高血压病伴糖尿病的处理策略.ppt

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1、高血压病伴糖尿病的处理策略中国医科大学一院心内科齐国先沈阳20090627HTN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PARTNERSINCRIME!共同土壤学说:“MetabolicSyndrome”HTNvsNoHTNDMvsNoDM2.4x↑inDM2.0x↑inHTNNEJM2000;342:905DiabetesCare2005;28:310SyndromeXorMetabolicsynd.美国糖尿病患者高血压的发病率%withBP140/90AllU.

2、S.adults30%DiabeticU.S.adults60%•Type1DM-Normoalbuminuria30%-Microalbuminuria40%-Macroalbuminuria80%•Type2DM-AtDx50%-Microalbuminuria80%-Macroalbuminuria95%NEJM2000;342:905DiabetesCare2005;28:310AmJKidDis2007;49(Suppl2):S74JCardiometabSyndr2006;1:95(86%≥130/80)DatafromKingHetal.Diabetes

3、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RelativeRiskofComplicationsDiabetesvsNoDiabetes:CVD2.0–4.0ESRD7.0DiabetesBPvsDiabetesCHD3.0Stroke4.0Retinopathy2.0Nephropathy2.0Neuropathy1.6Mortality2.075%diefromCVDJAMA2004;292:2495KidInternat2000;59:703NEJM20

4、05;352:341DM+HTNdoublestheriskof-cardiovascularevents-cardiovascularmortality-totalmortalitycomparedwithpeoplewithhypertensionaloneAssociationofSBPandCVMortalityinMenWithType2Diabetes250200150100500<120120-139140-159160-179180-199SBP(mmHg)CVmortalityrate/10,000person-yrNondiabeticD

5、iabeticCV,cardiovascular;SBP,systolicbloodpressure.StamlerJetal.DiabetesCare.1993;16:434-444.≥200NephropathyhistoryinDMHTN伴DM的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:<6.5%InitialFU:7.8yExtendedFU:13.3yNEJM20

6、03;348:383NEJM2008;358:580STENO-2STUDY:危险因素的控制IntensiveGroupConventionalGroupSystolicBP↓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%(5

7、0%vs30%)Cardiovascularevents↓59%(65%vs30%)Proliferativeretinopathy↓55%---Nephropathy↓56%---NEJM2008;358:580糖尿病患者预防性抗血小板指征Aged>50 yearsDiabetes for> 10 yearsTakingtreatmentforHTNEvidenceoftarget-organdamageorestablishedcardiovasculardiseaseAtrialfibrillationLipid-loweringtherapy