高血压代谢危险因素控制面临的困惑与启示课件.pptx

1、Abdominal ObesityEndothelium damageHypertensive Syndrome-Constellations of Cardiometabolic Risk FactorsHypertension80%高血压危险因素危险因素CVD事件事件 Waist circumference 102cm(M),88cm(W)l TC5.0 mmol/l(原为原为6.1)orl LDL-C 3.0 mmol/l(原为原为4.0)orl HDL-C:M 1.0 mmol/l(40 mg/dL),W 1.7 mmol/l(150 mg/dL)l Fasting plasma gl

2、ucose 5.6-6.9 mmol/L(102-125 mg/dL)l Abnormal glucose tolerance testthe cluster of three out of 5 risk factors among abdominal obesity,altered fasting plasma glucose,BP130/85mmHg,low HDL-cholesterol and high TG(as defined above)l Fasting plasma 7.0 mmol/l(126 mg/dL)on repeated measurements,orl Postl

3、oad plasma glucose 11.0 mmol/l(198 mg/dL)如何评估高血压的代谢危险性Diabetes Vasc Dis Res 2008;5:914心血管代谢危险性评估心血管代谢危险性评估1.Framingham score(USA)Age,Sex,SBP,TC,Smoking,HDL-c2.The UKPDS risk engine(UK)Age,Sex,SBP,Smoking,TC/HDL-c,HbA1c3.PROCAM score(Germany)Age,LDL-c,TC,smoking,HDL-c,SBP,FH of MI,DM,TG4.ICVD(China)A

4、ge,Sex,SBP,BMI,TC,Smoking,DMNo BP interventionNo BP interventionLifestyle changes for several months then drug treatment if BP uncontrolledLifestyle changes for several weeks then drug treatment if BP uncontrolledLifestyle changes+immediate drug treatmentLifestyle changesLifestyle changesLifestyle c

5、hanges for several weeks then drug treatment if BP uncontrolledLifestyle changes for several weeks then drug treatment if BP uncontrolledLifestyle changes+immediate drug treatmentLifestyle changesLifestyle changes and consider drug treatmentLifestyle changes+drug treatmentLifestyle changes+drug trea

6、tmentLifestyle changes+immediate drug treatmentLifestyle changesLifestyle changes+drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug tre

7、atment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(Lower lipids Yes(Lower body weight Paradox Lower glucose Uncertain BMI and WC vs fat parameters 肥胖与心血管危险存在U形关系Gu DF,et al.JAMA.2006;295:776-783肥胖与心衰 Paradox prognosis:Paradox prognosis:excess body weight have a paradoxical protective role?Enc

8、haiah S,et al.N Engl J Med 2002;347:305-13.DIAMOND study groupGustafsson1 F,Eur Heart J,2005,26:5864肥胖与AMI Obesity and the risk of myocardial infarction in 27 000 participants from 52 countries:a case-control study Yusuf S,et al.Lancet 2005;366:1640Nicoletti I,et al.Inter J Cardiol,2006,107:395399Pa

9、radox prognosis:Paradox prognosis:excess body weight have a paradoxical protective role?BMI不能反映内脏脂肪的实际变化非肥胖组非肥胖组隐性内脏脂肪型肥胖组隐性内脏脂肪型肥胖组(Masked VFO)假性内脏脂肪型肥胖组假性内脏脂肪型肥胖组(Pseudo VFO)内脏型腹型肥胖组内脏型腹型肥胖组(visceral fat obesity，VFO)MS 43%MS 78%MS 89%中华医学杂志中华医学杂志 2008 2008Proposed mechanisms by which visceral obes

10、ity,as the most dangerous form of obesity,could be linked to the athero-thrombotic-inflammatory abnormalities of insulin resistance.ATVB,2008微血管并发症微血管并发症心肌梗死心肌梗死HbA1c37%14%糖尿病相关的死亡糖尿病相关的死亡21%1%Stratton IM,et al.BMJ 2000;321:405412.糖尿病作为冠心病的等危症是有条件的糖尿病作为冠心病的等危症是有条件的Diabetes and Coronary Risk Equivale

11、ncy糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖至少在短期对心血管危害不大。糖尿病合并其他危险因素，其心血管危险性明显增加，可视为冠心病等危症。Grandy SM,Diabetes Care,2006 降压和调脂的临床试验证实：血压和血脂水平降压和调脂的临床试验证实：血压和血脂水平控制得越严格，获得的益处更大。控制得越严格，获得的益处更大。A C C O R D,A D VA N C E,VA D T 强化血糖控制无益处强化血糖控制无益处 在在ACCORD试验结果公布之前一个月，试验结果公布之前一个月，Eur Heart J连续刊登了连续刊登了2篇降糖治疗增加心血管事篇降糖治疗

