高血压的预防及控制.ppt

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1、高血壓的預防與控制 JNC7 張孟源醫師主講張孟源醫師主講高血壓程度上之分類18歲以上之成人收縮壓及舒張壓血壓分類 收縮壓 舒張壓理想血壓 120 160 100獨立收縮性高血壓 140-149 135/85 and during sleep 120/75BP drop 10 to 20%at night if not signs possible increase risk of CVD 張孟源內科診所張孟源內科診所斜塔JNC7的新遠景和新資訊任何一個50歲以上的個人其收縮壓的控制比舒張壓更為重要在55歲時為正常血壓的人其一生中有90%的機率產生高血壓。張孟源內科診所張孟源內科診所心血管疾病

2、的盛行率CVD account for 30%of death world wildCVD leading cause of deaths in developed countriesBy 2020 CVD will become#1 killer in developedCountries/economies in transition 張孟源內科診所張孟源內科診所 心血管疾病的盛行率36 out of 100 people will die of CVD in 2020Cause 1990 1999 2020 million(%)million(%)million(%)冠狀動脈疾病 6.2

3、(12.4%)7.1(12.7%)11.1(16.2%)腦中風 4.3(8.5%)5.5(9.9%)7.7(11.3%)其他血管疾病 2.6(5.1%)4.3(7.7%)6.0(8.8%)所有血管疾病 13.1(26%)16.9(30.3%)24.8(36.3%)WHO 張孟源內科診所張孟源內科診所Causes of HypertensionEssential hypertensionChronic renal disease,renovascular dxPrimary hyperaldosteronismPheochromocytoma,cushing syndromeSleep apne

4、aDrug induced and chronic steroid userThyroid or parathyroid disease 張孟源內科診所張孟源內科診所代謝性症候群：大流行的反擊.全球現代化的改變糖尿病和CVD危險因子糖尿病高血壓高罹患率與死亡率高社經地位代謝性症候群：遺傳因子與環境的交互作用.環境因素Early Life Adult Life 出生你體重不足 做是生活型態營養不足 飲食因素代謝性症候群心血管疾病基因高血壓是否屬於代謝性症候群？造成高血壓因素：肥胖胰島素抗性遺傳老化飲食因素高血壓是否為一代謝性危險份子？高血壓前期是否亦計算成危險份子？中央肥胖與代謝異常中央肥胖與代

5、謝異常動脈硬化血脂異常胰島素抗性血栓栓塞發炎反應Primary prevention1 Primary prevention of HTN may improve quality of life and costs associated with medical management and its complication2.In those higher than optimal120/80mmHg decrease 3 mmHg decrease 8%stroke 5%CVD risk 3.Individuals at highest risk should be strongly en

6、couraged to adapt healthy life 張孟源內科診所張孟源內科診所Pre-hypertension stagePre-hypertension signals the need for Increase education to reduce BP in order to prevent hypertension Pre-hypertension are at increased risk for Progression to hypertension at double risk 張孟源內科診所張孟源內科診所JNC7的新遠景和新資訊即使收縮壓在120-139之間舒張壓

7、在80-89之間，仍是為高血壓前期，必須改善健康的生活型態，以避免高血壓的產生。自從115/75mmHg以上每增加20/10mmHg心血管得危險性倍增。張孟源內科診所張孟源內科診所 Benefits of Lowering BP Average percent reductionStroke incidence 35-40%Myocardial infarction 20-25%Heart failure 50%張孟源內科診所張孟源內科診所Benefits of Lowering BPIn stage I hypertension and additional CVDRisk factors,

8、achieving a sustained 12mmHgReduction in SBP over 10 yrs will prevent1 death for 11 patientsEach increment of 20/10mmHg double theRisk of CVD across the entire BP rangeStarting from 115/75 張孟源內科診所張孟源內科診所高血壓治療原則血壓必須控制在理想範圍 SBP 140mmHg,DBP 90mmHg血壓必須長期控制 張孟源內科診所張孟源內科診所Treatment of hypertension inadult

