高血压英文PPT精品课件ThePharmacistsRoleinTreating 49页

ThePharmacists’RoleinTreatingHypertensionThomasOwens,MDSaintFrancisUniversityCERMUSA ObjectivesEnhanceyourunderstandingofhypertensiontoincludecardiovascularrisks,management,andgoalsforindividualpatientsReviewanddiscussthecurrentpharmacotherapystandardsofcareforhypertensionDescribethepharmacist’sroleincounselingpatientsonhypertensivemedications Hypertension>140/90mmHgUnitedStates:65millionadultsRiskfactorsinclude:Stroke,myocardialinfarction,heartfailure,peripheralvasculardisease,aorticdissection,chronicrenalfailureHypertensionpricetag:$59.7billionWexler&Feldman,2005 HypertensionTypicalonsetseconddecadeoflifePrimaryHypertensionidentifiablebehaviorsSecondaryHypertensionmorediscreteCecil,2004 EthnicGroupsAfricanAmericans43%female&39%maleRatio1:3Increaseinsodiumsensitivity?Caucasians28%female29%maleMexicanAmericansRatio1:4or1:5DASHDietCecil,2004 DietarySodiumIntakeSaltHypothesis?StronggeneticunderpinningADA,2005 MetabolicSyndromeRiskofHypertensionincreaseswithBMIObesityaccountsfor50%to60%ofnewcasesofhypertensionCecil,2004 PotentialCausesofHypertensionExpandedplasmavolumeplussympatheticoveractivityPeripheralvasoconstrictionRenalsaltretentionRenalwaterretentionSleepApneawww.sleepconsultants.com,2007Cecil,2004 BloodPressureEquationBloodPressure=CardiacOutputxPeripheralVascularResistanceMostpharmacologicagentslowerSomepharmacologicagentslowerSomepharmacologicagentslowerbothCecil,2004 GeneticsofHighBPSympatheticup-regulationleadstoacascadeofeventsPeripheralvascularresistanceGeneticfactors30%ofcases2xaslikelyifparentshavehypertensionDiscoveryedge.mayo.com,2007;ADA,2003 Systolic&Diastolic??Whatismoreimportant?DependsonageLivelongenoughalmostalldevelopsystolichypertension12080systolicdiastolicCecil,2004 AgeDependantRiseinBP(Whelton&Rocella,1995) FraminghamStudy(age:50-79)(Khan,Wong,Larson,&Levy,1999) SystolicHypertensionDecreaseddistensibilityoflargearteriesMajorityofuncontrolledhypertensionDuetofocusondiastolicBPCecil,2004 RiskofcardiovascularmortalitybysystolicBP(NationalHighBloodPressureEducationProgramWorkingGroup,1993) HypertensionStudyResultsHypertensionisexcessof140/90mmHgStudiesfoundIncreaseriskwhenabove115mmHgsystolicor75mmHgdiastolicHighnormalBPhadtwiceincreasedriskforcardiodiseaseMorestudiesareneededtofullyunderstandCecil,2004 TheSilentKiller1/3ofadultsdonotknowtheyhavehypertensionHypertension:60%aretreated45%oftreatedremainuncontrolledDespiteover75differentantihypertensiveagentsin9differentclasses!Cecil,2004 ReclassificationofBPStagesBloodPressure(mmHg)Classification<120/80Normal120-139/80-89Pre-hypertension≥140/90Hypertension140-159/90-99Stage1160-179/100-109Stage2JointNationalCommitteeonPrevention,Detection,Evaluation,andTreatmentofHighBloodPressure(JNC)Newcategory“pre-hypertension”PharmacotherapynotrecommendedLifestylemodificationrecommended!Cecil,2004;JNC,2007 JNCDrugTherapyRecommendationsBloodPressure(mmHg)Classification<120/80Normal120-139/80-89Pre-hypertension≥140/90Hypertension140-159/90-99Stage1160-179/100-109Stage2recommendation(healthy)≥130/80(w/heartandkidneydiseaseordiabetesmellitus)JNC,2007 ModestreductioninBP=bigbenefits!!Decrease5mmHgdecreasesrisksSmallchangescanhaveabigdifferenceResultsofstudiesSystolicsurge34mmHg=3xincreaseofstrokeSystolic≥135mmHg=74%increaseofcardioeventBloodPressure(mmHg)CardiovascularRiskExceeds115/75IncreasesEachincreaseof20/10mmHgDoublesCecil,2004;JNC,2007 