从临床试验到JNC7-课件.ppt

1、10095908085Achieved DBP(mm Hg)Optimal DBP reductionHansson L et al.Lancet.1998;351:1755-1762Percentriskreduction in major CV events*Fatal and nonfatal MI,stroke,all other CV deaths.170160150130140Achieved SBP(mm Hg)Hansson L et al.Lancet.1998;351:1755-1762*Fatal and nonfatal MI,stroke,all other CV d

2、eaths.Percentriskreductionin majorCV events*Optimal SBP reductionHansson et al.,Lancet 1998:351:1755Hansson et al.,Lancet 1998:351:1755AASK Study Group,JAMA.2002;288:2421-2431Follow-up BP by Drug GroupFollow-up BP by Drug Group(Mean(Mean Summaries include visits after three months and exclude GFR vi

3、sits*Significant difference between amlodipine and metoprolol groups(p 0.05)AASK Study Group,JAMA.2002;288:2421-2431Main Clinical Composite OutcomeMain Clinical Composite OutcomeDeclining GFR Event,ESRD,or DeathDeclining GFR Event,ESRD,or Death%wi th EventsMetoprolol vs.Amlodipine:RR=20%,p=0.17 Rami

4、pril vs.Amlodipine:RR=38%,p=0.004 MetoprololRamiprilAmlodipine0510152025303540Follow-up Month06121824303642485460Ramipril vs.MetoprololRR=22%,p=0.042RR=Risk Reduction,Adjusting for Baseline CovariatesAASK Study Group,JAMA.2002;288:2421-2431Hard Clinical Endpoint Composite Hard Clinical Endpoint Comp

5、osite Of ESRD or DeathOf ESRD or Death Follow-up MonthMetoprolol vs.Amlodipine:RR=42%,p=0.003 Ramipril vs.Amlodipine:RR=49%,p 300 mg/24 hrs%of Patients Reached Urine Protein 300 mg/24 hrsDuring Follow-up by Drug GroupDuring Follow-up by Drug GroupRamipril vs.Metoprolol:p=0.014Amlodipine vs.Metoprolo

6、l:p=0.009Ramipril vs.Amlodipine:p0.001%wi th Events0102030405060Follow-up Month06121824303642485460Analysis of patients with UP/Cr 0.22 at baselineMetoprololRamiprilAmlodipineAASK Study Group,JAMA.2002;288:2421-2431%Controlled 140/90 mm HgRelative Risk(95%CI)AmlodipineLisinoprilFavors LisinoprilU.S.

7、Department of Health and Human ServicesNational Institutes of HealthNational Heart,Lung,and Blood InstituteThe Seventh Report of the Joint National Committee onPrevention,Detection,Evaluation,and Treatment of High Blood Pressure(JNC 7)For persons over age 50,SBP is a more important than DBP as CVD r

8、isk factor.Starting at 115/75 mmHg,CVD risk doubles with each increment of 20/10 mmHg throughout the BP range.Persons who are normotensive at age 55 have a 90%lifetime risk for developing HTN.Those with SBP 120139 mmHg or DBP 8089 mmHg should be considered prehypertensive who require health-promotin

9、g lifestyle modifications to prevent CVD.New Features and Key MessagesRisk of hypertension(%)Residual risk of developing hypertension among people with blood pressure 20/10 mmHg above goal,initiate therapy with two agents,one usually should be a thiazide-type diuretic.The most effective therapy pres

10、cribed by the careful clinician will control HTN only if patients are motivated.Motivation improves when patients have positive experiences with,and trust in,the clinician.Empathy builds trust and is a potent motivator.The responsible physicians judgment remains paramount.Classification of BP CVD Ri

11、sk Benefits of Lowering BP BP Control Rates BP Measurement Techniques In-office Ambulatory BP Monitoring Self-measurement Patient Evaluation Laboratory Tests and Other Diagnostic ProceduresSystolicDiastolicNormal129139 120-130-80-8485-89High NormalOptimal135/85 mmHg and during sleep 120/75 mmHg.BP d

12、rops by 10 to 20%during the night;if not,signals possible increased risk for cardiovascular events.Staessen et al.,JAMA 1997;278:1065Verdecchia P et al.Hypertension 24:793-801,1994 N=1187,mean age 4515 yearsNml.Daytime BP=136/87 for men 135/85 mmHg is generally considered to be hypertensive.Home mea

13、surement devices should be checked regularly.Evaluation of patients with documented HTN has three objectives:1.Assess lifestyle and identify other CV risk factors or concomitant disorders that affect prognosis and guide treatment.2.Reveal identifiable causes of high BP.3.Assess the presence or absen

14、ce of target organ damage and CVD.*Start with H&P:complete but CV-focused(fundi,pulses,bruits,etc)Sleep apnea Drug-induced or related causes Chronic kidney disease Primary aldosteronism Renovascular disease Chronic steroid therapy and Cushings syndrome Pheochromocytoma Coarctation of the aorta Thyro