9、 with DM SBP DBPGoal 130 mmHg 80 mmHg 張孟源內科診所張孟源內科診所Goal of TherapyReduce CVD and renal morbidity and mortalityTreatment of BP 140/90mmHg and BP 50 years of age 張孟源內科診所張孟源內科診所高血壓控制比率 全國健康評估報告美 1976-1986 1988-1991 1991-1994 1999-2000Awareness 51 73 68 70Treatment 31 55 54 59Control 10 29 27 34 張孟源內科診

10、所張孟源內科診所JNC7的新遠景和新資訊最有效的治療方式，必須由主動積極的高血壓患者，與具有專業及愛心的醫師互相配合。醫病關係是建立在，同理心，互相協商 彼此了解。正向的互動，與良好醫病關係，奠定治療 成功的基礎。張孟源內科診所張孟源內科診所 Follow-up and MonitorPatient should returned for follow-up and adjustment of medications until BP goal is reachedMore frequent visits for stage II HTN and complicated comorbid co

11、nditionSerum potassium and creatinine monitor 張孟源內科診所張孟源內科診所Hypertension in older personMore than two-third of people with 65 with HTNThis population has the lowest rate of BP controlTreatment including isolated systolic HTNLower initial drug dose and then standard dose will be needed to reach BP ta

12、rget 張孟源內科診所張孟源內科診所Hypertension in WomenOral contraceptives may increase BP and BP should check regularly,in contrast HRT Dose not raise BPPregnant women with HTN should be Followed carefully,BB and vasodilator 張孟源內科診所張孟源內科診所Left ventricular hypertrophyLVH is an independent risk factor that increase

13、s the risk of CVDRegression of LVH with aggressive BP Measurement and weight loss,exercise sodium restriction and medication control 張孟源內科診所張孟源內科診所Peripheral Arterial DiseasePAD is equivalence in risk to ischemic Heart diseaseOther risk factor should be managed aggressively,aspirin should be used.張孟

14、源內科診所張孟源內科診所DementiaDementia and cognitive impairment occurred more commonly in people with hypertensionReduced progression of cognitive impairment occurs with effective antihypertensive therapy 張孟源內科診所張孟源內科診所Target Organ DamageHeart:LVH,angina.coronary revascularization,heart failureBrain:stroke,tr

15、ansient ischemic attackChronic kidney diseasePeripheral vascular diseaseRetinopathy 張孟源內科診所張孟源內科診所Hypertensive urgencies and emergenciesPatients with marked BP elevations and acute TOD(encephalopathy,myocardial infarction unstable angina,pulmonary edema,eclampsia.stroke,head traumaAortic dissection

16、required hospitalization 張孟源內科診所張孟源內科診所Hypertensive urgencies and emergencies Patient with marked elevated BP without TOD should immediately antihypertensive drug.張孟源內科診所張孟源內科診所Postural hypotensionDecrease in standing SBP 10mmHg associated with dizziness/fainting,more frequent in older SBPBP in thes

17、e individuals should be monitor in upright positionAvoiding volume depletion and excessive rapid dose titration of drug 張孟源內科診所張孟源內科診所代謝性症候群成因ATPIII觀點.肥胖體能活動不足基因感受性動脈粥樣硬化血脂異常血壓升高胰島素抗性臨床前期血栓狀態臨床前期發炎狀態高血壓飲食原則1採行DASH飲食：即富含穀類、水果、蔬菜和低脂乳製品的飲食計畫，以攝取鈣、鉀和鎂。1.每日攝取7-8份五穀類2.每日攝取8-10份蔬菜水果3.每日攝取2-3份乳製品4.每日攝取4-5份堅

18、果類、種子類或豆類5.每日應攝取低於2份或更少的動物性蛋白質 張孟源內科診所張孟源內科診所 高血壓飲食原則2低鈉飲食1.選擇新鮮食物並自己做，減少攝取外食時所含量較高的味精和食鹽2.燉湯及濃湯、火鍋湯有較高鹽分，少飲用3.含鹽量高的食物宜注意食用。如：海帶、芹菜。4.低鈉鹽和低鈉醬油有大量的鉀，腎病患者不宜使用 張孟源內科診所張孟源內科診所健康的飲食Weight reduction program,total calories intakeHealthy diet:low salt,low fat and low cholesterol,and high fiber dietBalance d