ClinicalPresentationNospecificsignsorsymptomsPossiblesymptomsOccipitalheadache,dizziness,tinnitus,dimmedvision,palpitations,fatiguePhysicalExamMayrevealevidenceCecil,2004 HypertensiveRetinopathyGradesofhypertensiveretinopathyshown(Forbes,Jackson,2003) Electrocardiogram(ECGorEKG)GOOD(Normal)BAD(Antero-SeptalMI)physiol.umin.jp/cardiovasc,2007 CounselingPatients:ProperBPReadingsAtleast30minutesbeforeNOCaffeine,decongestants,oralcontraceptives,alcohol,tobaccoSitdownforatleast5minutesArmaboveheartlevel=FalselylowbloodpressurereadingArmbelowheartlevelFalselyelevatedbloodpressurereadingLoosecufforbladderFalselyelevatedbloodpressurereadingCecil,2004;ADA,2005 CounselingPatients:ProperFitofBPCuffLengthofbladderofthecuffatleast80%circumferenceofarmBladderofcuffatleast40%circumferenceofarmPlacethecenterofthebladderoverthebrachialarteryPumpuntilradialpulsedisappears,thencontinueforadditional30mmHg HelpPatientsUnderstand:WhiteCoatHypertensionAnxietyofgoingtodoctorofficeraisesBPRecommendself-monitoringDaytime:>135/85mmHgNighttime:>120/70mmHg24hr:>130/80mmHgFollowpatientsevery6monthsforpossibleprogressiontopersistenthypertensionCecil,2004 CloselyMonitorMedicationswithHigh-RiskPatientsCecil,2004 CounselingPatients:CausesofOrganDamageMajorRiskFactorsTargetOrganDamageCigarettesmokingHeartObesity(BMI>30kg/m2)*LeftventricularhypertrophyPhysicalinactivityAnginapectorisDyslipidemia*MyocardialinfarctionDiabetesmellitus*CoronaryrevascularizationAgeMen:Olderthan55Women:Olderthan65HeartFailureBrainStrokeFamilyHistoryofpre-matureCVDMen:Olderthan55Women:Olderthan65TransientischemicattackHypertensivenephrosclerosisGFR<60mL/minAnychronicdiseaseGFR<60mL/minUrineprotein>150mg/24hrUrineprotein>150mg/24hrRetinopathyPeripheralatherosclerosisComponentsofmetabolicsyndrome(TheJNC7Report.JAMA2003) CounselingPatients:TreatmentRiskGroupTreatmentMildRiskFreeofCVDLifestylemodificationLowRiskPre-hypertensionorStage1or2Pre&Stage1:LifestylemodificationStage2:LifestylemodificationandmedicationsModerateRisk1ormorecardioriskfactorsLifestylemodificationandmedicationsHighRiskEvidentorgandamage,diabetes,renalinsufficiencyLifestylemodificationandmedicationsJNC,2005 SUSPECTEDDIAGNOSISCLINICALFEATURESDIAGNOSTICTESTINGRenalparenchymalhypertensionElevatedserumcreatinineorabnormalurinalysis24-Hoururinecreatinineandprotein,renalultrasoundRenovasculardiseaseNewelevationinserumcreatinine,markedelevationinserumcreatininewithinitiationofACEIorARB,refractoryhypertension,flashpulmonaryedema,abdominalbruitCaptoprilrenogram,duplexDopplersonography,magneticresonanceorCTangiogram,invasiveangiogramCoarctationoftheaortaArmpulses>legpulses,armBP>legBP,chestbruits,ribnotchingonchestradiographMRI,aortogramPrimaryaldosteronismHypokalemia,refractoryhypertensionPlasmareninandaldosterone,24-hoururinepotassium,24-hoururinealdosteroneandpotassiumaftersaltloading,adrenalCTscanCushing"ssyndromeTruncalobesity,purplestriae,muscleweaknessPlasmacortisol,urinecortisolafterdexamethasone,adrenalCTscanPheochromocytomaSpellsoftachycardia,headache,diaphoresis,pallor,andanxietyPlasmametanephrineandnormetanephrine,24-hoururinecatechols,adrenalCTscanObstructivesleepapneaLoudsnoring,daytimesomnolence,obesitySleepstudyACEI=angiotensin-convertingenzymeinhibitor;ARB=angiotensinreceptorblocker;BP=bloodpressure;CT=computedtomography.