【高血壓英文課件】心血管代謝風(fēng)險(xiǎn)

CardiometabolicRisk:

Evaluation&TreatmentinYourPatientPopulation

--InsertHere—SpeakerTitleandAffiliationWhyFocuson

CardiometabolicRisk?Acomprehensiveapproachtopatientcare;MultiplediseasepathwaysandriskfactorsareconsideredtofacilitateearlierinterventionEarlyassessmentandtargetedinterventionareneededtotreatandpreventallriskfactorsassociatedwithCVDanddiabetesCardiometabolicRiskGivesacomprehensivepictureofapatient’shealthandpotentialriskforfuturediseaseandcomplicationsIsinclusiveofallrisksrelatedtometabolicchangesassociatedwithCVDAccommodatesemergingriskfactorsasusefulpredictivetoolsFocusesclinicalattentiontothevalueofsystematicevaluation,education,diseasepreventionandtreatmentSupportsanintegratedapproachtocareKahn,etal.TheMetabolicSyndrome:TimeforaCriticalAppraisal:JointStatementFromtheAmericanDiabetesAssociationandtheEuropeanAssociationfortheStudyofDiabetesDiabetesCare.2005;28(9)2289-2304.AbnormalLipidMetabolismLDLApoBHDLTrigly.CardiometabolicRiskGlobalDiabetes/CVDRiskOverweight/ObesityInflammationHypercoagulationHypertensionSmokingPhysicalInactivityUnhealthyEatingAge,Race,Gender,FamilyHistoryGlucoseBPLipidsAgeGeneticsInsulinResistance?InsulinResistanceSyndromeCardiometabolicRisk-GraphicNon-modifiableAgeRace/ethnicityGenderFamilyhistoryOverweightAbnormallipidmetabolismInflammation,hypercoagulationHypertensionSmokingPhysicalinactivityUnhealthydietInsulinresistanceCardiometabolicRiskFactorsModifiableCase-Mr.Martin47-year-oldAfricanAmericanman,hasn’tseendoctorinyearsWorksasatruckdriver,eatsmostlyfastfoodSmokes1packperdayAthealthfairfoundtohaveBP=146/86,totalcholesterol=210Weight=230lbs;BMI=29kg/m2FamilyhistoryofHTNanddiabetesWhat’sMr.Martin’sCardiometabolicRisk?Age 47Race/ethnicity AfricanAmericanGender MaleFamilyhistory HTNanddiabetesOverweight/obesity BMI=29Abnormallipidmetab TC=210Hypertension BP=146/86Smoking 1packperdayPhysicalInactivity YesUnhealthydiet FastfooddietNon-Modifiable

RiskFactorsNumberEst.NewDiabetesDiagnosesbyAge,2005CentersforDiseaseControlandPrevention.Nationaldiabetesfactsheet:generalinformationandnationalestimatesondiabetesintheUnitedStates,2005.Atlanta,GA:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2005.800,000600,000400,000200,0000AgeGroup20-3940-5960+CardiovascularRiskFactorTrendsAmongU.S.AdultsAged20-74CentersforDiseaseControl&Prevention,DivisionforHeartDiseaseandStrokePrevention,"AddressingtheNation'sLeadingKillers:AtAGlance200733.628.227.219.017.030.833.126.314.939.236.029.326.41.83.53.44.65.014.8DiagnosedDiabetesSmokingHighBloodPressureHighTotalCholesterol1960-19621971-19751976-19801988-19941999-2000CentersforDiseaseControlandPrevention.Nationaldiabetesfactsheet:generalinformationandnationalestimatesondiabetesintheUnitedStates,2005.Atlanta,GA:U.S.DepartmentofHealthandHumanServices,CentersforDiseaseControlandPrevention,2005.Hispanic/LatinoAmericansNon-HispanicWhitesAmericanIndians/AlaskaNativesNon-HispanicBlacks06421281020141618InsulinResistanceFactorsaffecting

insulinresistance

Overweight/fatdistributionAgeGeneticpredispositionActivitylevelMedicationsPubertyPregnancyIFGandIGT

