高血压病伴糖尿病的处理策略

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 沈阳沈阳 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 共同土壤学说:“Metabolic Syndrome”HTN vs No HTNDM vs No DM2.4 x in DM2.0 x in HTNNEJM 2000;342:905 Diabetes Care 2005;28:310LDLHDLCentral obesityType 2 DMAtherosclerosisMacrovasculardiseaseHypertension Insulin resistance(insulin)%with BP 140/90All U.S.adults30%Diabetic U.S.adults60%Type 1 DM -Normoalbuminuria30%-Microalbuminuria40%-Macroalbuminuria80%Type 2 DM -At Dx50%-Microalbuminuria80%-Macroalbuminuria95%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)Data from King H et al.Diabetes Care.1998;21:1414-1431.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 Mortality2.075%die from CVDJAMA 2004;292:2495 Kid Internat 2000;59:703 NEJM 2005;352:341 DM+HTN doubles the risk of -cardiovascular events -cardiovascular mortality -total mortalitycompared with people with hypertension alone Association of SBP and CV Mortalityin Men With Type 2 Diabetes250200150100500120120-139140-159160-179180-199SBP(mm Hg)CVmortalityrate/10,000 person-yrNondiabeticDiabeticCV,cardiovascular;SBP,systolic blood pressure.Stamler J et al.Diabetes Care.1993;16:434-444.200Steno-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:50years Diabetesfor 10years Taking treatment for HTN Evidence of target-organ damage or established cardiovascular disease Atrial fibrillation 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 6mmol/l 代谢综合征 直系亲属中有早发心血管疾病的家族史 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，克/天 控制体重控制体重 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/d5/3健康饮食 11/5饮酒 4/2步行,150 min/wk5/4J Hypertens 2006;24:269 Hypertension 2006;47:296 Can J Cardiol 2007;23:529DECREASE in CORONARY ATTACK in 2 YEARS,%CIGARETTES PER DAYMENWOMEN10(1/2 pack)192420(1 pack)344040(2 packs)5764 Ideal BP Targets 130/80 for people without proteinuria 125/75 for people with proteinuria%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 BP Activation of RAA system Volume overload,especially if CKD Sleep apnea from associated obesity Vascular 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 药品价格药品价格 adherence 30%患者教育患者教育 BP 7/3 mm Hg 药物副作用药物副作用 换药 25%用药方法用药方法 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 教育教育:goal BP,etc控制花费控制花费改善剂型改善剂型-长效、复方制剂长效、复方制剂关注药物副作用关注药物副作用降低医生用药的降低医生用药的 惰惰性性 诊室血压测定的准确性。

非诊室血压测定的Home BP measurement24-hour ambulatory BP BP(mm Hg)休息休息 5 min 12/6坐位,back supported 6/8袖带的水平 at midsternal 2/inch袖带大小袖带大小 6-18/4-13放气的速度 2 mm Hg/sec SBP/DBP测定测定3次，间隔次，间隔:1 min 1st reading higher 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 goals 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.343非诊室非诊室血压血压125/75130/80诊诊室血室血压压正常血正常血压压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75白大衣高血白大衣高血压压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75隐隐蔽性高血蔽性高血压压 Office BP 130/80 Day ABPM 125/75 Home BP 125/75 高血高血压压 Office BP 130/80 Day ABPM 135/85 Home BP 135/85首次血压测量 Proper techniqueBP=120/129/70-79BP 130/80 on 2 visits 1 mo apartBP 120/70FU BP Consider Out-of-office BP:Home BP 24 hr ABPMRisk Stratify 60y)less effective CHF:ACE-I，diuretics more effectiveCCBs less effective for prevention?ARBs effective?Arch 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 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 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 130/80 Single drug Rx BP by 10/5 mm HgBegin low-dose 2-drug Rx if BP 150/902-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 CCB Adjust diuretic（eGFR）-2 thiazide Chlorthalidone,25 mg/d if need 3 drugseGFR2 loop diuretic Furosemide bid Torsemide qd Uncertainty about optimal 4th drugAssess for causes of resistant HTN准确诊断: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）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):S74Diabetes Care 2007;30(Suppl 1):S4BP 130/80 after 1 moACE-I or ARB Diuretic CCB BBs or -blockers or 检查原因 BP 130/80 after 1 mo。