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糖尿病患者的血压管理课件

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糖尿病患者 血压 管理 课件
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Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 糖尿病患者的血压管理糖尿病患者的血压管理 ADVANCE ADVANCE研究结果的启示研究结果的启示 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内内 容容 强化降压达标是硬道理强化降压达标是硬道理 ADVANCE ADVANCE UKPDSUKPDS十年随访及十年随访及SANDS SANDS 培哚普利 丰富一致的循证医学证据 PROGRESS EUROPA HYVET ADVANCE ASCOT 联合治疗是强化降压达标的必由之路联合治疗是强化降压达标的必由之路 优化联合治疗方案优化联合治疗方案 ACEI CCB D Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 糖尿病糖尿病 高血压高血压 甜蜜杀手甜蜜杀手 隐形杀手隐形杀手 糖尿病合并高血压 140 90mmHg 40 60 糖尿病合并血压升高 130 80mmHg 75 糖尿病合并高血压死亡率 7 2倍 糖尿病死亡患者与高血压有关 44 糖尿病并发症与高血压有关 35 75 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 高危和极高危 2007ESC Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial HOT HOT研究结果研究结果 对于糖尿病患者 严格降压可进一步减少主要心血管事 件的发生 Hansson L Zanchetti A Carruthers SG et al Lancet 1998 351 1755 1762 P 0 005 P 0 045 P 0 016 51 事件 1000病人年 0 5 10 15 20 25 30 主要心血管事件心肌梗死心血管死亡 90 mm Hg n 501 85 mm Hg n 501 80 mm Hg n 499 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial UKPDS UKPDS试验试验 强化血糖控制和血压控制的疗效强化血糖控制和血压控制的疗效 卒中 任一糖尿病 终点 糖尿病死亡微血管并发症充血性心衰 心肌梗死 强化血糖控制 FPG 6 mmol L 强化血压控制 150 85 mm Hg 降低风险 50 40 30 20 10 0 10 UKPDS Group BMJ 1998 317 703 713 UKPDS Group Lancet 1998 352 837 853 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 通过降压最大限度地降低高血压病患者长 期的心血管疾病患病和死亡的总风险 所有高血压患者目标血压 140 90mmHg 有心血管高危因素患者目标血压 130 80mmHg 中国高血压防治指南 2005 ESH ESC 2007 20052005年中国高血压防治指南年中国高血压防治指南 高血压治疗的首要目标高血压治疗的首要目标 降压达标是关键 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial ADVANCE ADVANCE 一项在一项在1114011140名名2 2型糖尿病型糖尿病 患者中进行的强化降压和强化降糖患者中进行的强化降压和强化降糖 治疗的析因 随机试验治疗的析因 随机试验 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial ADVANCEADVANCE 研究概况研究概况 共登记12877名2型糖尿病 患者 11140 随机 5569 分到 培哚普利 吲达帕胺 组 筛选期1737名患 者退出 计划随访期限 4 3 年 最后一次随访4908人 88 4081 73 人坚持方案治疗 失访4 人失访11 人 计划随访期限 4 3 年 最后一次随访4863 人 87 4143 74 人坚持方案治疗 5571 分到常规治疗组 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 降压疗效降压疗效 2 2 mmHg 95 CI 2 0 2 4 p 0 001 5 6 mmHg 95 CI 5 2 6 0 p0 1 2 0 事件例数 加百普乐常规治疗 n 5 569 n 5 571 相对风险 下降 95 CI 偏向 加百普乐 偏向 常规治疗 风险比 0 51 0 年龄 岁 6553659211 0 to 21 性别 男546594 10 1 to 20 女315344 8 7 to 21 收缩压 mmHg 7 545148111 1 to 22 所有患者861938 9 0 to 17 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 冠状动脉事件冠状动脉事件 2P 0 02 非致死性心肌梗死或冠心病性死亡 需住院治疗的不稳定心绞痛 冠状动脉血运重建或隐匿性心肌梗死 主要冠心病事件 265294 11 6 to 24 所有冠心病事件468535 14 2 to 24 其他冠心病事件 283324 14 1 to 27 事件例数 n 5 569 n 5 571 相对风险 下降 95 CI 偏向偏向 风险比 0 51 02 0 常规治疗 常规治疗加百普乐 加用培哚普利 吲达帕胺 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 肾病事件肾病事件 2 0 风险比 0 51 0 新发肾病或原有肾病恶化181216 18 1 to 32 新发微量白蛋白尿10941317 21 14 to 27 所有肾脏事件12431500 21 