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1、高血壓的預防與控制,高血壓程度上之分類,18歲以上之成人收縮壓及舒張壓 血壓分類 收縮壓 舒張壓 理想血壓 160 100 獨立收縮性高血壓 140-149 90 張孟源內科診所,高血壓的診斷 實驗檢查:,心電圖 尿液檢查 血液檢查 生化檢查 胸部 x 光檢查 張孟源內科診所,Ambulatory BP monitor,ABPM is warranted for evaluation of white coat hypertension ABPM values usually lower than clinics reading Awake have an average 135/85 and
2、 during sleep 120/75 BP drop 10 to 20% at night if not signs possible increase risk of CVD 張孟源內科診所,斜塔,JNC7的新遠景和新資訊,任何一個50歲以上的個人其收縮壓的控制比舒張壓更為重要 在55歲時為正常血壓的人其一生中有90%的機率產生高血壓。 張孟源內科診所,心血管疾病的盛行率,CVD account for 30% of death world wild CVD leading cause of deaths in developed countries By 2020 CVD will b
3、ecome #1 killer in developed Countries/economies in transition 張孟源內科診所,心血管疾病的盛行率 36 out of 100 people will die of CVD in 2020,Cause 1990 1999 2020 million(%) million(%) million(%) 冠狀動脈疾病 6.2 (12.4%) 7.1(12.7%) 11.1(16.2%) 腦中風 4.3(8.5%) 5.5(9.9%) 7.7 (11.3%) 其他血管疾病 2.6(5.1%) 4.3 (7.7%) 6.0 (8.8%) 所有血
4、管疾病 13.1(26%) 16.9(30.3%) 24.8(36.3%) WHO 張孟源內科診所,Causes of Hypertension,Essential hypertension Chronic renal disease, renovascular dx Primary hyperaldosteronism Pheochromocytoma ,cushing syndrome Sleep apnea Drug induced and chronic steroid user Thyroid or parathyroid disease 張孟源內科診所,代謝性症候群：大流行的反擊,
5、.,全球現代化的改變,糖尿病和CVD 危險因子,糖尿病 高血壓,高罹患率與死亡率,高社經地位,代謝性症候群： 遺傳因子與環境的交互作用,.,環境因素,Early Life Adult Life 出生你體重不足 做是生活型態 營養不足 飲食因素,代謝性症候群,心血管疾病,基因,高血壓是否屬於代謝性症候群？,造成高血壓因素： 肥胖 胰島素抗性 遺傳 老化 飲食因素 高血壓是否為一代謝性危險份子？ 高血壓前期是否亦計算成危險份子？,中央肥胖與代謝異常,中央肥胖與代謝異常,動脈硬化 血脂異常,胰島素抗性,血栓栓塞,發炎反應,Primary prevention,1 Primary prevention
6、 of HTN may improve quality of life and costs associated with medical management and its complication 2.In those higher than optimal120/80mmHg decrease 3 mmHg decrease 8% stroke 5% CVD risk 3.Individuals at highest risk should be strongly encouraged to adapt healthy life 張孟源內科診所,Pre-hypertension sta
7、ge,Pre-hypertension signals the need for Increase education to reduce BP in order to prevent hypertension Pre-hypertension are at increased risk for Progression to hypertension at double risk 張孟源內科診所,JNC7的新遠景和新資訊,即使收縮壓在120-139之間舒張壓在80-89之間，仍是為高血壓前期，必須改善健康的生活型態，以避免高血壓的產生。 自從115/75mmHg以上每增加20/10mmHg心血
8、管得危險性倍增。 張孟源內科診所,Benefits of Lowering BP,Average percent reduction Stroke incidence 35-40% Myocardial infarction 20-25% Heart failure 50% 張孟源內科診所,Benefits of Lowering BP,In stage I hypertension and additional CVD Risk factors, achieving a sustained 12mmHg Reduction in SBP over 10 yrs will prevent 1