12、增加心血管事件的临床研究，编辑部予以评论。件的临床研究，编辑部予以评论。The impact of glucose lowering treatment on long-term prognosis in patients with type 2 diabetes and myocardial infarction:a report from the DIGAMI 2 trialEuropean Heart Journal(2008)Euro Heart Survey on Diabetes and the Heart Glucose lowering treatment in patient

13、s with coronary artery disease is prognostically important not only in established but also in newly detected diabetes mellitus:a report from the Euro Heart Survey on Diabetes and the Heart 本研究比较了目前的降糖治疗对冠心病己合并糖尿病和新发糖尿病的作用。从110个中心，入选4676例冠心病患者，其中1425例既往有糖尿病，452例为新发糖尿病。探讨不同的降糖治疗对心血管事件(死亡、心梗、卒中)的影响。Eu

14、ropean Heart Journal(2008)与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗合并糖尿病的冠心病，胰岛素治疗增加增加1 1年心血管死亡风险年心血管死亡风险2.23 2.23(95%CI 1.244.03;P=0.006)，但对新发糖尿病患者，与未降糖治疗相比，降糖治疗则明显减少其心血管事件Jessup M,et al.NEJM,2003,348:2007-18.Blaschke F,et al.ATVB,2006,26:28-40VanGaal LF,et al.Lancet,2005,365:1389-97多靶点药物多靶点药物Effect of Inhibition

15、of the RAS on Development of Type 2 Diabetes Mellitus(Meta-Analysis of Randomized Trials)Am J Cardiol 2007;99:1006 1012Irbesartan for the treatment of hypertension in patients with themetabolic syndrome:A sub analysis of the Treat to Target postauthorization survey.Prospective observational,two arme

16、d studyin 14,200 patients Cardiovascular Diabetology 2007,6:12降糖药对心血管事件的影响降糖药对心血管事件的影响European Heart Journal(2008)Bolen S Ann Intern Med.2007Diabetes,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

17、 Am J Cardiol 2005;96suppl:47E52E)Changes in Serum Potassium MediateThiazide-Induced DiabetesHypertension.2008;52:1022-1029Thiazide-induced diabetes occurs(42%)early after initiating treatment and appears to be mediated by changes in serum potassium.Potassium supplementation might prevent thiazide-i

18、nduced diabetes.Cardiologist&Endocrinologist Progression and outcomes of the metabolic syndromeGrundy SM,J Am Coll Cardiol 2006;47:1093100Abdominal ObesityEndothelium damageHypertensive Syndrome-Constellations of Cardiometabolic Risk FactorsHypertension80%高血压危险因素危险因素CVD事件事件No BP interventionNo BP in

19、terventionLifestyle changes for several months then drug treatment if BP uncontrolledLifestyle changes for several weeks then drug treatment if BP uncontrolledLifestyle changes+immediate drug treatmentLifestyle changesLifestyle changesLifestyle changes for several weeks then drug treatment if BP unc

20、ontrolledLifestyle changes for several weeks then drug treatment if BP uncontrolledLifestyle changes+immediate drug treatmentLifestyle changesLifestyle changes and consider drug treatmentLifestyle changes+drug treatmentLifestyle changes+drug treatmentLifestyle changes+immediate drug treatmentLifesty

21、le changesLifestyle changes+drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatmentLifestyle changes+immediate drug treatment糖尿病作为冠心病的等危症是有条件的糖尿病作为冠心病的等危症是有条件的Diabetes and C

22、oronary Risk Equivalency糖尿病不合并其他危险因素，其心血管危险不高，也即单纯高血糖至少在短期对心血管危害不大。糖尿病合并其他危险因素，其心血管危险性明显增加，可视为冠心病等危症。Grandy SM,Diabetes Care,2006与口服降糖药相比，对合并糖尿病的冠心病，胰岛素治疗合并糖尿病的冠心病，胰岛素治疗增加增加1 1年心血管死亡风险年心血管死亡风险2.23 2.23(95%CI 1.244.03;P=0.006)，但对新发糖尿病患者，与未降糖治疗相比，降糖治疗则明显减少其心血管事件Effect of Inhibition of the RAS on Development of Type 2 Diabetes Mellitus(Meta-Analysis of Randomized Trials)Am J Cardiol 2007;99:1006 1012Diabetes,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;96suppl:47E52E)