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1、高血压病伴糖尿病的处理策略,中国医科大学一院心内科 齐国先 沈阳 2009 06 27,HTN 伴 DM的流行病学 HTN 伴 DM的危害 HTN 伴 DM的控制 多重危险因素的共同控制 生活方式的改善 降压目标和降压药物的选择,主要内容,流行病学,高血压和糖尿病 PARTNERS IN CRIME!,共同土壤学说: “Metabolic Syndrome” HTN vs No HTN DM vs No DM 2.4 x in DM 2.0 x in HTN NEJM 2000; 342:905 Diabetes Care 2005; 28:310,Syndrome X or Metaboli
2、c synd.,美国糖尿病患者高血压的发病率,(86% 130/80),Data from King H et al. Diabetes Care. 1998;21:1414-1431.,Top Three Countries for Diabetes,HTN 伴 DM的危害,高血压增加糖尿病病人的并发症,DM + HTN doubles the risk of -cardiovascular events - cardiovascular mortality - total mortality compared with people with hypertension alone,Asso
3、ciation of SBP and CV Mortality in Men With Type 2 Diabetes,250,200,150,100,50,0,120,120-139,140-159,160-179,180-199,SBP (mm Hg),CV mortality rate/ 10,000 person-yr,Nondiabetic Diabetic,CV, cardiovascular; SBP, systolic blood pressure. Stamler J et al. Diabetes Care. 1993;16:434-444.,200,Nephropathy
4、 history in DM,HTN 伴 DM的控制,多重危险因素的共同控制,Steno-2 Study 2003, 2008 RCT 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: 7.8y Extended FU: 13.3y NEJM 2003; 348:383 NEJM 2008; 358:580,STENO-2 STUDY: 危险因素的控制,STENO-2 STUDY: 强化治疗的效果,糖尿病患者预防性
5、抗血小板指征,Aged 50 years Diabetes for 10 years Taking treatment for HTN Evidence of target-organ damage or established cardiovascular disease Atrial fibrillation,Lipid-lowering therapy- indications in DM,All people with established CVD All people 40 years All people 9%) 需要治疗的血压升高 总胆固醇 6 mmol/l 代谢综合征 直系亲
6、属中有早发心血管疾病的家族史,改善生活方式,规律的有氧运动，每周3-5次，每次30-60分钟 推荐适量的酒精摄入 限盐， 3.6克/天 控制体重 限制咖啡（或其他含咖啡因的饮料）,5杯/天, BP mm Hg 控制体重（Kg） 1/1,低盐 Na 2.4 g/d 5/3,健康饮食 11/5,饮酒 4/2,步行, 150 min/wk 5/4,J Hypertens 2006; 24:269 Hypertension 2006; 47:296 Can J Cardiol 2007; 23:529,www.nhlbi.nih.gov/health/public/heart/hbp/hbp_low/
7、hbp_low.pdf,高血压患者戒烟后的获益情况,降压目标和降压药物的选择,Ideal BP Targets 130/80 for people without proteinuria 125/75 for people with proteinuria,糖尿病伴高血压病的控制达标现状,控制不理想的原因,疾病本身的原因 Most DM pts need 3-4 drugs to control BP Activation of RAA system Volume overload, especially if CKD Sleep apnea from associated obesity V
8、ascular damage J Hypertens 2005; 23:2305 Hypertension 2000; 35:1038 Am J Hypertens 2004; 17:915 J Cardiometab Syn 2007; 2:114,控制不理想的原因,改善用药依从性的策略 IN DM-HTN,教育: goal BP, etc 控制花费 改善剂型 -长效、复方制剂 关注药物副作用 降低医生用药的 惰性,糖尿病伴高血压诊断中注意的问题,诊室血压测定的准确性。 非诊室血压测定的 Home BP measurement 24-hour ambulatory BP,诊室血压测量需要注意
9、的问题,非诊室 血压的测定,Recommended for all HTN pts by AHA, 2008 Best predictor of CVD events Detects “white coat” and “masked” HTN 非诊室 BP goals 诊室 BP goal Equivalent Goal BP Office BP 130/80 Home BP 125/75 24-h ABPM study: Daytime awake BP 125/75 Full 24-h BP 120/70 AHA Hypertension Primer, 2008; p.343,糖尿病患者