9、death for 11 patients Each increment of 20/10mmHg double the Risk of CVD across the entire BP range Starting from 115/75 張孟源內科診所,高血壓治療原則,血壓必須控制在理想範圍 SBP 140mmHg ,DBP 90mmHg 血壓必須長期控制 張孟源內科診所,Treatment of hypertension in adult with DM,SBP DBP Goal 130 mmHg 80 mmHg 張孟源內科診所,Goal of Therapy,Reduce CVD an
10、d renal morbidity and mortality Treatment of BP 50 years of age 張孟源內科診所,高血壓控制比率,全國健康評估報告美 1976-1986 1988-1991 1991-1994 1999-2000 Awareness 51 73 68 70 Treatment 31 55 54 59 Control 10 29 27 34 張孟源內科診所,JNC7的新遠景和新資訊,最有效的治療方式，必須由主動積極的高血壓患者，與具有專業及愛心的醫師互相配合。 醫病關係是建立在，同理心，互相協商 彼此了解。 正向的互動，與良好醫病關係，奠定治療 成功
11、的基礎。 張孟源內科診所,Follow-up and Monitor,Patient should returned for follow-up and adjustment of medications until BP goal is reached More frequent visits for stage II HTN and complicated comorbid condition Serum potassium and creatinine monitor 張孟源內科診所,Hypertension in older person,More than two-third of
12、people with 65 with HTN This population has the lowest rate of BP control Treatment including isolated systolic HTN Lower initial drug dose and then standard dose will be needed to reach BP target 張孟源內科診所,Hypertension in Women,Oral contraceptives may increase BP and BP should check regularly ,in con
13、trast HRT Dose not raise BP Pregnant women with HTN should be Followed carefully ,BB and vasodilator 張孟源內科診所,Left ventricular hypertrophy,LVH is an independent risk factor that increases the risk of CVD Regression of LVH with aggressive BP Measurement and weight loss, exercise sodium restriction and
14、 medication control 張孟源內科診所,Peripheral Arterial Disease,PAD is equivalence in risk to ischemic Heart disease Other risk factor should be managed aggressively ,aspirin should be used. 張孟源內科診所,Dementia,Dementia and cognitive impairment occurred more commonly in people with hypertension Reduced progres
15、sion of cognitive impairment occurs with effective antihypertensive therapy 張孟源內科診所,Target Organ Damage,Heart : LVH ,angina .coronary revascularization, heart failure Brain : stroke ,transient ischemic attack Chronic kidney disease Peripheral vascular disease Retinopathy 張孟源內科診所,Hypertensive urgenci
