getting blood pressure to goal - national kidney foundation课件

GettingBloodPressuretoGoal RulesofThree 3drugs3months3behaviors Activity Diet ControlofTobaccoandAlcohol 3Partners Patient Family Provider ThisprogramwassponsoredbytheNationalKidneyFoundationofMichigan NKFM andtheMichiganDepartmentofCommunityHealth MDCH FundingwasprovidedbyagenerousgrantfromNKFMandMDCHandvariouspharmacompanies ContinuingMedicalEducationcreditisprovidedbyWayneStateUniversitySchoolofMedicineTheprogramwasdevelopedandpreparedby DianeLevine MDWayneStateUniversitySilasNorman MD UniversityofMichiganRosalindPeters PhD RN WayneStateUniversitySusanSteigerwalt MD St JohnHospitalWithinputfromtheHypertensionExpertGroupofNKFMandtheexpertiseandcreativityofitsmemberswithspecialthankstoVelmaTheisenandLindaSmithWheelockACSW MSBA ConflictofInterest IndividualSpeakerstoAddtheirinformationpriortopresenting Objectives DiscussthescopeandsignificanceofuncontrolledhypertensioninU S ExaminepatientandproviderfactorsthatcontributetotheproblemReviewcurrentguidelinesandBPgoalsDiscusstheRulesof3toachievegoalDiscussgoalachievementinspecialpopulations ScopeoftheProblem 1in4Americans 65millionadults30 increasefrom1988 19942 3areuntreatedorundertreatedMillionsuncontrolled69 NHANES1999 200071 Framingham1990 199550 70 AmbulatorycarepracticesHigh riskgroupswithhypertension88 Diabetics NHANESIII89 CKD NHANESIII MajorityofUSHypertensivePatientsNotatSBPGoalof 140mmHg UnacceptableBPControlRatesRequireIncreasedAwareness MoreAggressiveTreatment SignificanceofHBPProblem 50 ofhypertensivesareuncontrolled UptohalfarenotreceivingpharmacologictreatmentAntihypertensivetherapycan Stroke 30 CHF 40 50 CAD 10 20 CADEvents 55 Mortality 10 1Billionindirectmedicalcosts year CardiovascularMortalityRiskDoublesWithEach20 10mmHgBPIncrement CV RelatedMortalityRatesAreHigherinAfricanAmericans CardiovascularEventsinTreatedHypertensiveDiabeticPatients PreventingKidneyFailure AfricanAmericansinMichiganhavepoorerbloodpressurecontrolthanCaucasiansAfricanAmericansareatfivetimesgreaterriskofprogressiontoendstagerenaldiseaseBetterbloodpressurecontrolSLOWSPROGRESSIONofrenaldiseaseBPcontrolreducestheriskofstroke MI andCHF FactorsContributingtoPoorBPControl PatientFactorsAgeRace ethnicityObesityAccessNonadherenceKnowledgeCostComplextreatmentPt ProviderCommunicationSecondaryHTN ProviderFactorsMeasurementissuesLackofknowledge DisagreementwithguidelinesConcernforsideeffectsNon advancingofdrugsinasymptomaticpatientsResponsetopatientsconcernsovercomplexityoftreatmentLackoftime MeasurementAccuracy AccuracyofofficemeasurementsManual RegularlycalibratedWhite CoatSyndromeHomeMonitoringOmronHealthcareArm notwrist monitorGoalreadings 135 85 MeasurementAccuracy PatientPosition BacksupportedFeetonthefloorArmattheleveloftheheartNotalkingCuffSize Mostadultsneedalargecuff SeeCDandAHAwebsitefordetails TaketwiceCheckorthostaticbloodpressure CDprovidedtosupportreviewandstandardizationofBPmeasurement MeasurementAccuracy OrthostaticHypotension 20 prevalenceincommunitydwellingadultsoverage65IncreaseswithagePresentinyoungerpatientswithdiabetesorautonomicdysfunction Iforthostasiscannotbecorrected usestandingBPtoassessgoalBP JNC 7 JNC7 NewBPClassifications JNC7RecommendedBPGoals 300mg 24hror 200mg gurinarycreatinineeGFR 60ml min 1 73m2SerumcreatininelevelsaloneoverestimatekidneyfunctionAssessandaddressothercardiovascularriskfactorsChobanianAVetal JAMA 2003 289 2560 2572 JNC7 ManagementofHypertensionbyBPClassification CommonProviderConcernswithGuidelineGoals NonAcceptanceofBPgoalsResistancetoacceptSBPthresholdsNottreatingunlessSBP 160mmHgConcernsofincreasedcardiovascularriskwithexcessiveloweringofDBP J Curve BelievethatmoretimeisneededtoreachgoalVALUE LANCET 2004 363 2022 2031 Ruleof3 MDBP 3Months3Drugs3Behaviors activity diet alcoholandtobaccocontrol 3Partners Patient Family Provider ItMightTake3Months GettingBPtogoalin3monthsRequiresmultiplevisitsGettingtoGoalvisitschedule MonthlyuntilgoalisreachedIncreasevisitfrequencyifStage2IncreasevisitfrequencywithcomorbidconditionsAtgoal followupvisitscheduleEvery3 6monthsdependingoncomorbiditiesCheckK andCreatinine1 2x year DrugTherapy StepApproach StartwithdiureticifnocontraindicationsAddACEICalciumChannelBlocker CCB Betablockers butcautionMostpatientsrequiremultipledrugstoachievecontrol average 3 5drugs Usemultipledrugsif