19、iet and heath food with adequate mineral and vitamin supple 張孟源內科診所張孟源內科診所運動的重要性脂肪能源對生存的重要性第二型糖尿病和腹腰部肥胖具高度關聯人類百萬年來大多依賴勞力求生存進20年產業轉型勞力性產減少交通建設與運輸便捷使身體活動減少飢荒已不在侵襲已開發國家缺乏運動因素已過度飲食因素強 張孟源內科診所張孟源內科診所運動處方建議原則強調相對運動速度和運動持續時間利用持續性耐力運動逐漸動員較多的肌肉利用間歇性高負荷運動來動員較多的肌肉選擇兩種不同型態的運動來動員不同部位的肌肉群對病患剛開始運動訓練，避免過度負荷以致於造成肌細胞

20、膜破壞-反而降低胰島素敏感度 張孟源內科診所張孟源內科診所下列狀況表示運動過量運動後休息2-3小時仍然筋疲力盡。持續亢奮睡不著覺肌肉持續痠痛和關節痛 張孟源內科診所張孟源內科診所 不宜繼續運動的身體訊號胸悶、痛暈眩不尋常呼吸困難疼痛，關節腫痛異常心律過速 張孟源內科診所張孟源內科診所代謝性症候群治療原則減少體重增加體能活動抗高血壓藥物抗高血壓藥物 張孟源內科診所張孟源內科診所代謝性症候群：討論ATPIII：準備做臨床介入肥胖或體能活動不足,是發病的警示.與胰島素抗性有高度相關具有高盛行情況生活模式治療優先強調藥物治療藥物治療對對-藥物研究和發展已驅成熟藥物研究和發展已驅成熟 張孟源內科診所張孟

21、源內科診所Life style modificationDiet ExerciseWeight reductionStress reliefQuit smoking 張孟源內科診所張孟源內科診所代謝性症候群治療方針減少基本因素1.過重或肥胖2.體能運動不足治療血脂異常相關因素1.高血壓2.血栓臨床前期3.動脈粥樣硬化血脂異常 張孟源內科診所張孟源內科診所Treatment overviewGoals of therapyLifestyle modificationPharmacologic treatmentClassification and management of BP for adu

22、ltFollow-up and monitor 張孟源內科診所張孟源內科診所冠狀動脈疾病的預防 張孟源醫師主講張孟源醫師主講Case1:謝陳OO.54yr old ladyCC:Severe chest pain,cold sweating PE:cons;clear,acute illness looking BP:136/86mmHg,heart;regular heart chest;clearLab:chole 176mg/dl,Glu 106,Tg132 EKG:acute myocardial infarctionPH:smoking(2PPD/day).HTNCase1:謝陳OO

23、.54yr old ladyShe admitted at NTUH ICU immediatelyThen received CABG surgery.2 months later she discharged from HospitalShe never smoke until now.心血管疾病的危險因子Sex:male gender vs female genderAge:male 40 and female 50 yrs of ageHeriditary:family history 張孟源內科診所張孟源內科診所心血管疾病的危險因子High blood pressureSmoking

24、Hypercholesterolemia Diabetes mellitusObesity(BMI27)Physical inactivityStress 張孟源內科診所張孟源內科診所冠狀動脈疾病的預防冠狀動脈疾病的預防Hypertension controlCessation smoking Hypercholesterolemia controlDM control 張孟源內科診所張孟源內科診所菸害的狀況1990年-300000000人死亡2000年-400000000人死亡2020年-840000000人死亡2030年-1000000000人死亡煙與心血管疾病1 心肌梗塞2 週邊血管疾病

