hypertension evidence the gold standard课件

Continuing Medical Implementation .bridging the care gap,Hypertension Evidence and CHS Guidelines 2005, Continuing Medical Implementation .bridging the care gap,Evidence Evolution,Hard end-points Mortality CVD events Cerebrovascular events PVD events CHF Progression to ESRD Surrogate end-points Rising CR Progression to proteinuria Progression/regression of micro-albuminuria, Continuing Medical Implementation .bridging the care gap, Continuing Medical Implementation .bridging the care gap,Evidence Evolution,MRC-1985 HAPPHY-1987 EWPHE-1991 STOP-1991 SHEP-1991-4 STONE-1996 SYS-EUR-1997 SYS-CHINA-1996-98 HOT-1998 UKPDS -1998 CAPPP-1999 STOP 2 -1999,HOPE -2000 MICRO-HOPE -2000 INSIGHT -2000 NORDIL -2000 CALM -2000 INDT -2001 IRMA -2001 RENAAL -2001 PROGRESS -2001 LIFE-2002 SCOPE 2002 ALLHAT 2002, Continuing Medical Implementation .bridging the care gap,CHS Guideline Evolution 2002,Impact of the ALLHAT - 2002 Consideration of PROGRESS - 2001 IDNT - 2001 RENAAL - 2001 ANBP2 - 2003, Continuing Medical Implementation .bridging the care gap, Continuing Medical Implementation .bridging the care gap,Guideline Evolution 2004,Hypertension ALLHAT - 2002 LIFE - 2002 ANBP2 - 2003 OPTIMAAL - 2002 EPHESUS - 2003 CHARM - 2003 Psaty-Network meta-analysis Law Meta-analysis Staessen Meta-regression analysis,Post stroke PROGRESS - 2001 ASA and Statins HOT - 1998 ASCOT-LLA - 2003 PROSPER - 2002 HPS - 2002 ALLHAT-LLT - 2002, Continuing Medical Implementation .bridging the care gap,CHS January 2004 Indications for drug therapy in adults with hypertension without compelling indications for specific agents:,Strongly consider antihypertensive therapy if DBP 90 with TOD or CV risk factors Elevated SBP, smoking, dyslipidemia, strong FH CAD, truncal obesity, sedentary lifestyle Rx antihypertensive therapy for DBP 100 or SBP 160 without TOD or CV risk factors Rx statin therapy in HTN patients 40 yr of age with 3 or more CV risk factors or established atherosclerotic disease Strongly consider low dose ASA in HTN patients 50 yr of age. (Caution if BP not controlled), Continuing Medical Implementation .bridging the care gap,Cardiovascular risk factors for consideration of statin therapy in non-hyperlipidemic patients with hypertension (derived from ASCOT-LLA),Male Age 55 years or older Left ventricular hypertrophy Other electrocardiogram abnormalities: left bundle branch block, left ventricular strain pattern, abnormal Q waves or ST-T changes compatible with ischemic heart disease Peripheral arterial disease,Previous stroke or transient ischemic attack Microalbuminuria or proteinuria Diabetes mellitus Smoking Family history of premature cardiovascular disease TC/HDL 6, Continuing Medical Implementation .bridging the care gap,CHS January 2004 Recommendations for individuals with diastolic hypertension with or without systolic hypertension. Initial therapy:,Grade A: thiazide diuretics Grade B: -blockers (in those younger than 60 years) ACE inhibitors (in non-Blacks) long-acting dihydropyridine CCBs angiotensin receptor antagonists (ARBs),If adverse effects substitute another drug from this group Avoid hypokalemia: Use K sparing diuretic with thiazides Use combination therapy if partial response Add other classes if poor control - blocker, centrally acting agents or non-DHP CCB - blocker not recommended as first line agents, Continuing Medical Implementation .bridging the care gap,CHS January 2004 Recommendations for individuals with Isolated Systolic Hypertension Initial therapy:,Grade A: thiazide diuretics long-acting dihydropyridine CCBs Grade B: angiotensin receptor antagonists (ARBs) If adverse effects substitute another drug from this group Avoid hypokalemia: Use K sparing diuretic with thiazides,Use combination therapy if partial response Add other classes if poor control or adverse effects - blocker, ACE inhibitors, centrally acting agents or non-DHP CCB -blockers and -blockers are not recommended as first line agents, Continuing Medical Implementation .bridging the care gap,Guideline Evolution 2005,SHEAF Study Ohasama Cohort OvA Study Staessen et al Thijs et al VALUE ACTION INVEST VALIANT BP Lowering Treatment Trialists Collaboration, Continuing Medical Implementation .bridging the care gap,Guideline Evolution 2005,Key Messages Expedited diagnosis of hypertension (HTN) Use any validated technology to diagnose HTN Office BP Ambulatory BP Self/Home BP Focus on BP control rather than preferred “first line” agent, Continuing Medical Implementation .bridging the care gap,Guideline Evolution 2005,Integrate global CVD management into HTN management plan Lifestyle modifications are key Combination therapies (lifestyle and Rx) to achieve target Focus on adherence,Choice of Pharmacological Treatment,Associated risk factors? or Target organ damage/complications? or Concomitant diseases/conditions?,Choice of pharmacological treatment for hypertensive