ImpairedFastingGlucose(IFG):aconditioninwhichthebloodglucoselevelisbetween100mg/dLto125mg/dLafteran8-to12-hourfast.ImpairedGlucoseTolerance(IGT):aconditioninwhichthebloodglucoselevelisbetween140and199mg/dLat2hoursduringanoralglucosetolerancetest(OGTT).InterpretingBlood

GlucoseLevels

HealthyBGFPG<100mg/dLPre-diabetesFPG100–125mg/dLDiabetesFPG≥126mg/dLCriteriafortestingfortype2diabetes

inasymptomaticchildren50

Overweight(BMI>85thpercentileforageandsex,weightforheight>85thpercentile,orweight>120percentofidealforheight)Plusanytwoofthefollowing:FamilyhistoryRace/ethnicitySignsofinsulinresistanceorconditionsassociatedwithinsulinresistanceMaternalhistoryofdiabetesorGDMCriteriafortestingfordiabetesinasymptomaticadultindividuals50

Testingshouldbeconsideredinalloverweightadults(BMI≥25kg/m2*)andhaveadditionalriskfactors:PhysicalinactivityFirst-degreerelativewithdiabetesMembersofahigh-riskethnicpopulationWomendeliveringbabyweighing>9lborwerediagnosedwithGDMHypertension(≥140/90mmHg)ContinuedCriteriafortestingfordiabetesinasymptomaticadultindividuals50

HDLcholesterollevel<35mg/dl(0.90mmol/l)and/oratriglyceridelevel>250mg/dl(2.82mmol/l)Womenwithpolycysticovariansyndrome(PCOS)IGTorIFGonprevioustestingOtherclinicalconditionsassociatedwithinsulinresistance(e.g.,severeobesityandacanthosisnigricans)HistoryofCVDCriteriafortestingfordiabetesinasymptomaticadultindividuals50

2.Intheabsenceoftheabovecriteria,testingforpre-diabetesanddiabetesshouldbeginatage45years3.Ifresultsarenormal,testingshouldberepeatedatleastat3-yearintervals,withconsiderationofmorefrequenttestingdependingoninitialresultsandriskstatus.*At-riskBMImaybelowerinsomeethnicgroups.0123CHDmortality,per1000FontbonneAM,etal.DiabetesCare.1991;14:461-469.Quintiles(pmol)offastingplasmainsulinP<.01InsulinResistanceandCHD

MortalityParisProspectiveStudyInsulinSensitive InsulinResistant(n=943)2930-5051-7273-114115Insulin

SensitivityInsulinSecretionAssociatedRiskFactors

Hypertension

DyslipidemiaAtherogenesisMicrovascularComplications

Type2DiabetesAge(years)Fasting

BloodGlucoseCardiometabolicRiskDiabetes

ImpairedFastingGlucoseEuglycemiaProposedMetabolicObservationsintheNaturalHistoryofType2DiabetesOverweight/ObesityUnderstandingCardiometabolicRisk:BroadeningRiskAssessmentandManagement

CardiometabolicRiskFactorsDesiredGoalsforHealthyPatientsOverweight/obesitySource:CDC,ADAPreventionofoverweight/obesityasmeasuredbyBMI(normal=18.5–24.9).Inthosewhoareoverweight/obese,thegoalistolose5–7%ofbodyweight.AbnormallipidmetabolismHighLDLcholesterolLowHDLcholesterolHightriglyceridesSource:NHLBI,ATPIIIGuidelines,ADADesirablelevelsarelessthan100mg/dL.Desirablelevelsaregreaterthan40mg/dLinmenandgreaterthan50mg/dLinwomen.Desirablelevelsarelessthan150mg/dLHypertensionSource:NHLBI,JNC7<140/90mm/Hgor130/80mm/Hgforpeoplewithdiabetes(Idealislessthan120/80mm/Hg)FastingbloodglucoseSource:ADABelow100mg/dLPhysicalinactivitySource:CDCAtleast30minutesofmoderateactivitymostdaysSmokingSource:ADAQuitorneverstartChildrenSource:ADAMaintainhealthyweightforage,sex,andheight.Screening:

OverweightMeasureBMIroutinelyateachregularcheck-up.Classifications:BMI18.5-24.9=normalBMI25-29.9=overweightBMI30-39.9=obesityBMI≥40=extremeobesityClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults:TheEvidenceReport.NIHPublication#98-4083,September1998,NationalInstitutesofHealth.MeasuringWaistCircumferenceLargewaistcircumference(WC)canidentifysomeatincreasedriskoverBMIaloneIfBMIandothercardiometabolicriskfactorsareassessed,currentlythereisinsufficientevidenceto:SubstituteWCforBMIMeasureWCinadditiontoBMIKlein,etal.WaistCircumferenceandCardiometabolicRisk.DiabetesCare.20070:dc07-9921v1-0.PrimaryMetabolicDisturbanceIntermediateVascularDiseaseRiskFactorIntravascularPathologyClinicalEventAtherosclerosisHypercoagulabilityCoronaryarteriesCarotidarteriesCerebralarteriesAortaPeripheralarteriesHypertensionDyslipidemiaHyperinsulinemiaHyperglycemiaInflammationImpairedFibrinolysisEndothelialDysfunctionInsulinResistance

CVDDespresJP,etal.Abdominalobesityandmetabolicsyndrome.

Nature.2006;444:881-887.MultipleFactorsAssociatedWithObesityGiveRisetoIncreasedRiskofCVDOvernutritionBodyWeightandCVD<100110-129130+<110110-129130+010015020025030050125200267105121128*MetropolitanRelativeWeightpercent

(percentageofdesirableweight)HubertHBetal.Circulation.1983;67:968-977MenWomenIncidenceofCVDper1,000n=56n=75n=30n=191n=199n=78RiskManagement

OverweightLifestylemodificationReducecaloricintakeby500-1000kcal/day(dependingonstartingweight)Target1-2pound/weekweightlossIncreasephysicalactivityHealthydietDiabetesPreventionProgramDASHdietClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults:TheEvidenceReport.NIHPublication#98-4083,September1998,NationalInstitutesofHealth.DiabetesPreventionProgram(DPP)DiabetesCare25:2165–2171,2002.TheSeventhReportoftheJointNationalCommitteeonPrevention,Detection,Evaluation,andTreatmentofHighBloodPressure,NIHPublicationNo.04-5230,August2004RiskManagement,cont.

OverweightConsiderpharmacologictreatmentBMI30withnorelatedriskfactorsordiseases,orBMI27withrelatedriskfactorsordiseasesAspartofacomprehensiveweightlossprogramincl.diet&physicalactivityConsidersurgeryBMI40orBMI35withcomorbidconditionsClinicalGuidelinesontheIdentification,Evaluation,andTreatmentofOverweightandObesityinAdults:TheEvidenceReport.NIHPublication#98-4083,September1998,NationalInstitutesofHealth.DiabetesPreventionProgram(DPP)DiabetesCare25:2165–2171,2002AbnormalLipidMetabolismTotalCholesterolGoals34Desirable—Lessthan200mg/dLBorderlinehighrisk—200–239mg/dLHighrisk—240mg/dLandoverAmericanDiabetesAssociation.UnderstandingCardiometabolicRisk:BroadeningRiskAssessmentandManagement,DyslipidemiaRichardMBergenstal,MDInternationalDiabetesCenterAbnormalLipidMetabolismIncreased:TriglyceridesVLDLLDLandsmalldenseLDLApoBDecreased:HDLApoA-IAmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.MajorRiskFactors