(Williams&Wilkins,2002) CounselingPatients:LifelongTreatmentObjective:reduceBPandmetabolicabnormalitiesPharmacotherapy&lifestylemodificationReducesodiumintakeWeightlossExerciseModeratingalcoholReducesystolicBPby21to55mmHgCecil,2004 CounselingPatients:DietaryChangesLosingonly10to12lbslowersBPby10/5mmHgReducedailysalt10to6gramsTeachpatientstoreadfoodlabelsDASHDietwww.nhlbi.nih.gov/health/public/heart/dashCecil,2004 CounselingPatients:HealthBehaviorsLifestylemodificationRecommendationRangeofsystolicbloodpressurereduction(mmHg)WeightlossMaintainanormalbodyweightbasedonBMI5–20DietaryApproachesDiethighinfruitsandvegetables,andreducedfat8–14LowsodiumdietLessthan6grams2–8Exercise30minofaerobicactivityatleast4d/wk4–9ModerateAlcoholconsumption2drinksorlessperdayformen,and1drinkorlessperdayforwomen2–4JNC,2005 CounselingPatients:HelpfulResourceswww.lotrel.com BarrierstoSuccessfulHealthBehaviorModificationsLackofeducationLackofaccesstosafeplacestoexerciseAddedsaltinpreparedfoodsandrestaurantmealsHighercostoffoodslowinsaltPatientself-managementisrealisticandfeasible!Cecil,2004 PharmacologicTherapyScientificproofloweringBPreducesorgandamageCertainclassesofantihypertensiveagentsexertorganoprotectiveeffectsNotallmedicationsequalCecil,2004;JNC,2005 MajorChallengesforScienceIdentifythekeygene-environmentinteractionsEliminatethepatientandmedicalproviderbarriersADA,2003 CounselingPatients:TargetBloodPressureMostpatientsbelow140/90mmHgPatientsw/diabetesorchronicdisease130/80mmHgHelppatientsself-monitorBP1/3donotknowtheyarehypertensiveResearchstudiesontargetingBPCecil,2004 ImproveHypertensionControlRatesTitratingbloodpressuremedicationstoachievetargetgoalsMostpatientsrequire2or3antihypertensivemedicationsPatientcompliancewithmulti-drugregimensADA,2005 PatientComplianceandQualityofLifeHypertensionrequireslifelongtreatmentMedicationscanproducesideeffectsMenoftenconcernedwithsexualdysfunctionPatientswithcontrolledBP,rateasignificantlyhigherqualityoflifeCecil,2004 PatientCompliancePrinciplesTitratingmedicaltherapybasedonhomereadingsLong-actingpreparationsw/oncedailydosingLowdosecombinationsofmedicationsfromdifferentdrugclassesFixed-dosecombinationstoreduceoverallnumberofpillsJNC,2005 DrugTherapyOldmethod:high-dosemonotherapyRecentstudies(ex.ALLHAT)Atleast2medicationsofdifferentclassestotreatmildhypertension3or4differentmedicationstotreatmoredifficultcasesThiazide-typeantihypertensivemedicationscost-effectiveInitialtreatment:Betablockers,Angiotensin-convertingenzyme(ACE)inhibitors,Angiotensinreceptorblockers,CalciumantagonistsCecil,2004 Stage2DrugTherapyJNCrecommends:2drugcombinationAdditionalmedicationsneededforeach10mmHgofsystolicBPabovegoalGreatmajorityshouldincludelow-dosediureticHigh-riskconditions(heartfailure/diabetes)Angiotensin-convertingenzymeinhibitors(ACE-Is)Angiotensinreceptorblockers(ARBs)Cecil,2004 CardioEventsinHypertensivePatientsVerdecchia,Carin,Circo,2001 LeftVentricularHypertrophywww.medem.com,2007 CounselingPatients:Contradictions&SideEffectsConsiderationsForIndividualizingAntihypertensiveDrugTherapy HypertensiveSub-PopulationsHypertensivepatientswithnephrosclerosisDiabetichypertensivepatientsHypertensivepatientswithcoronaryarterydiseaseIsolatedsystolichypertensioninolderpersonsHypertensivedisordersofwomenOralcontraceptivesPregnancyCecil,2004 HypertensionCaseStudyHowwouldwemodifyhistreatmentsincehedidnotchangehishealthbehaviors(andheisdiabetic)? 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