高血压病伴糖尿病的处理PPT.ppt

* 高血压病伴糖尿病的处理 中国医科大学一院心内科 齐国先 重庆 2008 12 13 多重危险因素的共同控制 Steno-2 Study 2003, 2008 RCT of 160 T2DM pts with microalbuminuria 强化干预 vs 常规干预 SBP: 130 mm Hg Total cholesterol 175 mg% HbA1c: 6.5% Initial FU: 7.8y Extended FU: 13.3y NEJM 2003; 348:383 NEJM 2008; 358:580 STENO-2 STUDY: 危险因素的控制 Intensive Group Conventional Group Systolic BP ↓ 15 mm Hg (146 ? 131) ↓ 3 mm Hg (149 ? 146) LDL-C ↓ 50 mg% (133 ? 83) ↓ 11 mg% (137 ? 126) HbA1c ↓ 0.5% (8.4 ? 7.9) ↑ 0.2% (8.8 ? 9.0) NEJM 2008; 358:580 STENO-2 STUDY: 强化治疗的效果 % Reduction in Complications With Intensive Rx at 13.3y Total Mortality ↓ 40% (50% vs 30%) Cardiovascular events ↓ 59% (65% vs 30%) Proliferative retinopathy ↓ 55% --- Nephropathy ↓ 56% --- NEJM 2008; 358:580 HYPERTENSION AND DIABETES: PARTNERS IN CRIME! 共同土壤学说: “Metabolic Syndrome” HTN vs No HTN DM vs No DM 2.4x ↑ in DM 2.0x ↑ in HTN NEJM 2000; 342:905 Diabetes Care 2005; 28:310 关注焦点“ SYSTOLIC BP” Stronger predictor of risk than diastolic BP: Cardiovascular disease Renal dysfunction 65% of DM hypertensives have isolated systolic hypertension Systolic hypertension more difficult to control Diabetes Care 1994; 17:1247 Lancet 2002; 360:1903 Hypertension 2003; 42:1206 糖尿病伴高血压病的控制达标现状 % With BP 130/80 NHANES, 2003-2004 35% VA, 2001-2002 23% Community 1? care, 2002-2004 31-35% Academic medicine, 2002 33% GEMINI RCT, 2004 68% Arch Int Med 2007; 167:2394 JAMA 2004; 292:2227 Ann Fam Med 2006; 4:23 J Gen Intern Med 2006; 21:1050 控制不理想的原因何在？ 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 damage J Hypertens 2005; 23:2305 Hypertension 2000; 35:1038