1、老年高血壓患者的治療ACC in ChinaHypertension, Prevention and Lipids (HPL) Jiguang WANG, MD, PhDShanghai Institute of Hypertension, Ruijin Hospital, Shanghai, China老年高血壓患者的治療Management of hypertension in the elderly Jiguang WANG, MD, PhDShanghai Institute of Hypertension, Ruijin Hospital, Shanghai, China老年高血壓患

2、者的治療nSize of the problem: hypertensionnCareful selection of antihypertensive drugs to potentiate the huge benefit and to avoid the potential harmnRoadmap to control blood pressure in resistant hypertensive patients老年高血壓患者的治療Awareness, treatment and control rates of hypertension in ChinaPrevalenceNum

3、ber of patientsAwareness TreatedControlled 1991 (15 y)11.394 million26.645.5% (12.1)23.1% (2.8)2002 (18 y）18.8160 million30.281.8% (24.7)25.0% (6.1)2002 (60 y）49.170 million37.696.3% (36.2)24.1% (7.6)Chin J Hypertens 1995;3(suppl):14 -18; Li Liming, et al. ChinJ E pidemiol 2005;26:,478-484.老年高血壓患者的治

4、療nSize of the problem: hypertensionnCareful selection of antihypertensive drugs to potentiate the huge benefit and to avoid the potential harmnRoadmap to control blood pressure in resistant hypertensive patients老年高血壓患者的治療Relative risk reductions by antihypertensive treatment in early trialsProgressi

5、on to severe HTCHFStrokeCHDTotal mortalityCV mortality-94*-53%*-40%*-16%*-13%-21%*P0.05Collins R et al. Br Med Bull 1994;50:272-298.老年高血壓患者的治療BPLTTC. Lancet 2003;362:1527-45.0-5-10-15-20-25-30StrokeCHDCHFTotal mortality -23%-15%-16%-14%4/3 mmHgN20 888Major CV events -15%Relative risk reductions by a

6、ntihypertensive treatment in recent trials老年高血壓患者的治療指南推薦指南推薦o利尿劑利尿劑o 阻滯劑阻滯劑o鈣離子拮抗劑鈣離子拮抗劑o轉換酶抑制劑轉換酶抑制劑o血管緊張素受體拮抗劑血管緊張素受體拮抗劑J Hypertens 2007;25:1105-87.老年高血壓患者的治療INTERMAP: Urinary electrolytes in menZhou BF et al. J Hum Hypertens 2003;17:623630. JapanChinaUKUSAUrinary Na(mg/day)4843563337024202Urinary

7、 Na(mmol/day)211245161183Urinary K(mg/day)1920150629122512Urinary K(mmol/day)49.238.674.764.4Urinary Na/K(mmol/mmol)4.56.82.33.1老年高血壓患者的治療INTERMAP: Urinary electrolytes in womenZhou BF et al. J Hum Hypertens 2003;17:623630.JapanChinaUKUSAUrinary Na(mg/day)4278483929293272Urinary Na(mmol/day)18621012

8、7142Urinary K(mg/day)1891147523781982Urinary K(mmol/day)48.537.961.050.8Urinary Na/K(mmol/mmol)4.16.02.23.1老年高血壓患者的治療HYVET: Serum concentrations of cholesterol, sodium and potassiumLiu LS et al. Chin Med J 2008; 121:1509-1512.MenWomen Characteristic (mmol/L)China Other countriesChina Other countries

9、 Total cholesterol4.691.05.451.15.021.15.601.1HDL cholesterol 1.370.36 1.290.391.430.361.330.43Sodium 1404.1 1424.11404.1 1424.3Potassium 4.250.47 4.420.404.260.494.380.40老年高血壓患者的治療SHEP: New-onset diabetes mellitusShafi T et al. Hypertension 2008;52:1022-9.45% per 0.5 mmol/L in K+老年高血壓患者的治療nSize of

10、the problem: hypertensionnCareful selection of antihypertensive drugs to potentiate the huge benefit and to avoid the potential harmnRoadmap to control blood pressure in resistant hypertensive patients老年高血壓患者的治療Hypertension 2008老年高血壓患者的治療Pharmacologic recommendations for the treatment of resistant h

11、ypertension (1) Use of a long-acting thiazide diuretic, preferably chlorthalidone Combine agents with different mechanisms of action Recommended triple regimen of - ACE inhibitor or ARB - Calcium channel blocker- Thiazide diuretic老年高血壓患者的治療oConsider addition of mineralocorticoid receptor antagonist.

12、 oUse of loop diuretic may be necessary in patients with CKD (creatinine clearance 30 mL/min). Pharmacologic recommendations for the treatment of resistant hypertension (2)老年高血壓患者的治療Number No. drugs 2 drugsALLHAT42,4241.840%ANBP26083 2.050%ASCOT19,2572.378%CONVINCE16,6021.840%INVEST22,5763.085%LIFE9

13、1932.046%VALUE15,2452.054%Number of drugs in recent large HT trialsAchieved 135/76147/82136/77136/79131/76144/81138/78老年高血壓患者的治療Catheter-Based Renal Sympathetic Denervationfor the Management of Resistant HypertensionHenry Krum MBBS PhD FRACPCentre of Cardiovascular Research & Education in Therapeuti

14、cs, Monash University/Alfred Hospital;Alfred Heart Centre, The Alfred Hospital, Melbourne, Australia老年高血壓患者的治療Treatments 老年高血壓患者的治療Catheter-Based Renal Sympathetic Denervationfor the Management of Resistant HypertensionHenry Krum MBBS PhD FRACPCentre of Cardiovascular Research & Education in Therape

15、utics, Monash University/Alfred Hospital;Alfred Heart Centre, The Alfred Hospital, Melbourne, Australia老年高血壓患者的治療Results: Blood Pressure Reduction 87% had a reductionin SBP 10 mmHgP0.001 except for DBP at 12 months (P=0.02)老年高血壓患者的治療Conclusions Therapeutic renal sympathetic denervation produced pred

16、ictable, significant, and sustained reductions in BP in patients with resistant hypertension. The brief and simple procedure was performed without significant complications to either the renal artery or the kidney. Results appear both to confirm the important role of renal sympathetic nerves in resi

17、stant hypertension and to suggest that renal sympathetic denervation could be of therapeutic benefit in this patient population. Prospective randomized clinical trials examining the treatment of hypertension are beginning in 2009, and trials in heart failure and chronic kidney disease are anticipate

18、d. 老年高血壓患者的治療n因為知曉率低、用藥后血壓控制率低，我國因為知曉率低、用藥后血壓控制率低，我國90%以上的高血壓患以上的高血壓患者的血壓未得到有效控制者的血壓未得到有效控制(140/90 mm Hg)，在廣大農村該比例，在廣大農村該比例甚至高達甚至高達96.5%。因此，必需大幅度提高高血壓檢出率與治療控。因此，必需大幅度提高高血壓檢出率與治療控制率。制率。n指南推薦使用的指南推薦使用的5大類降壓藥物均可在大類降壓藥物均可在50%以上的患者中發揮降以上的患者中發揮降壓作用。在關注降壓達標的同時，應盡可能減少降壓藥物的不良壓作用。在關注降壓達標的同時，應盡可能減少降壓藥物的不良反應，降低降壓治療的代價。反應，降低降壓治療的代價。n聯合降壓治療，特別聯合使用聯合降