高血压英文PPT精品课件Therapeuticroleofexerciseintreating 62页

TherapeuticroleofexerciseintreatinghypertensionDalynnT.Badenhop,Ph.D.,FACSMProfessorofMedicineDirector,CardiacRehabilitationMedicalCollegeofOhio EducationalObjectivesToexplaintheacutebloodpressureresponsetoexerciseTolistthemechanismsbywhichexercisemayimprovehypertensionToapplyexerciseguidelinesintreatinghypertensionToprescribeappropriatedrugtherapyforactivehypertensivepatients OverviewofHypertensionHighBPisariskfactorforstroke,CHF,angina,renalfailure,LVHandMIHypertensionclusterswithhyperlipidemia,diabetesandobesityDrugshavebeeneffectiveintreatinghighBPbutbecauseoftheirsideeffectsandcost,non-pharmacologicalternativesareattractive 1997JNCVIClassificationofBloodPressureBloodPressureCategorySystolicDiastolicOptimal<120<80Normal<130<85HighNormal130-13985-89HypertensionStage1(Mild)140-15990-99Stage2(Moderate)160-179100-109Stage3(Severe)>180>110 OverviewofHypertensionJointNationalCommitteeVI(JNCVI)onPrevention,Detection,Evaluation,andTreatmentofHighBloodPressure(1997)50millionhypertensivepatientsintheU.S.NationalHealthandNutritionExaminationSurveyIII(NHANESIII)(1995)only21%oftreatedhypertensivepatientshaveBPcontrolledto<140/90mmHg35%ofhypertensivepatientsareunawareoftheirconditionHigh-normalBPisassociatedwithanincresedriskofcardiovasculardiseaseNEngJMed2001;345;1291-7 PathophysiologyofHypertensionEssentialhypertensionischaracterizedbyincreasedDBPandrelatedarteriolarvasoconstrictionleadingtoincreasedSBPBPismainlydeterminedbycardiacoutputandtotalperipheralresistanceHighbloodpressuremaybelinkedtoage-relatedvascularstiffening PathophysiologyofHypertensionHighbloodpressureisalsoassociatedwithobesity,saltintake,lowpotassiumintake,physicalinactivity,heavyalcoholuseandpsychologicalstressIntra-abdominalfatandhyperinsulinemiamayplayaroleinthepathogenesisofhypertension PrevalenceofOtherRiskFactorsWithHypertensionRiskFactorPercentSmoking35LDLCholesterol>140mg/dl40HDLCholesterol<40mg/dl25Obesity40Diabetes15Hyperinsulinemia50Sedentarylifestyle>50KaplanNM.DisMon1992;38:769-838 CardiovascularConsequencesofHypertensionIndividualswithBP>160/95haveCAD,PVD&strokethatis3XhigherthannormalHTNmayleadtoretinopathyandnephropathyHTNisalsoassociatedwithsubclinicalchangesinthebrainandthickeningandstiffeningofsmallbloodvessels CardiovascularConsequencesofHypertensionIncreasedcardiacafterloadleadstoleftventricularhypertrophyandreducedearlydiastolicfillingIncreasedLVmassispositivelyassociatedwithCVmorbidityandmortalityindependentofotherriskfactorsHighBPalsopromotescoronaryarterycalcification,apredictorofsuddendeath Hypertension&CVDOutcomesIncreasedBPhasapositiveandcontinuousassociationwithCVeventsWithinDBPrangeof70-110mmHg,thereisnothresholdbelowwhichlowerBPdoesnotreducestrokeandCVDriskA15/6mmHgBPreductionreducedstrokeby34%andCHDby19%over5years LifestyleChangesforHypertensionReduceexcessbodyweightReducedietarysodiumto<2.4gms/dayMaintainadequatedietaryintakeofpotassium,calciumandmagnesiumLimitdailyalcoholconsumptionto<2oz.ofwhiskey,10oz.ofwine,24oz.ofbeerExercisemoderatelyeachdayEngageinmeditationorrelaxationdailyCessationofsmoking JNCVIBloodPressureClassification MedicalTherapyandImplicationsforExerciseTrainingPharmacologicandnonpharmocologictreatmentcanreducemorbiditySomeantihypertensiveagentshaveside-effectsandsomeworsenotherriskfactorsExerciseanddietimprovemultipleriskfactorswithvirtuallynoside-effectsExercisemayreduceoreliminatetheneedforantihypertensivemedications