AffectingLipidGoals36

CigarettesmokingHypertension(≥140/90mmHgoronantihypertensivemedication)LowHDL-C(<40mg/dL)FamilyhistoryofearlyheartdiseaseAge(men≥45years;women≥55years)Statins(alsocalledHMG-CoAreductaseinhibitors)workbyincreasinghepaticLDL-Cremovalfromtheblood.Resins(alsocalledbileacidsequestrants)bindtobileacidsintheintestinesandpreventtheirreabsorption,leadingtoincreasedhepaticLDL-Cremovalfromtheblood.CholesterolabsorptioninhibitorshelplowerLDL-Cbyreducingtheamountofcholesterolabsorbedintheintestines;increasesLDLreceptoractivity.Fibrates(alsocalledfibricacidderivatives)activateanenzymethatspeedsthebreakdownoftriglyceriderichlipoproteinswhilealsoincreasingHDL-C.Niacin(alsocallednicotinicacid)reducestheliver’sabilitytoproduceVLDL.Whengivenathighdoses,itcanalsoincreaseHDL-C.AmericanDiabetesAssociation.UnderstandingCardiometabolicrisk:BroadeningriskAssessmentandManagement,DyslipidemiaRichardMBergenstal,MDInternationalDiabetesCenterCholesterolManagement

Forpatients>20yearsofage,cholesterolshouldbecheckedevery5yearsOrderingafastinglipidpanelispreferredtogaugethepatient’stotalcholesterol,LDL-C,HDL-CandtriglyceridesTreatmentprioritiesCholesterolManagement

CategoryofriskLDL-CGoal0-1riskfactor*<160mg/dLorlowerMultiple(2+)riskfactors*<130mg/dLorlowerPeoplewithcoronaryheartdiseaseorriskequivalent(e.g.,diabetes)<100mg/dLorlowerKnownCADandDM<70mg/dLorlowermaybeidealLDL-C-loweringCholesterolManagement

ImproveglucosecontrolifdiabetesispresentWeightlossifoverweightDailyexerciseSmokingcessationDietarymodificationsincludinglowsaturatedfat(fatintakelessthan30%oftotalcaloriesandsaturatedfatlessthan7%oftotalcalories),lowcholesterol(nomorethan200mgdaily)dietPharmacologictreatmentfrequentlynecessaryRiskfactorsincludehypertension;HDL<40;familyhistoryofMIbeforeage55;male>45yearsold;female>55yearsold;smoking.RiskofCHDbyTriglycerideLevel:

TheFraminghamHeartStudyMenWomenn=5,127TriglycerideLevel,mg/dL50100150200250300350400RelativeRisk00.511.522.53CastelliWP.Epidemiologyoftriglycerides:aviewfromFraminghamAmericanJournalofCardiology.1992;70:3H-9H.ReavenGM,etal.JClinInvest.1993;92:141-146.AssociationBetweenSmall,

DenseLDLandInsulinResistanceMeanSteadyStatePlasmaGlucose(mmol/L)atIdenticalPlasmaInsulinALargerLDLparticlepatternIntermediatepatternBSmallLDLparticlepattern026101284LDL-SizePhenotype(n=52)(n=19)(n=29)LowHDL-C:IndependentPredictorofCHDRisk,EvenWhenLDL-CisLowLDL-C(mg/dL)HDL-C(mg/dL)RiskofCHD.GordonT,CastelliWP,HjortlandMC,KannelWB,DawberTR.Highdensitylipoproteinasaprotectivefactoragainstcoronaryheartdisease.TheFraminghamStudy.AmericanJournalofMedicine.1977;62:707-14.ScreeningforDyslipidemiaPersonswithoutDiabetesTestatleastevery5years,startingatage20,includingadultswithlow-riskvaluesPersonswithDiabetesInadults,testatleastannuallyLipoproteins:measureatafterinitialbloodglucosecontrolisachievedashyperglycemiamayalterresultsPreventingCancer,CardiovascularDisease,andDiabetes:ACommonAgendaforTheAmericanCancerSociety,theAmericanDiabetesAssociation,andtheAmericanHeartAssociation.Circulation.2004;109:3244-3255.AmericanDiabetesAssociation.StandardsofMedicalCareinDiabetes2007.Availableat:/cgi/reprint/30/suppl_1/S4HealthyLipidGoals