16、es and emergencies,Patients with marked BP elevations and acute TOD ( encephalopathy ,myocardial infarction unstable angina ,pulmonary edema, eclampsia .stroke ,head trauma Aortic dissection required hospitalization 張孟源內科診所,Hypertensive urgencies and emergencies,Patient with marked elevated BP witho
17、ut TOD should immediately antihypertensive drug. 張孟源內科診所,Postural hypotension,Decrease in standing SBP 10mmHg associated with dizziness /fainting ,more frequent in older SBP BP in these individuals should be monitor in upright position Avoiding volume depletion and excessive rapid dose titration of
18、drug 張孟源內科診所,代謝性症候群成因 ATPIII觀點,.,肥胖,體能活動不足,基因感受性,動脈粥樣硬化 血脂異常,血壓升高,胰島素抗性,臨床前期 血栓狀態,臨床前期 發炎狀態,高血壓飲食原則1,採行DASH飲食：即富含穀類、水果、蔬菜和低脂乳製品的飲食計畫，以攝取鈣、鉀和鎂。 1.每日攝取7-8份五穀類 2.每日攝取8-10份蔬菜水果 3.每日攝取2-3份乳製品 4.每日攝取4-5份堅果類、種子類或豆類 5.每日應攝取低於2份或更少的動物性蛋白質 張孟源內科診所,高血壓飲食原則2,低鈉飲食 1.選擇新鮮食物並自己做，減少攝取外食時所含量較高的味精和食鹽 2.燉湯及濃湯、火鍋湯有較高鹽分
19、，少飲用 3.含鹽量高的食物宜注意食用。如：海帶、芹菜。 4.低鈉鹽和低鈉醬油有大量的鉀，腎病患者不宜使用 張孟源內科診所,健康的飲食,Weight reduction program, total calories intake Healthy diet: low salt, low fat and low cholesterol , and high fiber diet Balance diet and heath food with adequate mineral and vitamin supple 張孟源內科診所,運動的重要性,脂肪能源對生存的重要性 第二型糖尿病和腹腰部肥胖具高
20、度關聯 人類百萬年來大多依賴勞力求生存 進20年產業轉型勞力性產減少 交通建設與運輸便捷使身體活動減少 飢荒已不在侵襲已開發國家 缺乏運動因素已過度飲食因素強 張孟源內科診所,運動處方建議原則,強調相對運動速度和運動持續時間 利用持續性耐力運動逐漸動員較多的肌肉 利用間歇性高負荷運動來動員較多的肌肉 選擇兩種不同型態的運動來動員不同部位的肌肉群 對病患剛開始運動訓練，避免過度負荷以致於造成肌細胞膜破壞-反而降低胰島素敏感度 張孟源內科診所,下列狀況表示運動過量,運動後休息2-3小時仍然筋疲力盡。 持續亢奮睡不著覺 肌肉持續痠痛和關節痛 張孟源內科診所,不宜繼續運動的身體訊號,胸悶、痛 暈眩 不
21、尋常呼吸困難 疼痛，關節腫痛 異常心律過速 張孟源內科診所,代謝性症候群治療原則,減少體重 增加體能活動 抗高血壓藥物 張孟源內科診所,代謝性症候群：討論,ATPIII：準備做臨床介入 肥胖或體能活動不足,是發病的警示. 與胰島素抗性有高度相關 具有高盛行情況 生活模式治療 優先強調 藥物治療對-藥物研究和發展已驅成熟 張孟源內科診所,Life style modification,Diet Exercise Weight reduction Stress relief Quit smoking 張孟源內科診所,代謝性症候群治療方針,減少基本因素 1.過重或肥胖 2.體能運動不足 治療血脂異常
22、相關因素 1.高血壓 2.血栓臨床前期 3.動脈粥樣硬化血脂異常 張孟源內科診所,Treatment overview,Goals of therapy Lifestyle modification Pharmacologic treatment Classification and management of BP for adult Follow-up and monitor 張孟源內科診所,冠狀動脈疾病的預防,張孟源醫師主講,Case1: 謝陳OO.54yr old lady,CC: Severe chest pain ,cold sweating PE: cons;clear ,acu
23、te illness looking BP:136/86mmHg ,heart;regular heart chest;clear Lab: chole 176mg/dl,Glu 106, Tg132 EKG:acute myocardial infarction PH: smoking( 2PPD/day).HTN,Case1: 謝陳OO .54yr old lady,She admitted at NTUH ICU immediately Then received CABG surgery. 2 months later she discharged from Hospital She
