高血压病伴尿病的处理

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%initial fu:7.8yextended fu:13.3ynejm 2003; 348:383 nejm 2008; 358:580intensive groupconventional groupsystolic bp 15 mm hg (1

2、46 131) 3 mm hg (149 146)ldl-c 50 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: “m

3、etabolic syndrome”htn vs no htndm 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% - macroalbumin

4、uria95%nejm 2000; 342:905 diabetes 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 mortality2.0

5、75% die from cvdjama 2004; 292:2495 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; 17:1247

6、lancet 2002; 360:1903hypertension 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 sys

7、temvolume overload, especially if 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

8、 regimens sbp 6 mm hg - qd dosing 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

9、 effects adherence! decrease clinician 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 goal

10、s 诊室诊室 bp goal equivalent goal bpoffice 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

11、abpm 125/75 home bp 125/75masked 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 st

12、ratify for rx 125/75 125/75 lower 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 r

13、isk dm5: bp = 130-139/80-89 no tod 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, diuretic

14、s more effective?acei effectivearch 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

15、in elderly 60y equally(not more) 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

16、eur heart j 2007; 28:1462hypertension 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

17、130/80 single drug rx bp by 10/5 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 egfr/professionals/kdoqi/gfr_calculator.cfmegfr 30-50 ml/min/1.73m2 thiazi

18、de chlorthalidone, 25 mg/d preferred if need 3 drugsegfr 30-50 ml/min/1.73m2 loop diuretic furosemide or bumetamide bid torsemide qd 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