TargetsforPatientsWithoutDMorCVD

ThirdReportoftheNationalCholesterolEducationProgram(NCEP)ExpertPanelonDetection,Evaluation,andTreatmentofHighBloodCholesterolinAdults(AdultTreatmentPanelIII);NationalCholesterolEducationProgram,NationalHeart,Lung,andBloodInstitute,NationalInstitutesofHealth.NIHPublicationNo.01-3670,May2001Total<200mg/dLLDL<70mg/dLHDL>40menmg/dL>50womenmg/dLTriglycerides<150mg/dLRiskManagement

AbnormalLipidsLifestylemodificationIncreasedphysicalactivityDiet:reducedsaturatedfat,transfat,andcholesterolWeightloss,ifindicatedAmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.Pharmacologictreatment:primarygoalisLDLloweringWithoutovertCVD:Ifover40,statintherapyrecommendedtoachieve30-40%LDLreductionWithovertCVD:Allpatientsshouldreceivestatintherapytoachieve30-40%LDLreductionLoweringtriglyceridesandraisingHDLwithafibrateisassociatedwithfewercardiovasculareventsinpatientswithclinicalCVD,lowHDL,andnear-normalLDLAmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.RiskManagement

AbnormalLipidsHypertensionHypertension:EvaluationandScreeningPersonswithoutDiabetesBPshouldbe

measuredateachregularvisitoratleastonceevery2yearsifBP<120/80mmHgBPmeasuredseatedafter5minrestinofficePersonswithDiabetesBPshouldbe

measuredateachregularvisitBPmeasuredseatedafter5minrestinofficePatientswith≥130or≥80mmHgshouldhaveBPconfirmedonaseparatedayPreventingCancer,CardiovascularDisease,andDiabetesACommonAgendafortheAmericanCancerSociety,theAmericanDiabetesAssociation,andtheAmericanHeartAssociation.Circulation.2004;109:3244-3255.AmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.ManagementofHypertension

Non-pharmacologicDASH

dietDietaryApproachestoStopHypertensionHighinwholegrains,fruits,vegetables,andlow-fatdairyLowinsaturatedandtransfat,cholesterolPhysicalActivityWeightloss,ifapplicableTheDashDiet..AmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.ManagementofHypertensionPharmacologicDrugtherapyindicatedifBP≥140/≥90mmHgCombinationtherapyoftennecessaryTreatmentshouldincludeACEorARBThiazidediureticmaybeaddedtoreachgoalsMonitorrenalfunctionandserumpotassiumTheDashDiet..AmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.ComplicationsofHypertension

inPatientswithDiabetesMicrovascularRenaldiseaseAutonomicneuropathyEyedisease(glaucoma,retinopathywithpotentialblindness) MacrovascularCardiacdiseaseCerebrovasculardiseaseReducedsurvivalandrecoveryratesfromstrokePeripheralvasculardiseaseAmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41..PhysicalInactivity35%ofcoronaryheartdiseasedeathsintheUScanbeattributedtoaninactivelifestyle*ConsistentexercisecanreduceCVDrisk*Exercise,combinedwithhealthydietandweightloss,isproventoprevent/delayonsetoftype2diabetes*AmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.

DiabetesPreventionProgramDiabetesCare25:2165–2171,2002.PhysicalActivityGuidelinesFitintodailyroutineAimforatleast150minutes/weekofmoderateaerobicexerciseStartslowlyandgraduallybuildintensityWearapedometer(10,000steps)Encouragepatientstotakestairs,parkfurtherawayorwalktoanotherbusstop,etc.AmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.PhysicalActivityBenefitsofExerciseIncreasedinsulinsensitivityImprovedlipidlevelsLowerbloodpressureWeightcontrolImprovedbloodglucosecontrolReducedriskofCVDPrevent/delayonsetoftype2diabetesAmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.PhysicalActivityExercisePrecautionsRelatedtoComplicationsofDiabetesPeripheralneuropathycancauselossofsensationinfeet;educateaboutpreventivecaremeasuresforfootprotectionPre-existingCVDcancausearrhythmias,myocardialischemia,orinfarctionduringexerciseInpresenceofPDRorsevereNPDR,vigorousexerciseorresistancetrainingmaybecontraindicatedbecauseofriskofvitreoushemorrhageorretinaldetachment