15 to 27 2P 0 01 事件例数 n 5 569 n 5 571 相对风险 下降 95 CI 偏向偏向 加百普乐 常规治疗 常规治疗 加用培哚普利 吲达帕胺 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 多数为新出现的微量白蛋白尿 常规服用常规服用 培哚普利培哚普利 吲达帕胺的绝对获益吲达帕胺的绝对获益 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 总结总结 对于2型糖尿病患者常规给予培哚普利 吲达帕 胺 将有以下疗效 总死亡率下降14 以上 心血管死亡下降18 以上 主要血管事件下降9 以上 所有冠状动脉事件下降14 以上 所有肾脏病事件下降21 以上 上述疗效在所有主要亚组之间相似 治疗的耐受性非 常好 几乎无副作用 患者的依从性与安慰剂相似 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Effect of lower targets for blood pressure and Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes LDL cholesterol on atherosclerosis in diabetes the SANDS randomized trialthe SANDS randomized trial 研究背景 糖尿病患者的心血管病 CVD 危险因素 增加 但目前仍缺乏更有力的危险因素控制目标 研究目的 比较2型糖尿病并有亚临床动脉粥样硬化患 者在强化治疗组 LDL C 70 mg L SBP 115 mmHg 与标准治疗组 LDL C 100 mg dL S BP 130 mmHg 的动脉硬化进展情况 JAMA 2008 Apr 9 299 14 1678 1689 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 试验设计 试验性质 随机 开放 双盲 起止时间 2003 4 2007 6 3年 参与单位 位于美国俄克拉荷马州 亚得桑那州 南达科他的4个临床中心 试验者 499名美国印地安人 男女不限 年龄 40岁 既往无CVD事件 试验方法 将试验者随机分为强化治疗组 N 252 与标准治疗组 N 247 逐渐增加剂量 试验终点 主要终点 通过测量颈动脉内膜中层厚度 IMT 诊断为动脉粥样硬化 次要终点 其它颈动脉与心脏超声测量或临床事件 JAMA 2008 Apr 9 299 14 1678 1689 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 结 果 JAMA 2008 Apr 9 299 14 1678 1689 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial ABCD ABCD研究研究 A Appropriate ppropriate B Blood pressure lood pressure C Control in ontrol in D Diabetes iabetes 糖尿病患者血压合理控制糖尿病患者血压合理控制 血压正常的糖尿病患者 目标血压 脑血管事件发生风险 OR 强化治疗128 75mmHg 1 7 一般治疗137 81mmHg 5 4 3 29 Kidney Int 2002 6 1086 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血压目标值 130 80mmHg还有待进一步 调整 120 75mmHg 早期 长期强化降压达标 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内内 容容 强化降压达标是硬道理强化降压达标是硬道理 ADVANCE ADVANCE UKPDSUKPDS十年随访及十年随访及SANDS SANDS 培哚普利 丰富一致的循证医学证据 PROGRESS EUROPA HYVET ADVANCE ASCOT 联合治疗是强化降压达标的必由之路联合治疗是强化降压达标的必由之路 优化联合治疗方案优化联合治疗方案 ACEI CCB D Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 各种药物适应证比较各种药物适应证比较 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Ang 肾小球毛细血管内压 单个肾单位的GFR 机械和氧化应激 蛋白尿 NF B活化 TGF 炎性介质 趋化因子 粘附分子 巨噬细胞浸润 肾小球硬化 小管间质纤维化 先天性或获得性 肾单位数量减少 Ang 在糖尿病肾病进展中的作用 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial ACEI治疗糖尿病的益处 抑制RAS系统活性 减少DN的发生 控制高血压 降低尿蛋白 延缓DN的进展 减少DN心血管事件的发生率及死亡率 减少高血压患者新发糖尿病的发生 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial J of Hypertension 2008 26 suppl 3 S21 S27 培哚普利 卓越的心血管保护作用 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利培哚普利 高质量降压 有效的器官保护作用 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利培哚普利2424小时降压疗效好小时降压疗效好 0 25 50 75 100 培哚普利 群多普利 氯沙坦 赖诺普利 雷米普利 喹那普利 贝那普利 依那普利 卡托普利 32 38 50 50 70 50 80 87 100 1 Physician s desk reference 2001 2 Elliott W Am J Hpertens 2001 14 291S 295S FDA FDA 认证认证 90 50 50 60 50 50 