24、never smoke until now.,心血管疾病的危險因子,Sex : male gender vs female gender Age: male 40 and female 50 yrs of age Heriditary : family history 張孟源內科診所,心血管疾病的危險因子,High blood pressure Smoking Hypercholesterolemia Diabetes mellitus Obesity (BMI27) Physical inactivity Stress 張孟源內科診所,冠狀動脈疾病的預防,Hypertension contr
25、ol Cessation smoking Hypercholesterolemia control DM control 張孟源內科診所,菸害的狀況,1990年-300000000人死亡 2000年-400000000人死亡 2020年-840000000人死亡 2030年-1000000000人死亡,煙與心血管疾病,1 心肌梗塞 2 週邊血管疾病 3腦中風 張孟源內科診所,未抽菸者,抽菸者,中年30-49心肌梗塞,已開發國家，每年有500000發生心肌梗塞，其中半數以上都是吸菸造成 30-39歲：6.3倍 40-49歲：5.3倍 50-59歲：3.4倍 60-69歲：2.9倍 70-79歲：
26、2倍 張孟源內科診所,腦中風,抽菸者中風機率為不抽菸者的3.7倍 頸動脈斑塊形成速度為不抽菸者的3.2倍 戒菸5年，中風機率與不抽菸者相同 張孟源內科診所,週邊血管疾病,動脈硬化 生活不便 截肢、感染 加速動脈硬化 增加糖尿病機率 張孟源內科診所,二手煙與心血管疾病,20% to 40% increase in cardiovascular morbidity and mortality (home ,workplace) Adverse cardiovascular effects: Production of artherosclerotic lesion Vascular endothe
27、lium injury and dysfunction Deminish HDL and oxygen transport Increase oxidation portion of LDL 張孟源內科診所,Positive associations with smoking,Cancers of mouth , esophagus,pharynx Lung Ca, pancreas Ca and bladder Ca Chronic obstructive lung disease Vascular disease Peptic ulcer Cirrhosis ,poisoning Nega
28、tive association was confirm with parkinsonism 張孟源內科診所,戒菸和死亡率,即使中年才戒菸也可以平均活幾年 35歲前戒菸可以活的與不吸煙者一樣久 張孟源內科診所,淡菸,降低吸菸者的健康疑慮 菸盒標示的尼古丁與焦油含量與吸煙者身體吸收量無明顯關係，卻可以留住可能戒菸的人,淡菸,FDA發現淡菸裡的尼古丁含量沒有減少，反而增加，這是由於菸裡的添加物增加尼古丁被身體吸收的有效量，卻不影響機器檢測數值。 張孟源內科診所,Nicotine is highly addictive,尼古丁成癮性和古柯鹼相當 ,是酒癮七倍 Nicotine addiction i
29、s behavior disorder Meeting criteria for drug dependent Psychoactive effect Compulsive use Self-reinforcing behavior Withdraw syndrome 張孟源內科診所,其他飲食中因子-酒精,適量飲酒可增加高密度膽固醇 大量喝酒會增加血壓和三酸甘油脂 Limited alcohol intake 1 oz(37.8gm) of ethanol/day 360cc beer x 2( 啤酒 ) 150cc wine x 2( 紅白葡萄酒 ) 30cc whiskey x2( 高梁,
30、白蘭地,威士忌) 0.5 oz(19gm) of ethanol /day for women and Lighter weight people 張孟源內科診所,其他飲食中的因子,咖啡-尚無法確實與CHD發生率或死亡率的關係，習慣喝咖啡者往往攝取較高的SFA和Cholesterol，且運動較少。 鈣質-雙盲實驗發現，為了預防骨質疏鬆而補充鈣片，可以同時降低低密度膽固醇4.4%並提升高密度膽固醇4.1% 抗氧化劑-有待更多研究確認其地位 張孟源內科診所,冠狀動脈疾病的預防,Hypertension control Cessation smoking Hypercholesterolemia c
31、ontrol DM control 張孟源內科診所,National Cholesterol education program ATP III,Adult treatment panel I (1988) Adult treatment Panel II(1993) Adult treatment Panel III(2001) LDL should be a primary target of therapy CHD LDL 100mg/dl Two risk factor LDL 130 mg/dl. no risk factor LDL 160 mg/dl. 張孟源內科診所,治療性生活