BP20 10mmHgabovegoal Stage2 2drugs StandingBPabovegoalinpatientsoverage65orDMNotatgoalafter3months MultipleAntihypertensiveAgentsAreNeededtoAchieveTargetBloodPressure DrugTreatment Diuretics Ifnocompellingindications CHF diabetes CKD Chlorthalidone orotherthiazides firstThenACEIorARBRememberBetaBlockersARENOTforprimarypreventionandareinferiortodiureticsasmonotherapyVigilantlypreventhypokalemiaSpironolactone HCTZisagreatcombination BringpatientsbackinoneweektocheckfordiureticinducedhypokalemiaWatchforhyponatremia DrugTreatment ACEinhibitors CheckElectrolytes BUN andCreatininepriortostartingRecheckK andCreatinine1weekafterinitiationoftherapyGenericavailableBIDDosing enalapril 5mgbid 20mgbid captopril 12 5mgbid 50mgbid DailyDosinglisinopril 5 40mgdaily Sideeffects Cough switchtoARBifaffordableHyperkalemiaandacuterenalfailureAngioedema WhatHaveWeLearned Treatment TreatmentoftheveryelderlydecreasesstrokeandCADbutdoesnotprolongsurvival Lancet1999 353 793 Bestdrugsinrankorder ChlorthalidoneACEinhibitorHCTZ Hypertension2004 44 800 CCB WhatHaveWeLearned Treatment ACEIandARBdecreasenewonsetofdiabetesby25 comparedtobetablockers LIFE 23 comparedtoCCBs VALUEtrial NewonsetofdiabeteswhileundergoingtreatmentforhypertensionconfersthesameexcessCVriskaspreexistingdiabetes Hypertension 2004 43p 963 WhatHaveWeLearned Treatment MonotherapywithatenololisNOTasefficaciousasotherantihypertensivesfordecreasingCVriskdespiteequivalentBPcontrol Lancet 2004 364 1684 BetablockersareinferiortodiureticsforbloodpressurecontrolandCVriskprotection stroke CHF inolderpatients MRCtrial 1990 JAMA1998 279 1903 1907 INVEST JAMA290 2805 2816 ASCOTTrial CombinationTreatments Logical additivecombinationsDiuretic ACEIorARBDiuretic BetaBlockerorsympatholyticsCCB ACEIorARBDiuretic BetaBlocker vasodilatorDiuretic CCB CombinationTreatments CombinationswithNOadditiveeffectBetaBlocker ACEIVasodilators CCBCombinationwithadditivesideeffectsBetaBlocker clonidineorguanfacineBetaBlocker verapamilordiltiazemClonidine guanfacine verapamilordiltiazem WhenaddingIndifficulttocontrolpatientsItTakes3DRUGS ChoosealogicalADDITIVEcombinations Diuretic ACEI CCBDiuretic BBlocker vasodilatorDiuretic clonidine vasodilator SpecialPopulations DiabetesACEIorARBDiureticsareimportantadjuncttherapy BScontrolassociatedwith BPcontrolCKDACEIorARBareimportanttopreserverenalfunctionIfeGFR 50starttorsemideorfurosemidebidPostMIBetablockersACEIorARBCheckK andCreatininepriortoinitiatingand1weekafterinitiatingACE ItMightTake3Months Butifnotatgoalby6monthsconsider PatientreasonsfornonadherenceSleepApneaAlcoholoveruseDiabetesChronicKidneyDiseaseSecondarycausesConsultwithorrefertoHypertensionSpecialistVALUE LANCET 2004 363 2022 2031 SleepApnea Upto60 maleswithresistanthypertension alsocommoninpostmenopausalfemales Suspectdiagnosis screenandreferPathophysiologyofhypertensionlikelySNSactivation Lifestyle ItTakes3BEHAVIORS ExerciseDietControloftobaccoandalcohol Lifestyle Exercise 4 9mmHgSBPreduction30 45minutes day 5 7days weekAerobicactivity e g briskwalking Writeaprescription FavoritePatientSig40minutesofwalking5X wkBPMD3333 Lifestyle Diet WeightControl5 20mmHgSBPreduction 10kgLowSodium 2 4g 2 8mmHgSBPreductionDASH8 14mmHgSBPreduction ControlofTobaccoandAlcohol SmokingCessationWriteprescriptionAlcoholModeration 2alcoholicdrinks day men 1alcoholicdrink day women2 4mmHgreductioninSBPAccessforothersubstances Partners Ittakes3Partners PatientFamilyProviderProvider PatientRelationshipKey ThePatient ParticipationiscrucialDescribethejourney Thisisaseriousdisease Iwillneedtoseeyouevery4 6weeks Thisisyourgoal 140 90 or130 80 Achievingyourgoalisimportantbecauseitlowersyourriskof Sharegoalsetting Let ssetsomegoals Thishowcanyouhelp Whatareyouwillingtodo Weareateam Patient provider family Ifwedonotachieveyourgoals Partners Patients Patientnon adherencetotherapyLackofconcernifasymptomaticFeel better withhigherBPDon tworryabout touch ofhighBPMistrustofhealthcareprovidersandhealthcaresystemImprovedadherencewithIncreasedcontactwithprovidersSelf homeBPmeasurement OMRONarm usuallyLARGEADULTcuff Bladderencircling80 arm Useofpatientrecordtokeeptrackofinfluenceoffactors e g diet onBP Partners Family Friends Community Involve family wheneverpossibleEssentialforlifestylemodificationBefamiliarwithcommunityresources Partners Providers FollowJNCandM