15、id or parathyroid disease Routine Tests Electrocardiogram Urinalysis Blood glucose,and hematocrit Serum potassium,creatinine,or the corresponding estimated GFR,and calcium Lipid profile,after 9-to 12-hour fast,that includes high-density and low-density lipoprotein cholesterol,and triglycerides Optio

16、nal tests Measurement of urinary albumin excretion or albumin/creatinine ratio More extensive testing for identifiable causes is not generally indicated unless BP control is not achieved Goals of therapy Lifestyle modification Pharmacologic treatment Algorithm for treatment of hypertension Compellin

17、g indications for specific drug classes Reduce CVD and renal morbidity and mortality.Treat to BP 140/90 mmHg or BP 50 years of age.Salt sdmnfabc Salt Food group Servings Serving sizes ExamplesGrains&grain 7-8 daily 1 slice bread Whole wheat bread,Englishproducts dry cereal muffins,pita bread,bagels,

18、1/2C cooked rice,cereals,grits,oatmealVegetables 4-5 daily 1 C raw,leafy Tomatoes,potatoes,carrots,peas,squash,broccoli,leafy 6 oz.Vegetable greens sweet potatoes,beans juiceFruits 4-5 daily 6 oz fruit juice Apricots,bananas,dates,grapes 1 medium fruit oranges,grapefruit,mangoes melons,peaches,pinea

19、pples,prunes,raisins,strawberries,Low-fat or nonfat 2-3 daily 8 oz milk Skim or 1%milk,nonfat or low 1 C yogurt fat yogurt,nonfat or part-skim 1.5 oz cheese cheeseMeats,poultry,2 or 3 oz.cooked meat Lean meats;trim visible fat;fish poultry or fish remove skin from poultry;broilNuts,seeds,4-5per 1.5

20、oz.Nuts Almonds,filberts,mixed nutslegumes 2 tbsp seeds peanuts,walnuts,sunflower seed kidney beans,lentils 122124126128130132134 SBP(mm Hg)ControlFruits&VegetablesCombination Diet7880828486Baseline1234567 and 8Intervention Week DBP (mmHg)Appel LJ,et al.,NEJM 1997;336:1117-1124Systolic BP(mmHg)13213

21、4136138140142144146148Baseline SBP Post-Diet SBP Control DietFruit/VegetableDietDASH Diet-0.6 mmHg-3.8 mmHg-11.8 mmHg*p0.001Moore et al.,Hypertension,2001;38:155-158Not at Goal Blood Pressure(140/90 mmHg)(160 or DBP 100 mmHg)2-drug combination for most(usually thiazide-type diuretic and ACEI,or ARB,

22、or BB,or CCB)Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)Thiazide-type diuretics for most.May consider ACEI,ARB,BB,CCB,or combination.Without Compelling IndicationsNot at Goal Blood PressureOptimize dosages or add additional drugs until goal blood pressure is achieved.Consider consultation with

23、 hypertension specialist.*Treatment determined by highest BP category.Initial combined therapy should be used cautiously in those at risk for orthostatic hypotension.Treat patients with chronic kidney disease or diabetes to BP goal of 130/80 mmHg.Number of BP MedicationsUKPDS(85 mm Hg,diastolic)4321

24、MDRD(92 mm Hg,MAP)HOT(80 mm Hg,diastolic)AASK(92 mm Hg,MAP)RENAAL(140/90 mm Hg)IDNT(135/85 mm Hg)Department of Medicine-Lenox Hill-NYU School of Medicineavg In general,treatment similar for all demographic groups.Socioeconomic factors and lifestyle important barriers to BP control.Prevalence,severit

25、y of HTN increased in African Americans.African Americans demonstrate somewhat reduced BP responses to monotherapy with BBs,ACEIs,or ARBs compared to diuretics or CCBs.These differences usually eliminated by adding adequate doses of a diuretic.-40-30-20-10-20-10 Systolic BP(mmHg)Diastolic BP(mmHg)*,

26、:significant vs placeboACE Inh,n=24bBlocker,n=13HCTZ+ACE Inh,n=13HCTZ+bBlocker,n=14Placebo,n=14Ca+Blocker,n=10HCTZ,n=18Department of Medicine-Lenox Hill-NYU School of MedicineLaffer and Elijovich,J Clin Hypertens 2002;4:266Potential favorable effects Thiazide-type diuretics useful in slowing deminer

27、alization in osteoporosis.BBs useful in the treatment of atrial tachyarrhythmias/fibrillation,migraine,thyrotoxicosis(short-term),essential tremor,or perioperative HTN.CCBs useful in Raynauds syndrome and certain arrhythmias.Alpha-blockers useful in prostatism.Potential unfavorable effects Thiazide

28、diuretics should be used cautiously in gout or a history of significant hyponatremia.BBs should be generally avoided in patients with asthma,reactive airways disease,or second-or third-degree heart block.ACEIs and ARBs are contraindicated in pregnant women or those likely to become pregnant.ACEIs should not be used in individuals with a history of angioedema.Aldosterone antagonists and potassium-sparing diuretics can cause hyperkalemia.