AmericanDiabetesAssociation.DiabetesCare.2007;30:S4-41.SmokingImpactofBaselineSmokingon

MIinType2Diabetes:UKPDSRCTurner,HMillns,HAWNeil,IMStratton,SEManley,DRMatthews,andRRHolman.Riskfactorsforcoronaryarterydiseaseinnon-insulindependentdiabetesmellitus:UnitedKingdomprospectivediabetesstudy(UKPDS:23)BMJ.1998;316:823-828.HazardsRatio(95%CI)NeverSmoked 1Ex-Smoker 1.08(0.75-1.54)CurrentSmoker 1.58(1.11-2.25)Smoking–ScreeningandInterventionObtaindocumentationofhistoryoftobaccouseAskwhethersmokeriswillingtoquitIfno,initiatebrief,motivationaldiscussionregarding:theneedtostopusingtobaccorisksofcontinueduseencouragementtoquit,aswellassupportwhenreadyIfyes,assesspreferenceforandinitiateeitherminimal,brief,orintensivecessationcounseling.AmericanDiabetesAssociation.DiabetesCare.2004;27:S27:S74-S75.ProvideSmoking

CessationResourcesSetaPlanOffercounselingandreferralsOffermedicationassistanceOffercombinedpharmacologicandbehavioralinterventionOnlineguidetoquitting:SmokeFAmericanDiabetesAssociation.DiabetesCare.2004;27:S27:S74-S75.InflammationInflammation/HypercoagulationProinflammatory/prothromboticfactorsunderliecardiometabolicriskInflammationisamajorcomponentofatherogenesisandothercardiometabolicproblemsObesityisassociatedwithinflammationRossR.Atherosclerosis:aninflammatorydisease.NEnglJMed.1999;340:115-126.BallantyneCH,NambiV.Markersofinflammationandtheirclinicalsignificance.Atherosclerosissuppl2005;6:21-9.McLaughlinTetal.DifferentiationbetweenobesityandinsulinresistanceintheassociationwithC-reactiveprotein.Circulation.2002;106:2908-2912.RiskManagement:InflammationHigh-sensitivityCRPtestsmaybeusedtofurtherevaluateunderlyingrisk

RelativeriskcategoriesLowrisk <1mg/LAveragerisk 1-3mg/LHighrisk >3mg/LAspirinandstatinsreduceCRPlevelsUnclearwhetherCRPshouldbeatreatmenttargetReduceweightRossR.Atherosclerosis:aninflammatorydisease.NEnglJMed.1999;340:115-126.BallantyneCH.Pre-Diabetesand

DiabetesPreventionPre-Diabetes

Pre-diabetesisanimportantriskfactorforfuturediabetesandcardiovasculardiseaseRecentstudieshaveshownthatlifestylemodificationcanreducetherateofprogressionfrompre-diabetestodiabetesAmericanDiabetesAssociation,DiabetesCare.2007:30:S4-41..GlucoseToleranceCategoriesAdaptedfromTheExpertCommitteeontheDiagnosisandClassificationofDiabetesMellitus.DiabetesCare2004;Supplement1FastingPlasmaGlucose126mg/dLNormal2-hourPlasmaGlucoseOnOGTT200mg/dL140mg/dLDiabetesMellitusImpairedGlucoseToleranceNormalDiabetesMellitusAnyabnormalitymustberepeatedandconfirmedonaseparateday**Onecanalsomakethediagnosisofdiabetesbasedonunequivocalsymptomsandarandomglucose>200mg/dL“Pre-Diabetes”100mg/dLImpairedFastingGlucoseADAConsensusConference

onIFGandIGT:

ImplicationsforDiabetesCare

October16-18,2006Results:TreatIFGandIGTwithaggressivelifestylemodificationForcertainpatientswithbothIFGandIGTconsidermetforminNathanD,etal.ImpairedFastingGlucoseandImpairedGlucoseTolerance:ImplicationsforCare.DiabetesCare.200730:753-7