高血压代谢危险因素控制面临的困惑与启示_祝之明.pptVIP

高血压代谢危险因素控制面临的困惑与启示 祝之明 第三军医大学全军高血压代谢病中心 重庆大坪医院高血压内分泌科 重庆市高血压研究所 如何评估高血压的代谢危险性 干预高血压相关的代谢危险因素能显著降低心脑血管事件吗？ Lower blood pressure Yes (30%-60%) Lower lipids Yes (17%-43%) Lower body weight Paradox Lower glucose Uncertain BMI and WC vs fat parameters 肥胖与心衰 Paradox prognosis: excess body weight have a paradoxical protective role ? 肥胖与AMI  BMI不能反映内脏脂肪的实际变化 Proposed mechanisms by which visceral obesity, as the most dangerous form of obesity, could be linked to the athero-thrombotic-inflammatory abnormalities of insulin resistance. Changes in Serum Potassium MediateThiazide-Induced Diabetes Summary 降压药物的选择 Effect of Inhibition of the RAS on Development of Type 2 Diabetes Mellitus (Meta-Analysis of Randomized Trials)  Am J Cardiol 2007;99:1006 –1012 Irbesartan for the treatment of hypertension in patients with themetabolic syndrome: A sub analysis of the Treat to Target postauthorization survey. Prospective observational, two armed studyin 14,200 patients Cardiovascular Diabetology 2007, 6:12 降糖药对心血管事件的影响 European Heart Journal (2008)  不同降糖药组合对LDL-C和血压影响不同  Bolen S Ann Intern Med. 2007 客观评价β-blocker在糖尿病治疗中的作用 予100 mg/d阿替洛尔能防止低血糖诱发的QTc延长和QTd离散Diabetes, 2003 虽然予beta受体阻断剂可能增加糖脂代谢紊乱和胰岛素抵抗，但可显著降低糖尿病合并心衰的死亡率。 对降糖治疗中出现的低血糖诱发的致死性心律失常的防治，也是其他药物难以取代的。 Fonarow GC. An Approach to Heart Failure and Diabetes Mellitus Am J Cardiol 2005;96[suppl]:47E–52E) Hypertension. 2008;52:1022-1029 Thiazide-induced diabetes occurs (42%) early after initiating treatment and appears to be mediated by changes in serum potassium. Potassium supplementation might prevent thiazide-induced diabetes. Cardiologist Endocrinologist Progression and outcomes of the metabolic syndromeGrundy SM, J Am Coll Cardiol 2006;47:1093–100 * * 蓝色为本版增加的危险因素；棕色为本版修改的危险因素。本版还删去了hs-CRP，原因是hs-CRP能否独立地增加心血管危险尚不确定；但对于MS人群的危险性评估， hs-CRP仍有价值。 * * 新的指南舍弃了2003版指南的流程图模式，对于“何时开始治疗”用一个对应