【高血壓英文課件】Hypertension-in-CKD整理

HypertensioninCKDMichaelJCasey,MDWakeNephrologyAssociatesHypertensionStatsHTNaffectsapproximately1billionworldwide$500billionindirectcostsContinuous,consistentandindependentrelationshipbetweenBPandCadsForthoseage40-70,eachincreasedincrementof20/10mmHginBPdoublestheriskofCVDacrosstheentireBPrangeof115/75to185/115.Only35%ofhypertensivepatientsontreatmentareundercontrol.HypertensionasDefinedbyJNCVII120/80-normal;“optimal”121-139/80-89-“pre-hypertension”ControversialMoreahealthpolicystatement140-160/90-100-Stage1Hypertension>160/100-Stage2HypertensionMeasurementofBloodPressureSeatedpositionwitharmsupportedidealAllowpatienttosettleforseveralminutesPropersizedcuffBladdertoencircle80–100%armBladderwidth40-50%ofarmConfirm2readings5minutesapartinbotharmsforinitialdiagnosisIftakeninwristorlegs,thecuffmustbeattheleveloftheheartBPMeasurementHomeBPMonitoringSelfreadingsorcontinuousambulatorymonitoringHelpfuladjuncttoofficereadingsMorereadingsinpatientsusualenvironmentBettercorrelatedwithcardiovascularoutcomesImprovespatientcomplianceHelpsclarifysymptomsDefinesmaskedandwhitecoathypertensionHomeBPMonitoringPatientsneedtobetaughtpropermethodsNowristcuffsSemi-automatedelectroniccuffsCuffneedstobecheckedagainstofficereadingsFrequencyofmonitoringcanvaryAllcurrentoutcomedata/guidelines/trailsarefromofficereadingsAmbulatoryBPMonitoringAmbulatoryBPMonitoringAmbulatoryBPMonitoringMorereproduciblethanofficemeasurementsHelpfulinearlydiagnosisUnexplainedmicroalbuminuriaorLVHWhiteCoatHypertensionResistantHypertensionNolongtermstudiesyetPrevalenceofHTNinCKDHypertensioninCKD80%ofpatientswithCKDhaveHBPMoststartwithessentialhypertensionAsGFRdecreasesitismoredependentonsalt/waterretentionfromdecreasedGFRCKDpatientsalsohavederangementsintheRenin/Angiotensin/AldosteronesystemTreatmentofHypertensionGoaldependsondiseasestate<130/80ifDM,CKD,CVDz<125/75ifCKDwithproteinuriaSBPistheissueintheoldDiastolicHBPisaproblemoftheyoungReachingthetargetismoreimportantthanhowyougetthereMultipleinterventionsarenecessaryinmostHypertensiveEmergenciesHypertensionisachronicoutpatientdiseasewithrareacutesideeffectsHeadache,MSchanges,ICH,Papilledema,CHF,Angina,Renalfailurewithhematuria,HemorrhageareemergenciesrequirehospitalizationOtherwisetreatasymptomaticsevereHBPoverdays/weeksClonidineeffectiveforoutpatientacuteBPloweringHoldESAProgressionofCKDandBPBP=COXSVRBP=HRXStrokeVolumeXSVRCO=cardiacoutputSVR=systemicvascularresistanceBPFormulaLifestyleModificationFirst(Always)LowSalt(3gm/day)DASHdietExerciseTobaccoAlcoholSleepApneaNSAIDSDecongestantsDietPillsRenininhibitorsRAASAgentsACEInhibitorscaptopril,enalapril,lisinopril,ramipril…AngiotensinReceptorBlockerslosartan,irbesartan,valsartan,telmisartan…DirectReninInhibitors-aliskirenAldosteroneReceptorBlockersspironolactone,eplerenoneDrugsofChoiceinCKDNotinpregnancyACEI/ARBinCKDTrialPOPULATIONDRUGViberti;JAMA94Type1DMCaptoprilREIN,KI98NephroticRamiprilAASK;JAMA02AAptswCKDRamiprilIRMA2;NEJM01Type2DMValsartanIDNT;NEJM01Type2DMIrbesartanRENAAL;NEJM01Type2DMLosartanMicro-HopeHighriskCVDzRamiprilGlomerularPerfusionACEInhibitorsFirstclassdrugforallCKDpatientsShouldbeconsideredinallstagesIftoleratedthenreduceddevelopmentofESRD,CKDprogressionBestoutcomedatainproteinuricCKDAngioedemaandcoughHyperkalemiaandworseningrenalfunctionAngiotensinReceptorBlockersNextchoiceafterACEIbecauseofcostEqualoutcomedataatthispointNoCoughSameissueswithhyperkalemiaandARFCombowithACEIcomingunderfireDirectReninInhibitorsAliskiren(Tekturna)isonlydrugFirstnewantihypertensiveclassin15yearsPromisingrenal/CHFdatabutnohardoutcomesMaybeusefulforproteinuriareductionincombowithARBGIupsetSameissueofhyperkalemiaandARFaswithallRAASagentsAldosteroneBlockersPotassiumsparingdiureticsCanboostefficacyofloopdiureticsImprovessurvivalinCHFpatientsReductioninproteinuria+/-otherRAASagentsGynecomastiawithspironolactoneSameissueofhyperkalemiaandARFDiureticsKeytoHBPmanagementinnon-ESRDCKDRAASagentsynergyThiazides:hydrochlorothiazide;chlorthalidone,metolazoneK-Sparing:amiloride,triamterene,spironolactone,eplerenoneLoops:furosemide,bumetanide,torsemideThiazideDiureticsJNCfirstchoiceBPmedVeryeffectiveinmultipletrialsOftenavailableincombowithRAASagentLowK,increaseBG,lipidsatdose>25mgIneffectiveatGFR<50CanboostefficacyofloopdiureticsLoopDiureticsNecessarytomaintainvolumestatusinGFR<50FurosemideisclassicbutshorthalflifesopoorforHBPBumetanideissamebutbetterabsorbedTorsemidehasmuchlongerhalf-lifeandismychoicenowthatitisgenericTitratetoincreaseUOPthenincreasefrequencyLowpotassiumismainissue,especiallywiththiazides(metolazone)BetaBlockersSelectiveBetaBlockersAtenolol,metoprolol,bisoprolol,nebivololNon–selectiveBetaBlockersPropranololAlpha–BetaBlockersLabetolol,carvedololBetaBlockersNextclassinCKDpatientsReducesHR,SVandalsoreninReducesincidenceofsuddencardiacdeathandarrhythmiasReducesCVeventsinCHF,post-MICounter-actsreflexincreaseinHR/COinducedbyvasodilatorsanddiureticsBetaBlockersCarvedolol,labetololarebetterforHBPAtenolol,metoprololbetterforCHF,HRreductionandarrhythmiaPropranololforascites/cirrhosis,anxietyBradycardiaandfatiguearemainsideeffectsCentralAdrenergicAgentsClonidineispredominantdrugProbablysamebenefitsasbblockersNostudiesandneverwillbeSynergywithbblockersdebatableDrymouth,fatigue,t.i.d.,bradycardiaGoodforacuteHBP/prnusePatchavailableMethyldopaforHBPinpregnancyDihydropyridineCalciumChannelBlockersNifedipine,amlodipine,felodipineDirectvasodilatorsVeryeffective–prob4thdrugofchoiceCancauseperipheraledemaespeciallyinfemalesNoeffectonHR,CHFIncreaseGFR,proteinuriaGlomerularPerfusionNon-DihydropyridineCCB’sDiltiazemandVerapamilReduceHRandLowerBPArrhythmiacontrolReductioninproteinuriabutnorenaloutcomesEdema,bradycardia,gingivalhyperplasia,CyP450interactionsOtherVasodilatorsAlphablockers–doxazosin,terazosin,prazosinHelpwithBHPOncedailyOrthostatichypertension,tachycardia,CHFHydralazineImprovedoutcomesinAAwithCHFBIDorTIDLupussyndromeModeratelyeffectiveMinoxidilMostpotentantihypertensiveagentSeverereboundtachycardiaandedemaNeedbetablockerandloopdiureticHairgrowthPericarditisInexpensiveHypertensioninESRDGreatareaofdebateRAASAgentsandBetablockersmayimproveoutcomesinnon-RCTsWhatiscorrectmeasurement?Pre-HDBPPost-HDBPHomeBPWhentotake/holdBPMedsHypertensioninESRDHypertensioninESRDHypertensioninESRDHypertensioninESRDJ-shapedcurveofsurvivalvsBPinESRDBettersurvivalwithmoderateHBPOnlycomparedtootherESRD?Skewedbyyoungpatients?SkewedbycardiomyopathyMostHBPisduetoinadequatevolumecontrolDecreaseinterdialyticweightgainChallengeweightLongerHDtimes(daily,nocturnal,PD)TreatmentofHBPinESRDGraduallychallengeweighteachHDNoedemaCrampingLowBPManagementofintradialyticHBPUFprofilingNa+modelingLowerdialysatetemperatureCarnitenelevelsTreatmentofHBPinESRDDonotholdBetablockers/Clo