25、3腦中風 張孟源內科診所張孟源內科診所中年30-49心肌梗塞已開發國家，每年有500000發生心肌梗塞，其中半數以上都是吸菸造成30-39歲：6.3倍40-49歲：5.3倍50-59歲：3.4倍60-69歲：2.9倍70-79歲：2倍 張孟源內科診所張孟源內科診所腦中風抽菸者中風機率為不抽菸者的3.7倍頸動脈斑塊形成速度為不抽菸者的3.2倍戒菸5年，中風機率與不抽菸者相同 張孟源內科診所張孟源內科診所週邊血管疾病動脈硬化生活不便截肢、感染加速動脈硬化增加糖尿病機率 張孟源內科診所張孟源內科診所二手煙與心血管疾病20%to 40%increase in cardiovascular morbid

26、ity and mortality(home,workplace)Adverse cardiovascular effects:Production of artherosclerotic lesionVascular endothelium injury and dysfunction Deminish HDL and oxygen transportIncrease oxidation portion of LDL 張孟源內科診所張孟源內科診所Positive associations with smoking Cancers of mouth,esophagus,pharynx Lung

27、 Ca,pancreas Ca and bladder CaChronic obstructive lung diseaseVascular diseasePeptic ulcerCirrhosis,poisoningNegative association was confirm with parkinsonism 張孟源內科診所張孟源內科診所戒菸和死亡率即使中年才戒菸也可以平均活幾年35歲前戒菸可以活的與不吸煙者一樣久 張孟源內科診所張孟源內科診所淡菸降低吸菸者的健康疑慮菸盒標示的尼古丁與焦油含量與吸煙者身體吸收量無明顯關係，卻可以留住可能戒菸的人淡菸FDA發現淡菸裡的尼古丁含量沒有減少，

28、反而增加，這是由於菸裡的添加物增加尼古丁被身體吸收的有效量，卻不影響機器檢測數值。張孟源內科診所張孟源內科診所Nicotine is highly addictive尼古丁成癮性和古柯鹼相當,是酒癮七倍Nicotine addiction is behavior disorderMeeting criteria for drug dependent Psychoactive effect Compulsive use Self-reinforcing behavior Withdraw syndrome 張孟源內科診所張孟源內科診所其他飲食中因子-酒精適量飲酒可增加高密度膽固醇大量喝酒會增加血

29、壓和三酸甘油脂Limited alcohol intake 1 oz(37.8gm)of ethanol/day 360cc beer x 2(啤酒)150cc wine x 2(紅白葡萄酒)30cc whiskey x2(高梁,白蘭地,威士忌)0.5 oz(19gm)of ethanol/day for women and Lighter weight people 張孟源內科診所張孟源內科診所其他飲食中的因子咖啡-尚無法確實與CHD發生率或死亡率的關係，習慣喝咖啡者往往攝取較高的SFA和Cholesterol，且運動較少。鈣質-雙盲實驗發現，為了預防骨質疏鬆而補充鈣片，可以同時降低低密度膽

30、固醇4.4%並提升高密度膽固醇4.1%抗氧化劑-有待更多研究確認其地位 張孟源內科診所張孟源內科診所冠狀動脈疾病的預防冠狀動脈疾病的預防Hypertension controlCessation smoking Hypercholesterolemia controlDM control 張孟源內科診所張孟源內科診所National Cholesterol educationprogram ATP IIIAdult treatment panel I(1988)Adult treatment Panel II(1993)Adult treatment Panel III(2001)LDL sh

31、ould be a primary target of therapy CHD LDL 100mg/dl Two risk factor LDL 130 mg/dl.no risk factor LDL 160 mg/dl.張孟源內科診所張孟源內科診所治療性生活型態的改變延續ATPII及實驗基礎，使用TLC DIET減低飽和脂肪酸至總熱量的7%以下減低每日膽固醇攝取量至200毫克以下運用其他降低LDL-C的治療方法使用植物性的stanolsterol增加水溶性纖維的攝取控制體重增加體能活動 張孟源內科診所張孟源內科診所Major emphasis of ATPIIIAssessing diet