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 极低的不良反应发生率极低的不良反应发生率 首剂低血压发生率低首剂低血压发生率低 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 雅施达首剂低血压发生率低雅施达首剂低血压发生率低 MAP mmHg 时间 h Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利改善血管紧张素培哚普利改善血管紧张素IIII和缓激肽平衡和缓激肽平衡 提高提高eNOSeNOS活性活性 Ferrari R Expert Rev Cardiovasc Ther 2005 3 15 29 P perindopril vs placebo pg ml 血管进展素II P 0 05 缓激肽 P 0 05 eNOS 活性 P 0 05 pmol min mg protein Controls Baseline Perindopril 8 mg PERTINENT Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial P P 0 05 0 05 Apoptosis 对照对照稳定性冠心病患者稳定性冠心病患者 基线基线1年后 PlaceboPlacebo n 44n 44 PlaceboPlacebo n 44n 44 Treated n 43 Treated n 43 Controls n 45 0 10 20 P P 0 01 0 01 内皮细胞凋亡 P controls vs baseline P perindopril vs placeboCeconi C et al Cardiovasc Res 2006 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 正常凋亡率 3 维持内皮层稳定 过度凋亡 发生粥样硬化 对抗动脉硬化 内皮细胞凋亡和动脉硬化 形成斑块 斑块破裂 内皮的连续性 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial Perindopril improves cerebral blood flow significantly Perindopril improves cerebral blood flow significantly more than a blockermore than a blocker 130 140 150 160 120 156 135 131 Systolic BP mm Hg CBF Index 25 30 35 40 25 23 30 90 33 98 p 0 01 vs blocker p 0 01vs placebo perindopril acebutolol placebo p 0 01 vs blocker 30 hypertensive patients Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利培哚普利 高质量降压 有效的器官保护作用 预防事件 挽 救生命 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利全面干预心血管事件链证据 n 54 667 高血压 n 19 257 稳定性冠心病 n 12 218 糖尿病 n 11 140 卒中后 n 6 105 心肌梗死后 n 1 252 舒张性心力衰竭 n 850 高血压 n 3845 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利大型临床研究一览培哚普利大型临床研究一览 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利 氨氯地平组显著降低主要和次要终点 阻滞剂 利尿剂有利 ACEI CCB有利 危险比 总死亡 主要终点非致死性 MI 和 CHD 所有冠心病事件 主要终点 新发心绞痛 致死性 非致死性心衰 致死性 非致死性卒中 所有 CV 事件 和血管重建 CV 死亡率 0 511 5 终点 P 值 0 005 0 12 0 0048 0 0007 0 0001 0 0017 Bjorn Dahlof Peter S Sever Neil R Poulter et al Published online September 4 2005 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 不论血压是否增高 结果高度一致 总人群总人群 高血压人群高血压人群 非高血压人群非高血压人群 PROGRESS Collaborative Group Lancet 2001 358 1033 41 EUROPA Investigators Lancet 2003 362 782 88 ADVANCE Collaborative Group Lancet 2007 370 829 40 卒中后患者卒中后患者 卒中再发卒中再发 20 20 10 10 0 0 30 30 RRRRRR 32 27 28 心血管死亡 心肌梗死和可复苏的心脏骤停心血管死亡 心肌梗死和可复苏的心脏骤停 15 15 10 10 5 5 0 0 20 20 RRRRRR 20 18 20 稳定性冠心病患者稳定性冠心病患者 血管事件血管事件 5 5 0 0 10 10 RRRRRR 9 10 9 糖尿病患者糖尿病患者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 不论血糖是否增高 结果高度一致 Berthet K Blood Pressure 2004 EUROPA Investigators Lancet 2003 362 782 88 Dahlof B Lancet 2005 366 895 906 15 15 10 10 5 5 0 0 20 20 RRRRRR 13 18 16 15 15 10 10 5 5 0 0 20 20 RRRRRR 20 19 19 30 30 20 20 10 10 0 0 40 40 RRRRRR 38 28 28 心血管死亡 心肌梗死和可复苏的心脏骤停心血管死亡 心肌梗死和可复苏的心脏骤停 