AcuteBPResponsetoExercise ExaggeratedBPResponsetoExerciseAmongnormotensivemenwhohadanexercisetestbetween1971-1982,thosewhodevelopedHTNin1986were2.4timesmorelikelytohavehadanexaggeratedBPresponsetoexerciseExaggeratedBPresponseincreasedfuturehypertensionriskby300%afteradjustingforallotherriskfactors ExaggeratedBPResponsetoExerciseExaggeratedBPwaschangefromrestinSBP>60mmHgat6METs;SBP>70mmHgat8METs;DBP>10mmHgatanyworkload.SubjectsinCARDIAstudywithexaggeratedexerciseBPwere1.7timesmorelikelytodevelopHTN5yearslaterJClinEpidemiol51(1):1998 NIHConsensusConferenceonPhysicalActivityandCVHealth(1995)Reviewof47studiesofexerciseandHTN70%ofexercisegroupsdecreasedSBPbyanavg.of10.5mmHgfrom15478%ofsubjectsdecreasedDBPbyanavg.of8.6mmHgfrom98Only1studyshowedincreasedBPw/EXBeneficialresponsesare80timesmorefrequentthannegativeresponsesHagberg,J.,et.al.,NIH,1995:69-71 IncreasingLifestyleActivityforPatientswithHigh-NormalBloodPressureandStageIHypertensionMedicalCollegeofOhioStudyGroupKevinA.Phelps,D.O.LarryJohnson,M.D.SandraPuczynski,Ph.D.DalynnBadenhop,Ph.D.MichaelMcCreaWendyBoone,RN,M.P.H LifestyleActivityvs.StructuredExerciseJAMA1999;281(4):327-334moderate-intensitylifestyleactivityshowedsimilarorbetterresultsversusstructuredexerciseforimprovedcardiovascularfitnessreducedbodyfatdecreasedtotalcholesterolreducedbloodpressurepatientcomplianceInthepastfiveyearstheSurgeonGeneral,CDC,NIH,andACSMhavepublishedpositionstatementsonthepotentialhealthbenefitsoflifestyleactivity Twenty-fourweek,physician-directedinterventionprogramtolowerBPbyincreasingphysicalactivityPatientsrandomizedintotwogroups:Group1-educationalinterventionmonitoredviaactivitylogsGroup2-educationalinterventionmonitoredviaactivitylogsandpedometerStudyDesign ThePedometerasmalldevicewornatthewaistthatcountsstepsusedsuccessfullyinobesitystudies StudyHypothesesAddingapedometertogoalsettingwillincreasethelevelandfrequencyofphysicalactivitywillimproveBPcontrolofadultpatientswithhigh-normalBPorStage1HTN MainOutcomeMeasuresBloodPressureandBMIPhysicalActivityassessedby:twoquestionnairesPhysicalActivityRecallScale(PASE):assessedactivityinpastsevendaysPhysician-basedAssessmentandCounselingforExercise(PACE):assessedreadinessforchangeinlevelofphysicalactivity PatientEducationTool Methods:PatientIdentificationPotentialsubjectsidentifiedbychartauditaverageBPofpastthreevisitsinHighNormalBPorStage1HTNcategoryExclusionCriteria:AntihypertensivemeduseconfirmedBP³160/100DxDM,CHF,CAD,CVD,CA,MRpregnantchild(<18yrs) Methods:PatientRecruitmentIdentifiedsubjectscontactedduringregularlyscheduledphysicianvisitPhysicianintroducedstudytopatientInterestedpatientsmetwithresearchassistantformoreinformationaboutstudy Methods:PatientEligibilityInterestedpatientshadtwoeligibilityvisitstwoweeksaparttoconfirmelevatedBPIfaverageBPattwovisitsconfirmedHigh-NormalBPorStage1HTNfromchartaudit,thenpatientwasscheduledforfirststudyvisit(t0) SampleCharacteristics Methods:StudyVisitsResearchAssistantmeasuredBPandweight,reviewedactivitylogatallvisitsadministeredPASEandPACEatbaselineandcompletionPhysiciandiscussedbarrierstoincreasingactivitynewactivitygoalsettingassistedwithproblemsolving