10、的血压类型,非诊室 血压,125/75,130/80,诊室血压,正常血压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75,白大衣高血压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75,隐蔽性高血压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75,高血压 Office BP 130/80 Day ABPM 135/85 Home BP 135/85,糖尿病患者高血压的评价 流程,首次血压测量 Proper technique,BP = 120/129/7
11、0-79,BP 130/80 on 2 visits 1 mo apart,BP 120/70,FU BP,Consider Out-of-office BP: Home BP 24 hr ABPM,Risk Stratify, 125/75, 125/75,Office BP 130/80 on 2 visits 1 month apart or Home BP or daytime awake BP by 24-hr ABPM 125/75,Higher Risk DM5: BP 140/90, or Albuminuria, or CVD or LVH,Lower Risk DM5: B
12、P = 130-139/80-89 无靶器官损伤, Pharmacologic Rx Lifestyle modification, Lifestyle modification for 3 mo trial,Modified from: Diabetes Care 2007; 29(Suppl):S4 Can J Cardiol 2007; 23:529,BP 130/80,最新2007年欧洲高血压指南：心血管危险分层,SBP：收缩压, DBP：舒张压, CV：心血管，HT = 高血压，OD = 亚临床器官损害， MS： 代谢综合征,合并糖尿病的高血压患者高危高度增加,危险分层-初始治疗,L
13、ower CVD risk Initial lifestyle Rx Higher CVD risk Initial drug Rx Lifestyle Rx Diabetes Care 2008; 31(Supple 1):S24,糖尿病患者的降压药的选择,Optimal drug(s) for CVD outcomes? 75% of DM pts die from CVD Optimal drug(s) for renal outcomes? 10-20% of DM pts develop nephropathy,糖尿病患者的心血管疾病预防,Meta-analyses of RCTs
14、for DM-HTN: CHD/Stroke/CVD events: D = ACE-I = ARB = CCB Alpha-blockers, BBs (age 60y) less effective CHF: ACE-I ，diuretics more effective CCBs less effective for prevention ? ARBs effective? Arch Intern Med 2005; 165:1410 Ann Intern Med 2006 ; 144:272,BBs vs OTHER ANTI-HTN AGENTS,BBs FOR HTN: NEW G
15、UIDELINES,Not 1st - line Rx unless HF, post-MI, angina: AHA, 2007 NICE/BHS, 2006 CHEP, 2008 and ESC/ESH, 2007 Carvedilol possibly favored over metoprolol: Greater in microalbuminuria Lesser in wt, TG, HbA1c Circulation 2007; 115:2761 Can J Card 2007; 23:529 Eur Heart J 2007; 28:1462 Hypertension 200
16、5; 46:1309 Kid Internat 2006; 70:1905,LESS EFFECTIVE BP DRUGS: ALPHA-BLOCKERS (Doxazosin, Terazosin),糖尿病患者的药物治疗,BP 130/80 Single drug Rx BP by 10/5 mm Hg Begin low-dose 2-drug Rx if BP 150/90 2-drug 联合应用: ACE-I (ARB) Diuretic vs ACE-I (ARB) CCB Most DM pts require 3-drug Rx 标准方案 ACE-I (ARB) Diuretic
17、 CCB,糖尿病患者的药物治疗,Adjust diuretic （eGFR） - eGFR 30-50 ml/min/1.73m2 thiazide Chlorthalidone, 25 mg/d if need 3 drugs eGFR 30-50 ml/min/1.73m2 loop diuretic Furosemide bid Torsemide qd Uncertainty about optimal 4th drug Assess for causes of resistant HTN,糖尿病患者的药物治疗流程,准确诊断: BP 130/80 in office, and/or B
18、P 125/75 out-of-office, ACE-I or ARB Lifestyle s If BP 150/90: - ACE-I or ARB Diuretic （or CCB）,ACE-I or ARB Diuretic CCB Loop diuretic if eGFR 30-50 (Cr 1.6-1.9 mg%),Am J Kid Dis 2007; 49(Suppl 2):S74 Diabetes Care 2007; 30(Suppl 1):S4,BP 130/80 after 1 mo,ACE-I or ARB Diuretic CCB BBs or -blockers or 检查原因,BP 130/80 after 1 mo,探索!学习!,