卒中再发卒中再发 血管事件血管事件 总人群总人群 糖尿病人群糖尿病人群 非糖尿病人群非糖尿病人群 卒中后患者卒中后患者稳定性冠心病患者稳定性冠心病患者高血压患者高血压患者 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利预防心力衰竭的发生或因心力衰竭住院培哚普利预防心力衰竭的发生或因心力衰竭住院 39 P 0 002 37 P 0 033 26 P 0 02 28 NS 稳定性冠心病患者稳定性冠心病患者 舒张性心衰舒张性心衰 心梗后患者心梗后患者卒中后患者卒中后患者 EUROPA Investigators Lancet 2003 362 782 88 Cleland JGF Eur Heart J 2006 27 2338 2345 PROGRESS Collaborative Group Eur Heart J 2003 24 475 484 PREAMI Investigators Arch Intern Med 2006 166 659 666 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 79 6 1 1 83 0 1 2 83 6 1 2 Perindopril Placebo 75 78 81 84 87 LVEDV Volumes ml means SE Baseline6 month12 month p 0 01 p 0 01 81 1 1 1 81 2 1 2 81 8 1 3 n 631 n 619 PREAMI Investigators PREAMI Investigators Arch Intern MedArch Intern Med 2006 166 659 666 2006 166 659 666 Prevention of cardiac remodeling in post AMI Prevention of cardiac remodeling in post AMI patients with preserved LV functionpatients with preserved LV function Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial PREAMI Investigators Arch Intern Med 2006 166 659 666 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 培哚普利 ACEI中的典范 高血压 n 19 257 稳定性冠心病 n 12 218 糖尿病 n 11 140 卒中后 n 6 105 心肌梗死后 n 1 252 舒张性心力衰竭 n 850 高血压 n 3845 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 内内 容容 强化降压达标是硬道理强化降压达标是硬道理 ADVANCE ADVANCE UKPDSUKPDS十年随访及十年随访及SANDS SANDS 培哚普利 丰富一致的循证医学证据 PROGRESS EUROPA HYVET ADVANCE ASCOT 联合治疗是强化降压达标的必由之路联合治疗是强化降压达标的必由之路 优化联合治疗方案优化联合治疗方案 ACEI CCB D Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 糖尿病合并高血压的血压糖尿病合并高血压的血压达标率低达标率低 控制值 比例 140 90mmHg 33 1 3 130 80mmHg 25 1 4 NHANES 国家健康与营养调查研究 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 糖尿病合并高血压患者糖尿病合并高血压患者 水钠潴留 肾病 交感神经活性 RASS激活 睡眠呼吸暂停 难以降压 难以降压 血管重构 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 1 杓型血压 2 非杓型血压 3 超杓型血压 夜间血压变化 10 20 20 4 反杓型血压 夜间血压高于 白天血压5 5 晨起高血压 晨起血压高于夜间 平均血压的30 糖尿病血压变异的常见类型糖尿病血压变异的常见类型 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 血压达标所需使用降压药数量血压达标所需使用降压药数量 一般糖尿病合并高血压 2 9 合并肾病 3期 3 5 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 地尔硫卓 1974 联合治疗是降压达标的必由之路联合治疗是降压达标的必由之路 Monotherapy is usually inadequate therapy BHS IV 肾素抑制剂 ALK ACE2激动剂 MR 3 ACEI NO供体结构 NCX899 抗高血压疫苗 CYT006 AngQ6 应用Rheos压力反射 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 2007 2007 ESC ESHESC ESH高血压诊疗指南推荐的联合方案高血压诊疗指南推荐的联合方案 钙拮抗剂 噻嗪类利尿剂 受体阻滞剂 受体阻滞剂 ACEI ARB Adapted from J Hypertens 2007 25 1105 1187 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial 已被证实的临床有效的降压组合已被证实的临床有效的降压组合 ACEI ARB CCB ACEI ARB 利尿剂 CCB 阻滞剂 CCB 利尿剂 从中我们能 找到优化组 合吗 证据 Five weeks of practice ended in this way and my feelings can only be summed up in eight words although hard but very substantial J o
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