PreliminaryResultsOutcomemeasuresanalyzedatbeginningofstudy,week0(t0)endofinterventionperiod,week12(t1)endofmaintenanceperiod,week24(t2) ChangeinSystolicBPfromTime0toTime1(12weeks)forbothgroupsP=.005 ChangeinSystolicBPacrosstimeforbothgroups(24weeks) ChangeinDiastolicBPfromTime0toTime1forbothgroups(12weeks) ChangeinDiastolicBPacrosstimeforbothgroups(24weeks) ChangeinBMIacrosstimeforbothgroups(24weeks) ChangeinPASEacrosstimeforbothgroups(24weeks) PreliminaryConclusionsInterventionalone(Group1)didnotsignificantlyimproveBPInterventionplusapedometer(Group2)significantlyimprovedBP,butonlywithregularphysicianvisits PossibleMechanismsofBPReductionwithExerciseReducedvisceralfatindependentofchangesinbodyweightorBMIAlteredrenalfunctiontoincreaseeliminationofsodiumleadingtoreducefluidvolumeAnthropomorphicparametersmaynotbeprimarymechansimsincausingHTN PossibleMechanismsofBPReductionwithExerciseLowercardiacoutputandperipheralvascularresistanceatrestandsubmaximalexerciseDecreasedHRDecreasedsympatheticandincreasedparasympathetictoneLowerbloodcatecholaminesandplasmareninactivity Antihypertensive&VolumeDepletingEffectsofMildExerciseonEssentialHTN20subjectswithHTN(155/100)randomizedtoExerciseorControlgroupCycleErgometerExerciseatBloodLacticAcidThresholdfor60min.3X/wkfor10weeksChangesinBP,hemodynamicsandhumoralfactorsofEXgroupcomparedwithcontrolgroupUrata,H.,et.al.Hypertension9:245-252,1987 Antihypertensive&VolumeDepletingEffectsofMildExerciseonEssentialHTN Antihypertensive&VolumeDepletingEffectsofMildExerciseonEssentialHTNWholebloodandplasmavolumeindicesweresignificantlyreduced(p<0.05)ChangeinserumNa+:serumK+positivelycorrelatedwithchangeinSBPPlasmaNEconcentrationsatrest&Workload@BLATduringGXT’swerereducedChangeinrestingNEcorrelatedwithchangeinmeanBPUrata,H.,et.al.Hypertension9:245-252,1987 ChangesinTaurine&otherAminoAcidsinResponsetoMildExerciseBloodpressuresweresignificantlydecreasedby14.8/6.6mmHgintheEXgroupbutnottheControlgroupSerumconcentrationincreasesoftaurine(26%),cystine(287%),asparagine(11%),histidine(6%)andlysine(7%)intheEXSerumtaurinewasnegativelycorrelatedwiththechangeinplasmaNETanabe,Y,et.al.,Clin&ExperHyper11:149-165,1989 ChangesinTaurine&otherAminoAcidsinResponsetoMildExercise ExercisePrescriptionsforPatientsWithBorderline-to-ModerateHypertensionPatientevaluationLookforlipiddisorders,DM,retinopathy,neuropathy,PVD,renalinsufficiency,LVdysfunction,silentMI/ischemiaosteoarthritis,osteoporosisExercisetestingGXTwithmodifiedNaughtonprotocol,R/OasymptomaticischemicCAD,radionuclideExercisetypeAerobic,low-impactactivities:walking,biking,swimming,taichi,stepper,treadmillwalking ModifiedNaughtonTreadmillProtocol ExercisePrescriptionsforPatientsWithBorderline-to-ModerateHypertensionFrequency5days/weekasaminimumIntensityStartat50-60%maximumHRR&slowlyincreaseto70%;within6weeksworkat85%HRRorfrom50-90%ofmaximalheartrateDurationStartwith20-30min/dayofcontinuousactivityforfirst3wk,then30-45min/dayfornext4-6wk,and60min/dayasmaintenance ExercisePrescriptionsforPatientsWithBorderline-to-ModerateHypertensionExcessiverisesinbloodpressureshouldbeavoidedduringexercise(SBP>230mmHg;DBP>110mmHg).Restrictionsonparticipationinvigorousexerciseshouldbeplacedonpatientswithleftventricularhypertrophy. WeightTrainingResistiveexerciseproducesthemoststrikingincreasesinBPResistiveexerciseresultsinlessofaHRincreasecomparedwithaerobicexerciseandasaresultthe“ratepressureproduct”maybelessthanaerobicexerciseAssessmentofBPresponsebyhandgripshouldbeconsideredinpatientsw/HTNGrowingevidencethatresistivetrainingmaybeofvalueforcontrollingBPKelemen,et.al.,JAMA263:2766-71,1990 