32、型態的改變,延續ATPII及實驗基礎，使用TLC DIET 減低飽和脂肪酸至總熱量的7%以下 減低每日膽固醇攝取量至200毫克以下 運用其他降低LDL-C的治療方法 使用植物性的stanolsterol 增加水溶性纖維的攝取 控制體重 增加體能活動 張孟源內科診所,Major emphasis of ATPIII,Assessing diet and lifestyle behaviors and using behavior strategies to enhance adherence is important Intensified therapeutic lifestyle chang
33、es Diagnosis of multiple syndrome should be a secondary target of therapy 張孟源內科診所,多吃什麼可以降膽固醇,燕麥粥：含豐富的可融纖維，每天早上吃一碗，持續8週可降低10%低密度膽固醇 豆類：含豐富的可融纖維，每天吃半碗，持續8週可降低20%低密度膽固醇 大蒜：含有硫化物可抑制肝臟合成膽固醇，每日3瓣，持續8週可降低10%低密度膽固醇 洋蔥：每天生吃半個持續八週可以上升高密度膽固醇20% 張孟源內科診所,多吃什麼可以降膽固醇,清蒸鮭魚：每週2次清蒸鮭魚3兩，持續8週可使高密度膽固醇上升10%，三酸甘油脂下降 薑湯：薑中
34、的生薑醇和薑烯酚，持續8週可降三酸甘油之27%&33%的低密度膽固醇 蔬菜水果 芥菜仔油、橄欖油、苦茶油 張孟源內科診所,健康的飲食,Cut down the total amount of fat Replace animal fat with vegetable oil Eat more fresh fruit and vegetables Go on a sensible weight reducing diet if necessary 張孟源內科診所,Classification of triglyceride,Normal TG 500 mg/dl in ATPIII the cu
35、t point are lower for TG level. 張孟源內科診所,Trans fatty acid,Being another LDL-C raising fat that Should be kept at low intake Cookies and crackers made from partial Hydrogenated vegetable oil contain 3% to 9 % TFA and many snack foods contain 8% to 10 % . 張孟源內科診所,冠狀動脈疾病的預防,Hypertension control Cessatio
36、n smoking Hypercholesterolemia control DM control 張孟源內科診所,胰島素抗性：隱藏的危險,第二型糖尿病,高胰島素血症,血糖耐受性不良,高脂血症,高血壓,凝血異常,胰島素抗性/血脂異常、動脈硬化及血糖異常長期表現,.,胰島素抗性/高脂血症,血脂異常,動脈硬化症,第二型糖尿病發展階段,.,遺傳,周邊胰島素抗性,高血耐受性不良,早期糖尿病,晚期糖尿病,糖尿病,高胰島素血症,Defecvive glucorecorecognition Deterioration of -cell function,-cell failure,胰島素抗性與冠狀動脈疾病,
37、.,胰島素抗性,胰島素分泌不良,代償性 高胰島素血症,第2型糖尿病,X症候群,冠狀動脈疾病,高血壓、高血脂、糖尿病生活調適和飲食計畫,生活調適 飲食計畫 高血壓 體重控制 限鈉飲食 飲食清淡 注意礦物質的攝取 高血脂 多吃高纖 限油及限膽固醇飲食 適量飲酒 不吃甜食 糖尿病 規律運動 均衡飲食並注意血糖變化 生活輕鬆 避免含糖點心及食物 避免過鹹及膽固醇過高的食物,代謝性症候群治療原則,減少體重 增加體能活動 抗高血壓藥物 服用降LDL藥物 e.g. statin , fibrate，nicotinic acid 低劑量阿斯匹靈 抗胰島素藥物 張孟源內科診所,Public health cha
38、llenges and community program,Public health approach e.g. reduce Calories ,saturated fat, and salt restriction Increase physical activity could downward Shift in the distribution of hypertension Reduce morbidity , mortality and lifetime Risk of an individual becoming HTN Public health can prevent continuing Costly cycle of management HTN 張孟源內科診所,護心10大秘訣,能做的 1.運動 2.健康飲食 3.注意體重 4.戒菸 5.避免壓力 配合醫生 6.檢查血壓 7.檢查有沒有糖尿病 8.檢測膽固醇 9.定期做徹底的健康檢查 10.實行心生活 照顧心臟，並告訴家人朋友。,謝謝各位學員的參與 祝大家身體健康 張孟源內科診所,.,