04.Cong-Thuoc Chen Calci

8/4/2019 04.Cong-Thuoc Chen Calci

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TNG HUYT P NGI LN TUI

CP NHT IU TR

VI THUC CHN CALCI

PGS.TS.Nguyn c Cng

Bnh Vin Thng Nht

i hcy dc Tp H Ch Minh


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I. TNG HUYT P

NGI LN TUI


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Tui th Tui th ngy cng tng

c tnh n 2030, ngi > 65 tui chim 20% dn sHoa K.


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Tui i v bnh tt

Tui cng caocng tng t l bnh tt vmc nng ca bnh.


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NGUYN NHN GY T VONG (US)

Accidents5%

Pneumonia3%

COPD3%

CVD50%

Other18%

Cancer21%


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TNG HUYT P L MT TRONG NHNGYU T NGUY C QUAN TRNG NHT

BP > 140/90 mmHg is associated with:

277,000 deaths in 2003

BP, blood pressure; CHF, congestive heart failure;

MI, myocardial infarction.

Rosamond W et al. Circulation. 2007;115:1-103.


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Tnh hnh bnh tng huyt pti Vit Nam

iu tra dch t: t l bnh THA gia tng nhanh trongcng ng.

* 1960: 1% dn s trng thnh min Bc.* 1976: 1,9% dn s trng thnh min Bc.

* 1992: 11,7% ngi ln c nc.

* 1999: 16,05% ti ni & ngoi thnh HNi.* 2002: 16,32% ngi 25 tui pha Bc VN.

* 2008: 27,2% ngi 25 tui (iu tra ti 8 tnh/thnhph VN)


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II. THAY I HUYT P

& H THNG TIM MCHTHEO TUI


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HUYT P

HA tm thu khuynh hng tng dn theo tui. Tng 5-8 mm Hg cho mi thp nin sau tui 40-50.

HA tm trng tng nh n 60 tui, sau nnh v gim nh.

(Generally increases 1 mm Hg per decade)


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0

20

40

60

80

100

0 2 4 6 8 10 12 14 16 18 20Ris

kofhypert

ension(%)

Residual lifetime risk of developinghypertension among people with bloodpressure 65 tui

Men Women

Vasan RS, et al. JAMA. 2002; 287:1003-1010.Copyright 2002, American Medical Association.


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Partners in Healthcare Education, LLC 2009 12

Vin cnh xut hin bnh tng HA

90% ngi > 55 tui s xut hin tng HA thi im no trong cuc i.

TNG HUYT P TM THU


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Nhp tim

Khng thay i khi nm ngh, gim t thngi (gim p ng vi h giao cm) D b h HA tth

Khi gng sc, nhp tim gim theo tui. 200 beats/min tui 20

140 beats/min tui 80

(Tn s tim c tinh theo tui = 220 tui)


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Thay i h thng ng mch

Thnh ng mch dy v km n hi. Tng HA

Tng khng lc mch mu ngoi bin


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p ng vi kch thch giao cm

Gim p ng vi cc kch thch bta giaocm. Gim tn s tim ti a.

1 & 2 effect Gim kh nng gin mch ngoi bin.

2 effect


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Cung lng tim

Khng c s thay i quan trng theo tui trng thi ngh ngi, c th gim khi hot ngth lc.

C th do gim th tch cui tm trng tht tri dothnh tht tri dy v km n hi.


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III. Y HC BNG CHNG


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Tng huyt p tm thu v nguy ct vong do bnh l tim mch.

Adapted from Neaton JD et al. Arch Intern Med. 1992;152:56-64.

SBP versus DBP in Risk of CHD Mortality

Diastolic BP(mm Hg)

Systolic BP(mm Hg)

CHD Death Rate

100+

90998089

75797074


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Disease Relative Risk

Kidney failure (ESRD) 2.8

Stroke 2.7Heart failure 1.5Peripheral vascular disease 1.8Myocardial infarction* = 1.6Coronary artery disease 1.5

ESRD = end-stage renal disease; SBP 165 mm Hg.*Men only.

Adapted from Kannel WB. Am J Hypertens. 2000;13:3S-10S; Perry HM Jr et al. Hypertension. 1995;25(part1):587-594;

Klag MJ et al. N Engl J Med. 1996;334:13-18; Nielsen WB et al. Ugeskr Laeger. 1996;158:3779-3783; NeatonJD et al.Arch Intern Med. 1992;152:56-64.

Tng huyt p tm thu n c gytng nguy c bnh l tim mch v

bnh thn.


