高血压病伴糖尿病的处理

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1、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20081213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:<6.5%InitialFU:7.8yExtendedFU:13.3yNEJM2003;348:383NEJM2008;358:580STENO-2STUDY:危险因素的控制IntensiveGro

2、upConventionalGroupSystolicBP↓15mmHg(146131)↓3mmHg(149146)LDL-C↓50mg%(13383)↓11mg%(137126)HbA1c↓0.5%(8.47.9)↑0.2%(8.89.0)NEJM2008;358:580STENO-2STUDY:强化治疗的效果%ReductioninComplicationsWithIntensiveRxat13.3yTotalMortality↓40%(50%vs30%)Cardiovascular

3、events↓59%(65%vs30%)Proliferativeretinopathy↓55%---Nephropathy↓56%---NEJM2008;358:580HYPERTENSIONANDDIABETES:PARTNERSINCRIME!共同土壤学说:“MetabolicSyndrome”HTNvsNoHTNDMvsNoDM2.4x↑inDM2.0x↑inHTNNEJM2000;342:905DiabetesCare2005;28:310高血压的发病率INDIABETES%withBP

4、140/90AllU.S.adults30%DiabeticU.S.adults60%•Type1DM-Normoalbuminuria30%-Microalbuminuria40%-Macroalbuminuria80%•Type2DM-AtDx50%-Microalbuminuria80%-Macroalbuminuria95%NEJM2000;342:905DiabetesCare2005;28:310AmJKidDis2007;49(Suppl2):S74JCardiometabSyndr2

5、006;1:95(86%≥130/80)高血压增加糖尿病病人的并发症RelativeRiskofComplicationsDiabetesvsNoDiabetes:CVD2.0–4.0ESRD7.0DiabetesBPvsDiabetesCHD3.0Stroke4.0Retinopathy2.0Nephropathy2.0Neuropathy1.6Mortality2.075%diefromCVDJAMA2004;292:2495KidInternat2000;59:703NEJM2005;35

6、2:341关注焦点“SYSTOLICBP”StrongerpredictorofriskthandiastolicBP:CardiovasculardiseaseRenaldysfunction65%ofDMhypertensiveshaveisolatedsystolichypertensionSystolichypertensionmoredifficulttocontrolDiabetesCare1994;17:1247Lancet2002;360:1903Hypertension2003;4

7、2:1206糖尿病伴高血压病的控制达标现状%WithBP<130/80NHANES,2003-200435%VA,2001-200223%Community1care,2002-200431-35%Academicmedicine,200233%GEMINIRCT,200468%ArchIntMed2007;167:2394JAMA2004;292:2227AnnFamMed2006;4:23JGenInternMed2006;21:1050控制不理想的原因何在？疾病本身的原因MostDMptsn

8、eed3-4drugstocontrolBPActivationofRAA–systemVolumeoverload,especiallyifCKDSleepapneafromassociatedobesityVasculardamageJHypertens2005;23:2305Hypertension2000;35:1038AmJHypertens2004;17:915JCardiometabSyn2007;2:114控制不理想的原因何在？用药依从性低Cost↑a