Ασθενής με σακχαρώδη διαβήτη και αρτηριακή υπέρταση Τι το νεότερο το 2017; Πετίδης Κωνσταντίνος Παθολόγος Β ΠΠ Κλινική ΑΠΘ

Μέγεθος: px

Εμφάνιση ξεκινά από τη σελίδα:

Download "Ασθενής με σακχαρώδη διαβήτη και αρτηριακή υπέρταση Τι το νεότερο το 2017; Πετίδης Κωνσταντίνος Παθολόγος Β ΠΠ Κλινική ΑΠΘ"

Ἡρωδίωνν Στεφανόπουλος
6 χρόνια πριν
Προβολές:

1 Ασθενής με σακχαρώδη διαβήτη και αρτηριακή υπέρταση Τι το νεότερο το 2017; Πετίδης Κωνσταντίνος Παθολόγος Β ΠΠ Κλινική ΑΠΘ

2 Diabetes alone Hypertension Is Prevalent Among Diabetic Adults 29% 71% Diabetes + HTN* NHANES III = Third US National Health and Nutrition Examination Survey ( ). * Hypertension defined according to JNC-6: BP 130/85 mm Hg Geiss LS et al. Am J Prev Med. 2002;22:

3 Impacts of hypertension and Diabetes Mellitus on all-cause and cardiovascular mortality The Rancho Bernardo Study Journal of Hypertension35(1):55-62, 2017.

4 Διάγνωση υπέρτασης Παρακολούθηση αρτηριακής πίεσης

5 ADA guidelines 2017 Διάγνωση αρτηριακής υπέρτασης Recommendations Blood pressure should be measured at every routine clinical care visit. Patients found to have an elevated blood pressure (140/90 mmhg) should have blood pressure confirmed using multiple readings, including measurements on a separate day, to diagnose hypertension. B All hypertensive patients with diabetes should have home blood pressure monitored to identify white-coat hypertension. B Orthostatic measurement of blood pressure should be performed during initial evaluation of hypertension and periodically at follow-up, or when symptoms of orthostatic hypotension are present, and regularly if orthostatic hypotension has been diagnosed. E

6 Έναρξη θεραπείας

7 ADA guidelines 2017 Έναρξη θεραπείας Patients with confirmed office based BP 140/90mmHg should, in addition to lifestyle therapy, have timely titration of pharmacologic therapy to achieve blood pressure goals. A Patients with confirmed office based BP 160/100mmHg should, in addition to lifestyle therapy, have prompt initiation and timely titration of two drugs or a single-pill combination of drugs demonstrated to reduce cardiovascular events in patients with diabetes. A

8 2013 ESH/ESC Guidelines for the management of arterial hypertension: The Task Force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC)

9 ADA position statement Αλγόριθμος De Boer, Diabetes Care 2017

10 ADA, Diabetes Care 2017 ADA guidelines 2017 Έναρξη θεραπείας Απώλεια βάρους Περιορισμός άλατος Άσκηση

11 Vogt, JASN 2008 ARBs+αλάτι 38pts Πρωτεϊνουρία: 3.8gr Περιορισμός άλατος: 196 σε 92 meq/24ωρο Ελάττωση πρωτεϊνουρίας: 22% Λοσαρτάνη: ελάττωση 30% Λοσαρτάνη+αλάτι: ελάττωση 70%

12 Άσκηση και θνητότητα: Σ.Δ. Kokkinos Diab Care 2009

13 Στόχος θεραπείας

14 Κατευθυντήριες οδηγίες Στόχος θεραπείας ESH JNC-8 ASH ADA ADA <140/85 mmhg <140/90 mmhg <140/90 mmhg <140/80 mmhg <140/90 mmhg < 130/80 mmhg (νέοι, λευκωματουρία, >1 CV RF)

15 Diabetes and Hypertension: A Position Statement by the ADA Blood Pressure Targets Recommendations Most patients with diabetes and hypertension should be treated to a systolic blood pressure goal of 140 mmhg and a diastolic blood pressure goal of 90 mmhg. A Lower systolic and diastolic blood pressure targets, such as 130/80 mmhg, may be appropriate for individuals at high risk of cardiovascular disease if they can be achieved without undue treatment burden. B