32、 and lifestyle behaviors and using behavior strategies to enhance adherence is importantIntensified therapeutic lifestyle changesDiagnosis of multiple syndrome should be a secondary target of therapy 張孟源內科診所張孟源內科診所多吃什麼可以降膽固醇燕麥粥：含豐富的可融纖維，每天早上吃一碗，持續8週可降低10%低密度膽固醇豆類：含豐富的可融纖維，每天吃半碗，持續8週可降低20%低密度膽固醇大蒜：含有

33、硫化物可抑制肝臟合成膽固醇，每日3瓣，持續8週可降低10%低密度膽固醇洋蔥：每天生吃半個持續八週可以上升高密度膽固醇20%張孟源內科診所張孟源內科診所多吃什麼可以降膽固醇清蒸鮭魚：每週2次清蒸鮭魚3兩，持續8週可使高密度膽固醇上升10%，三酸甘油脂下降薑湯：薑中的生薑醇和薑烯酚，持續8週可降三酸甘油之27%&33%的低密度膽固醇蔬菜水果芥菜仔油、橄欖油、苦茶油 張孟源內科診所張孟源內科診所健康的飲食Cut down the total amount of fatReplace animal fat with vegetable oilEat more fresh fruit and veget

34、ablesGo on a sensible weight reducing diet if necessary 張孟源內科診所張孟源內科診所Classification of triglycerideNormal TG 500 mg/dl in ATPIII the cut point are lower for TG level.張孟源內科診所張孟源內科診所Trans fatty acidBeing another LDL-C raising fat that Should be kept at low intakeCookies and crackers made from partial

35、 Hydrogenated vegetable oil contain 3%to 9%TFA and many snack foods contain 8%to 10%.張孟源內科診所張孟源內科診所冠狀動脈疾病的預防Hypertension controlCessation smoking Hypercholesterolemia controlDM control 張孟源內科診所張孟源內科診所胰島素抗性：隱藏的危險第二型糖尿病高胰島素血症血糖耐受性不良高脂血症高血壓凝血異常胰島素抗性/血脂異常、動脈硬化及血糖異常長期表現.胰島素抗性/高脂血症血脂異常動脈硬化症第二型糖尿病發展階段.遺傳周邊胰

36、島素抗性高血耐受性不良早期糖尿病晚期糖尿病糖尿病高胰島素血症Defecvive glucorecorecognitionDeterioration of-cell function-cell failure胰島素抗性與冠狀動脈疾病.胰島素抗性胰島素分泌不良代償性高胰島素血症第2型糖尿病X症候群冠狀動脈疾病高血壓、高血脂、糖尿病生活調適和飲食計畫 生活調適 飲食計畫高血壓 體重控制 限鈉飲食 飲食清淡 注意礦物質的攝取高血脂 多吃高纖 限油及限膽固醇飲食 適量飲酒 不吃甜食糖尿病 規律運動 均衡飲食並注意血糖變化 生活輕鬆 避免含糖點心及食物 避免過鹹及膽固醇過高的食物代謝性症候群治療原則代謝性

37、症候群治療原則減少體重增加體能活動抗高血壓藥物服用降服用降LDL藥物藥物 e.g.statin,fibrate，nicotinic acid低劑量阿斯匹靈低劑量阿斯匹靈抗胰島素藥物抗胰島素藥物 張孟源內科診所張孟源內科診所Public health challengesand community programPublic health approach e.g.reduce Calories,saturated fat,and salt restriction Increase physical activity could downward Shift in the distributio

38、n of hypertension Reduce morbidity,mortality and lifetime Risk of an individual becoming HTNPublic health can prevent continuing Costly cycle of management HTN 張孟源內科診所張孟源內科診所護心10大秘訣能做的1.運動2.健康飲食3.注意體重4.戒菸5.避免壓力配合醫生6.檢查血壓7.檢查有沒有糖尿病8.檢測膽固醇9.定期做徹底的健康檢查10.實行心生活 照顧心臟，並告訴家人朋友。謝謝各位學員的參與謝謝各位學員的參與祝大家身體健康祝大家身體健康 張孟源內科診所張孟源內科診所.