“Thisisaseriousdisease”“Iwillneedtoseeyouevery4-6weeks”“Thisisyourgoal<140/90(or130/80)”“Achievingyourgoalisimportantbecauseitlowersyourriskof…Sharegoalsetting“Let’ssetsomegoals“Thishowcanyouhelp“Whatareyouwillingtodo?“Weareateam—Patient,provider,“family”Ifwedonotachieveyourgoals…Partners:PatientsPatientnon-adherencetotherapyLackofconcernifasymptomaticFeel“better”withhigherBPDon’tworryabout“touch”ofhighBPMistrustofhealthcareprovidersandhealthcaresystemImprovedadherencewithIncreasedcontactwithprovidersSelf/homeBPmeasurement-OMRONarm,usuallyLARGEADULTcuff(Bladderencircling80%arm)Useofpatientrecordtokeeptrackofinfluenceoffactors(e.g.diet)onBPPartners:

“Family”,Friends,CommunityInvolve“family”wheneverpossibleEssentialforlifestylemodificationBefamiliarwithcommunityresourcesPartners:ProvidersFollowJNCandMQIC*GuidelinesDocumentGoalSchedulefrequentv