高血压病伴糖尿病的处理策略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 27HTN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主要内容流行病学高血压和糖尿病高血压和糖尿病PARTNERS IN CRIME!共同土壤学说:“MetabolicSyndrome”HTNvsNoHTNDMvsNoDM2.4xinDM2.0xinHTNNEJM2000;342:905DiabetesCare2005;28:310SyndromeXorMetabolicsynd.LDLHDLCentral obesityType 2 DMAtherosclerosisMacrovasculardiseaseHypertension Insulin resistance ( insulin)美国糖尿病患者高血压的发病率%withBP140/90AllU.S.adults30%Diabetic U.S. adults60% Type 1 DM-Normoalbuminuria30%-Microalbuminuria40%-Macroalbuminuria80%Type 2 DM-AtDx50%-Microalbuminuria80%-Macroalbuminuria95%NEJM2000;342:905DiabetesCare2005;28:310AmJKidDis2007;49(Suppl2):S74JCardiometabSyndr2006;1:95(86%130/80)Data from King H et al. Diabetes Care. 1998;21:1414-1431. TopThreeCountriesforDiabetesHTN伴DM的危害高血压增加糖尿病病人的并发症RelativeRiskofComplicationsDiabetes vs No Diabetes:CVD2.04.0ESRD7.0Diabetes BP vs DiabetesCHD3.0Stroke4.0Retinopathy2.0Nephropathy2.0Neuropathy1.6Mortality2.075% die from CVDJAMA2004;292:2495KidInternat2000;59:703NEJM2005;352:341Association 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;16:434-444.200NephropathyhistoryinDMHTN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Steno-2Study2003,2008RCTof160T2DMptswithmicroalbuminuria强化干预vs常规干预SBP:130mmHgTotalcholesterol 175mg%HbA1c:50yearsDiabetesfor10yearsTakingtreatmentforHTNEvidenceoftarget-organdamageorestablishedcardiovasculardiseaseAtrialfibrillationLipid-loweringtherapy-indicationsinDMAllpeoplewithestablishedCVDAllpeople40yearsAllpeople9%)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改善生活方式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/天控制体重控制体重限制咖啡（或其他含咖啡因的饮料）,5杯/天BPmmHg控制体重（Kg）1/1低盐Na2.4g/d5/3健康饮食11/5饮酒4/2步行,150min/wk5/4JHypertens2006;24:269Hypertension2006;47:296CanJCardiol2007;23:529www.nhlbi.nih.gov/health/public/heart/hbp/hbp_low/hbp_low.pdfDECREASEinCORONARYATTACKin2YEARS,%CIGARETTESPERDAYMENWOMEN10(1/2pack)192420(1pack)344040(2packs)5764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IdealBPTargets130/80forpeoplewithoutproteinuria125/75forpeoplewithproteinuria糖尿病伴高血压病的控制达标现状%WithBP130/80NHANES,2003-200435%VA,2001-200223%Community1care,2002-200431-35%Academicmedicine,200233%GEMINIRCT,200468%ArchIntMed2007;167:2394JAMA2004;292:2227AnnFamMed2006;4:23JGenInternMed2006;21:1050控制不理想的原因疾病本身的原因疾病本身的原因MostDMptsneed3-4drugstocontrolBPActivationofRAAsystemVolumeoverload,especiallyifCKDSleepapneafromassociatedobesityVasculardamageJHypertens2005;23:2305Hypertension2000;35:1038AmJHypertens2004;17:915JCardiometabSyn2007;2:114控制不理想的原因用药依从性低用药依从性低 药品价格药品价格adherence30%患者教育患者教育BP7/3mmHg 药物副作用药物副作用换药25% 