DrugTherapyforActiveHypertensivePatientsHypertensiononlyThiazidediureticsincombinationwithapotassiumsupplementareeffectiveandinexpensiveDiureticslimitplasmavolumeexpansionanddecreaseperipheralresistanceOtherantihypertensivedrugscanbeusedasmonotherapyforthistypeofpatient DrugTherapyforActiveHypertensivePatientsHypertensionwithotherdiseasesCAD-calcium-channelblockerorabeta-blockerDiabetes-ACEinhibitorLVHbutcoughswithACEinhibitor-angiotensin-2-receptorblockerElderlymenwithprostatism-peripheralalpha-blocker(terazosin,doxazosin) DrugTherapyforActiveHypertensivePatientsBeta1-selectiveblockerssuchasatenololormetoprololarepreferabletonon-selectiveagentssuchaspropranolol,nadololorpindololforhypertensivepatientsengagedinregularexerciseKaplan,N.M.,AmJHypertens2:75-77,1989 Beta-blockertherapyandexerciseNon-selectiveBeta-blockersmayincreaseapatient’sdispositiontoexertionalhyperthermia.SopatientsshouldadherestrictlytoguidelinesforfluidreplacementPatientsshouldusefluidreplacementdrinkswithlowconcentrationsofK+toavoidtheriskofhypokalemiaGordon,N.F.,AmJCardiol55:74-78,1985 Beta-blockertherapyandexerciseExercisetherapyisdesirableduringBeta-blockertherapytooffsettheadversealterationsinlipoproteinmetabolismcontributedbysomeBeta-blockermedicationsGordon,N.F.,ComprTher14:52-57,1988 Beta-blockertherapyandexerciseExerciseintensityforpatientsonBeta-blockermedicationsshouldbeinaccordancewithtraditionalguidelinesbasedontheresultsofindividualizedexercisetestingperformedonthemedication.AmericanCollegeofSportsMedicineGuidelinesforExerciseTestingandPrescription,2000 Beta-blockertherapyandexerciseNon-selectiveBeta-blockersdramaticallyreducepeakaerobiccapacityandatthesametimeincreaseapatient’sratingofperceivedexertionforagivenamountofwork.Kaplan,N.M.,AmJHypertens2:75-77,1989 Beta-blockertherapyandexercisePatientstreatedwithBeta-blockersarecapableofderivingtheexpectedenhancementofcardiorespiratoryfitnessduringtraining,irrespectiveofthetypeofdrugusedBlood,S.M.,JCardiopulmonaryRehabil8:141-144,1988 SUMMARYPhysicalactivityhasatherapeuticroleinthetreatmentofhypertensionNoconsistentrelationshipbetweenreducedweightandlowerBPExerciseatlowerintensitiesiseffectiveintreatingmildtomoderatehypertensionExercisetestingmayhelpidentifyexaggeratedBPresponsestoexercise SUMMARYExerciseprescriptionforHTNshouldbebasedonmedicalhxandriskfactorstatusExerciseprescriptionshouldbeadaptedtoantihypertensivemedicationsthatmayaffectexerciseHR,BP&performanceIncorporatingresistivetrainingintotheexerciseprescriptionmaybeofvalueforcontrollingbloodpressure ReferencesChintanadilok,J.,ExerciseinTreatingHypertension,PhysSportsMed30:11-23,2002Urata,H.,AntihypertensiveandVolume-DepletingEffectsofMildExerciseonEssentialHypertension,Hypertension9:245-52,1987.Tanabe,Y.,ChangesinSerumConcentrationofTaurineandOtherAminoAcidsinClinicalAntihypertensiveExerciseTherapy,ClinandExperHyperA11:149-165,1989.AmericanCollegeofSportsMedicine,PhysicalActivity,PhysicalFitnessandHypertension,MedSciSportsExerc25:i-x,1993.ACSM’sResourceManualforGuidelinesforExerciseTestingandPrescription,Baltimore,Williams&Wilkins,p.275-280,1998.