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LI IM KHI IU TRTNG HUYT P

BN < 60 tui (gim HA 10/5-6 mmHg) Gim nguy c t qu 42%

Gim nguy c xut hin bin c bnh MV 14%

BN > 60 tui (gim HA 15/6 mmHg) Gim t vong ton b 15%

Gim t vong do bnh l TM 36%

Gim t qu 35%

Gim bnh l ng mch vnh 18%Lancet 1990;335:827-38 Arch Fam Med 1995;4:943-50


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LI IM KHI IU TR T

HUYT P MC TIU BN > 60 tui

(SBP 160 mm Hg and DBP < 90 mm Hg)

Gim nguy c t qu 42% Gim nguy c xut hin bin c bnh l ng

mch vnh 26%

Lancet 1997;350:757-64


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Meta-analysis of 61 prospective, observational studies*

1 million adults

12.7 million person-years

*Epidemiologic studies, not clinical trials of HTN agents.

BP, blood pressure; IHD, ischemic heart disease.

Lewington S et al. Lancet2002;360:1903-1913.

H p l vn then cht

Gim 2 mm HgHATTh trung

bnhGim 10% nguyc t vong do

t qu

Gim 7%nguy c tvong bnhtim thiumu cc b


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*LV Hypertrophy, Angina, MI, PTCA, Bypass; Sroke or TIA, Peripheral Arterial Disease, retinopathy, carotid plaque, microalbuminurea

2007 Guidelines for the Management of Arterial Hypertension: The Task Force for the Management of Arterial Hypertension of the EuropeanSociety of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens. 2007;25(6):1105-87

Mc HA mc tiu cn t n ty theo din tinbnh v tn thng c quan ch


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NHNG TH NGHIM LM SNG


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The Hypertension Optimal

Treatment Study (HOT Study)


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S lng bnh nhn tham gia NCA total of 18.790 patients from 26 countries were randomised

Country/ No. of randomised Country/ No. ofrandomisedarea patients area patients

Argentina 47 Israel 411Austria 628 Italy 2.702Belgium 755 Mexico 49

Canada 838 Norway 432Denmark 503 South East Asia 71East Asia 134 Spain 806

Finland 373 Sweden 492France 1.574 Switzerland 797Germany 4.269 The Netherlands 603

Great Britain 131 USA 2.646Greece 335Hungary 194


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Tiu ch chnh.

nh gi mi lin quan gia nhng bin c vtim mch vi 3 tr s HA tm trng ch ( 140mmHg v/hay DBP > 90mmHg

N khng mang thai hay cho con b.

Khng s dng Plendil t nht 4 tun l.


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Cc bc nghin cu

1st step Plendil5mg*

Plendil10mg + Betaloc25mg BID/Low dose of ACEI

Plendil10mg + Betaloc50mg BID/High dose of ACEI

Plendil10mg + Betaloc50mg BID/High dose of ACEI+ Low dose of other anti-hypertensive drugs(-blocker/ACEI)/Diuretic

* Target DBP < 90mmHg after 2 weeks treatment.

2nd step

3rd step

4th step

5th step

*

*

*

Plendil5mg + Betaloc25mg BID /Low dose of ACEI


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Dn s nghin cu

Unqualified data(age, gender or baseline BP missing)

1,530

Data

sum58,289

Repeated data321

Qualifieddata

56,438

Intention-to-treatpopulation (ITT)

53,040


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KT QU


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KT QU


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TC DNG PH

AE = Ankle Edema


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HOT China: Kt lun

Cc bc iu tr tng HA trong NC HOT ph hpvi bnh tng HA nguyn pht ngi Trung Quc.Cc bc iu tr c tnh an ton, hiu qu v dung

np tt. Kt hp thuc liu thp gia cc nhm thuc nh

Plendil + Betaloc / ACEI khng lm tng thm hiuqu h HA nhng lm gim c tc dng ph khi

tng liu thuc trong ch iu tr 1 thucBnh nhn tng HA nguyn pht ngi Trung Qucc kim sot HA an ton v hiu qu hn.


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The Felodipine Event Reduction (FEVER) Study

A Randomized Long-Term Placebo-Controlled Trial

in Chinese Hypertensive Patients

Design and Principal Results

Lisheng Liu, Yuqing Zhang, Guozhang Liu, Wei Li, Xuezhong Zhang and

Alberto Zanchetti for the FEVER Study Group

(Beijing, China and Milan, Italy)


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FEVER: MC TIU

1340 Z

1.