patients without other compelling indications:,Treatment of Systolic Diastolic hypertension Treatment of Isolated Systolic hypertension,Treatment of Adults with Systolic-Diastolic Hypertension without Other Compelling Indications,INITIAL TREATMENT AND MONOTHERAPY,* Not indicated as first line therapy over 60,Beta- blocker*,Long-acting CCB,Thiazide,Lifestyle modification therapy,TARGET 140 mm Hg systolic and 90 mmHg diastolic,Combination Therapy for Systolic-Diastolic Hypertension without Other Compelling Indications,If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker).,If partial response to monotherapy,Summary: Treatment of Systolic-Diastolic Hypertension without Other Compelling Indications,* Not indicated as first line therapy over 60,Choice of pharmacological treatment for hypertensive patients with other compelling indications,Treatment of diastolic-systolic hypertension Treatment of isolated systolic hypertension,Treatment Algorithm for Isolated Systolic Hypertension without Other Compelling Indications,INITIAL TREATMENT AND MONOTHERAPY,TARGET 140 mmHg Systolic BP,Summary: Treatment of Isolated Systolic Hypertension without Other Compelling Indications,CONSIDER Nonadherence? Secondary HTN? Interfering drugs or lifestyle? White coat effect?,Thiazide diuretic,Long-acting DHP CCB,Dual combination,Triple or Quadruple* combination,Lifestyle modification therapy,ARB,TARGET 140 mmHg Systolic BP,*If blood pressure is still not controlled, or there are adverse effects, other classes of antihypertensive drugs may be combined (such as alpha blockers, centrally acting agents, or nondihydropyridine calcium channel blocker)., Continuing Medical Implementation .bridging the care gap,Anti-Hypertensive Therapeutic Classification,ACE inhibitor ARB,(K sparing) DIURETIC (Thiazide),-blocker*,Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker, Continuing Medical Implementation .bridging the care gap,First Line Therapy,ACE inhibitor ARB,(K sparing) DIURETIC (Thiazide),-blocker*,Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker, Continuing Medical Implementation .bridging the care gap,Systolic/Diastolic HTN,ACE inhibitor ARB,-blocker*,(K sparing) DIURETIC (Thiazide),Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker, Continuing Medical Implementation .bridging the care gap,Post-CVA or TIA,ACE inhibitor ARB,-blocker*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,Long Acting CCB*,(K sparing) DIURETIC (Thiazide), Continuing Medical Implementation .bridging the care gap,Isolated Systolic HTN-Elderly,ACE inhibitor ARB,-blocker,Long Acting DHP-CCB,(K sparing) DIURETIC (Thiazide), Continuing Medical Implementation .bridging the care gap,Isolated Systolic HTN-Elderly,ACE inhibitor/ ARB,-blocker,Long Acting DHP-CCB,(K sparing) DIURETIC (Thiazide), Continuing Medical Implementation .bridging the care gap,CAD - Chronic Angina,ACE inhibitor ARB,-blocker*,Consider adding ACE-I for all patients with documented CAD (Grade A) based on HOPE and EUROPA,Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,(K sparing) DIURETIC (Thiazide), Continuing Medical Implementation .bridging the care gap,CAD-Recent MI or LV Dysfunction,ACE inhibitor,-blocker*,Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,(K sparing) DIURETIC (Thiazide), Continuing Medical Implementation .bridging the care gap,CHF + HTN,ACE inhibitor ARB if ACE intolerant,DIURETIC (loop/spironolactone),-blocker,Long Acting DHP-CCB, Continuing Medical Implementation .bridging the care gap,DM without Nephropathy BP Target 130/80,ACE inhibitor or ARB,-blocker*,(K sparing) DIURETIC or (Thiazide),Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker, Continuing Medical Implementation .bridging the care gap,DM with Nephropathy First line therapy:,ACE inhibitor or ARB,-blocker*,(K sparing) DIURETIC (Thiazide),Long Acting CCB*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker, Continuing Medical Implementation .bridging the care gap,DM with Nephropathy Second line therapy:,ACE inhibitor or ARB,-blocker*,(K sparing) DIURETIC (Thiazide),*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,Long Acting CCB*, Continuing Medical Implementation .bridging the care gap,DM with Nephropathy Second line therapy:,ACE inhibitor or ARB,Cardioselective -blocker*,(K sparing) DIURETIC (Thiazide),*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,Long Acting CCB*, Continuing Medical Implementation .bridging the care gap,(K sparing) DIURETIC (Thiazide),DM with Nephropathy Second line therapy:,ACE inhibitor or ARB,-blocker*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,Long Acting CCB*, Continuing Medical Implementation .bridging the care gap,(K sparing) DIURETIC (Thiazide),DM with Nephropathy Second line therapy:,ACE inhibitor and ARB,-blocker*,*Caution combining non-DHP-CCB (especially verapamil) with a -blocker,Long Acting CCB*, Continuing Medical Implementation .bridging the care gap,Non-diabetic