16 Reduction in Risk (%) UKPDS: Tight BP Control Confers CV Benefits in Diabetic Patients Tight control (n=758): mean achieved BP of 144/82 mmhg Less tight control (n=390): mean achieved BP of 154/87 mmhg 0 Stroke Any DM endpoint DM death Microvascular complications DM=diabetes mellitus FPG=fasting plasma glucose *P<0.05. * * Tight glucose control (FPG < 107 mg/dl) UKPDS 35. BMJ. 2000;321: ; UKPDS 38. BMJ. 1998;317: * Tight BP control (<150/85 mm Hg ) * vs <180/105 mm Hg

17 Significant Benefits From Intensive BP Reduction in Diabetic Patients 30 24, ,6 HOT STUDY Major CV Events/1000 Patient-yr P = for trend ,9 5 0 < 90 mm Hg <85 mm Hg (target DBP) < 80 mm Hg Hansson, Lancet, 1998

18 ACCORD Study N Engl J Med 2010;362:

19 ACCORD 37% 13% Cushman, NEJM 2010

20 SPRINT prediabetes Bress, Doumas, Diabetes Care 2017

21 Με ποια φάρμακα;

22 ADA guidelines 2017 Είδος θεραπείας ADA, Diabetes Care 2017

23 ADA position statement Αλγόριθμος De Boer, Diabetes Care 2017

24 Effects of BP-lowering treatment on outcome incidence in patients with Hypertension with and without Diabetes Mellitus. Journal of Hypertension35(5): , May

25 Effects of BP-lowering treatment on outcome incidence in patients with Hypertension with and without Diabetes Mellitus. 25 Journal of Hypertension35(5): , May 2017.

26 Microalbuminuria or Low-grade proteinuria

27 % change in urinary albumin excretion Microalbuminuria DM pts UA IRMA II Placebo mg of irbesartan Months of Follow-up 300 mg of irbesartan *P<0.001 for difference between both irbesartan groups and placebo Parving, NEJM 2001

28 Incidence of Diabetic Nephropathy (%) Microalbuminuria DM pts Renal progression IRMA II P<0.001 for difference between 300 mg irbesartan group and placebo Placebo 150 mg of irbesartan Placebo (n) Irbesartan 150 mg (n) Irbesartan 300 mg Months of Follow-up mg of irbesartan Parving, NEJM 2001

29 ARBs vs placebo or Ca-antagonists Albuminuria Kunz, Ann Intern Med 2008

30 Angiotensin-Receptor Blockade versus Converting Enzyme Inhibition in Type 2 Diabetes and Nephropathy-RESULTS Baseline GFR 91 ml/min Barnett AH et.al N Engl J Med 2004;351:

31 ARBs vs ACE-inh Albuminuria Kunz, Ann Intern Med 2008

32 Advanced Diabetic Nephropathy

33 ACE-I is More Renoprotective than Conventional Therapy in Type 1 Diabetes (Total N = 409) % with Doubling of Baseline Creatinine Captopril Conventional therapy 100 Baseline creatinine > 1.5 mg/dl Decrease in Mean Blood Pressure (mm Hg) % Reduction in Proteinuria P < NS - 60 Lewis et al. N Engl J Med. 1993;329:

34 RENAAL ARB Reduction of Renal Failure 16% 25% 28% 20% Brenner BM et al, N Eng J Med 345:861, 2001

35 IDNT ARB Reduction of Renal Failure 20% 23% 33% Lewis EJ et al, N Eng J Med 345:851, 2001

36 Ποιοι συνδυασμοί;

37 ACCOMPLISH Diabetics 21% n=6,946 Weber, JACC 2010

38 ACCOMPLISH Renal outcome 48% Lancet, Feb 2010

39 Percentage of Adults with Diabetes Who Achieved Recommended Goals of Cardiovascular Risk Factors in NHANES NHANES III NHANES IV 50 % Saydah S et.al JAMA 2004;291:335 0 HbA1c<7% BP <130/80 mmhg TC <200 mg/dl Good Control

40 Αρχίζει από τον άρρωστο Συνεχίζεται με τον άρρωστo και Τελειώνει στον άρρωστο

Σχετικά έγγραφα

Αρτηριακή υπέρταση στον σακχαρώδη διαβήτη

Αρτηριακή υπέρταση στον σακχαρώδη διαβήτη Μιχάλης Δούμας Παθολόγος Β ΠΠ Κλινική ΑΠΘ Diabetes alone Hypertension Is Prevalent Among Diabetic Adults 29% 71% Diabetes + HTN* NHANES III = Third US National