用药方法用药方法SBP6mmHg-QDdosing-Fixed-dosecombopillsadherence10-20%ArchIntMed2006;166:332,1836AmJTherap2005;12:605JGenInternMed2008;23:588AnnInternMed2006;145:165IntJClinPrac2006;51:441改善用药依从性用药依从性的策略INDM-HTN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HomeBPmeasurement24-hourambulatoryBP诊室血压测量需要注意的问题BP(mmHg)休息休息 5 min 12/6坐位,backsupported6/8袖带的水平atmidsternal2/inch袖带大小袖带大小 6-18/4-13放气的速度2mmHg/secSBP/DBP测定测定3次，间隔次，间隔: 1 min 1st reading higher Discard 1st, average last 2Hypertension2005;45:142JHypertens2005;23:697CanJCard2007;23:529非诊室血压的测定Recommended for all HTN pts by AHA, 2008BestpredictorofCVDeventsDetects“whitecoat”and“masked”HTN非诊室非诊室 BP goals 诊室诊室 BP goal EquivalentGoalBPOfficeBP130/80 HomeBP125/7524-hABPMstudy:DaytimeawakeBP125/75Full24-hBP120/70AHAHypertensionPrimer,2008;p.343糖尿病患者的血压类型非诊室非诊室血压血压125/75130/80诊室血室血压正常血正常血压OfficeBP130/80DayABPM125/75HomeBP125/75白大衣高血白大衣高血压OfficeBP130/80DayABPM125/75HomeBP125/75隐蔽性高血蔽性高血压OfficeBP130/80DayABPM125/75HomeBP125/75 高血高血压 OfficeBP130/80DayABPM135/85HomeBP135/85糖尿病患者高血压的评价流程首次血压测量PropertechniqueBP=120/129/70-79BP130/80on2visits1moapartBP120/70FUBPConsiderOut-of-officeBP:HomeBP24hrABPMRiskStratify60y)lesseffective CHF:ACE-I，diureticsmoreeffectiveCCBslesseffectiveforprevention?ARBseffective?ArchInternMed2005;165:1410AnnInternMed2006;144:272BBsvsOTHERANTI-HTNAGENTSMeta-analyses:# RCTsHazard Ratio For StrokeLindholm,2005131.16(1.04-1.30)Bangalore,2007121.15(1.01-1.30)Khan,2006:Age60y71.18(1.07-1.30)Age60y50.99(0.67-1.44) 15-18% stroke risk with BB-Especiallyinelderly60y Equally(not more) protective for MI, deathAmJCard2007;100:1254JAmCollCard2007;50:563BBsFORHTN:NEWGUIDELINESNot 1st - line Rx unless HF, post-MI, angina:AHA,2007NICE/BHS,2006CHEP,2008andESC/ESH,2007Carvedilol possibly favored over metoprolol:GreaterinmicroalbuminuriaLesserinwt,TG,HbA1cCirculation2007;115:2761CanJCard2007;23:529EurHeartJ2007;28:1462Hypertension2005;46:1309KidInternat2006;70:1905LESSEFFECTIVEBPDRUGS:ALPHA-BLOCKERS(Doxazosin,Terazosin)ALLHAT:-blockervsdiuretic,8749DMpatientsDoxazosinvsChlorthalidoneFatal/non-fatalCHDNodifferenceCombinedCVDevents22%bydiureticCHF85%bydiuretic Limit -blockers to 4th Step RxJClinHypertens2004;6:116糖尿病患者的药物治疗BP 130/80Single drug Rx BP by 10/5 mm HgBeginlow-dose2-drugRxifBP150/902-drug联合应用:ACE-I(ARB)DiureticvsACE-I(ARB)CCBMost DM pts require 3-drug Rx标准方案ACE-I(ARB)DiureticCCB糖尿病患者的药物治疗Adjust diuretic （eGFR） - eGFR 30-50 ml/min/1.73m2 thiazideChlorthalidone,25mg/difneed3drugseGFR 30-50 ml/min/1.73m2 loop diureticFurosemidebidTorsemideqdUncertainty about optimal 4th drugAssessforcausesofresistantHTN糖尿病患者的药物治疗流程准确诊断:BP130/80inoffice,and/orBP125/75out-of-officeACE-IorARBLifestylesIfBP150/90:-ACE-IorARBDiuretic（orCCB）ACE-I or ARB Diuretic CCBLoopdiureticifeGFR30-50(Cr1.6-1.9mg%)AmJKidDis2007;49(Suppl2):S74 DiabetesCare2007;30(Suppl1):S4BP130/80after1moACE-I or ARB Diuretic CCBBBs or -blockers or 检查原因 BP130/80after1mo