2.

So snh hiu qu trn bin c v bnh l tim mch ca Plendil liuthp 5mg/ngy vi placebo BN tng HA c iu tr bngthuc li tiu liu thp (HCTZ 12,5mg/ngy).

So snh hiu qu h HA tch cc t c mc HA mc tiu theocc khuyn co.


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FEVER: Inclusion Criteria

1342 Z

50-79 tui, c nam v n

i tng < 60 tui: c t nht 1 bin c tim mch nhNMCT, t qu, autht ngc, suy tim, bnh ng mch ngoi vi, cn thieesyu mu no thongqua hoc c 2 yu t nguy ctim mch (nam, ht thuc l, TC > 5.7 mmol/l,tiu ng, LVH (voltage), proteinuria > +, BMI > 27 kg/m2)

i tng > 60 tui: c t nht mt bin c tim mch hoc mt yu t nguyc.

Khm sng lc: Bnh nhn iu tr: SBP/DBP < 210/115 mmHg

: Bnh nhn cha iu tr : SBP 160-210 mmHg hoc DBP 95-115mmHg

Chn ngu nhin: SBP 140-180 or DBP 90-100 mmHg, sau 6 tun dngHCTZ 12.5 mg/ngy (ct thuc dng trc y)


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Giam tai bien mach mau nao

Theo doi (thang)

HR = 0.732, 95% CI: 0.601-0.891, p = 0.0019

Ty le benh nhan xay ra bien co (%)

0 6 12 18 24 30 36 42 48 54 60

0

2

4

6

8

10

-26.8%

(the FEVER Study Group)

Xanh: Placebo

Chm: Plendil


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Giam tong bien co tim mach

Theo doi (thang)


0 6 12 18 24 30 36 42 48 54 60

0

3

6

9

12

15

HR = 0.726, 95% CI: 0.612-0.860, p = 0.0002

-27.4%


Xanh: Placebo

Chm: Plendil


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Giam t vong do nguyen nhan tim mach

Theo doi (thang)


HR = 0.668, 95% CI: 0.489-0.912, p = 0.0112

0 6 12 18 24 30 36 42 48 54 600

1

2

3

4

-33.2%


Xanh: Placebo

Chm: Plendil

FEVER: Endpoint Analysis


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FEVER: Endpoint Analysis(first time occurrence in each category)

1355 Z

Stroke

Fatal

Non-fatal

All CV events

All cardiac events

All cause death

CV death

Coronary events

Heart failure

New onset diabetesCancer

Felodipine

11.2

2.1

9.1

15.2

4.6

7.1

4.6

4.5

1.1

3.62.6

Placeb

o

15.9

3.1

12.7

21.2

6.6

9.6

6.4

6.2

1.7

3.53.9

Hazard Ratio (95% CI)Per 1000 patient-years

0.4 0.6 0.8 1.0 1.5 2.0

Felodipine better Placebo better

0.72

0.70

0.72

0.72

0.66

0.70

0.68

0.68

0.76

1.030.60

FEVER KT LUN


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FEVER: KT LUN

1362 Z

BN tng HA ngi Trung Quc iu tr bng HCTZ (12.5mg/d) v Felodipine liu thp 5mg/ngy gim c HA nhiu

hn (SBP/DBP # 4/2 mmHg) v gim quan trng cc bin c

t qu (28%), bin c v bnh tim mnh (28%), bin c v

bnh ng mch vnh (32%), gim t vong do tt c cc

nguyn nhn (30%), gim tvong do bnh l tim mch (17%).

iu tr kt hp liu thp UC knh Ca v HCTZ cho kt qutt hn n tr liu HCTZ liu thp.

iu tr vi liu thp ch c 1% xut hin bnh l T mimc.


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IV. NHNG KHUYNCO IU TR

TNG HUYT P

BHS IV, 2004 and Update of the NICE Hypertension Guideline, 2006

BHS Guidelines for the management of hypertension


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BHS Guidelines for the management of hypertension


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ESH


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Compelling and possible indications, contraindications, and

cautions for the major classes of antihypertensive drugs

Class of drugCompellingindications

Possibleindications Caution

Compellingcontraindications

Beta-blockers MI,Angina

Heart failure Heart failure,PVD,

Diabetes(except with

CHD)

Asthma/COPD,Heart block

CCBs(dihydropyridine)

Elderly, ISH Angina - -

CCBs(rate limiting)

Angina Elderly Combinationwith beta-blockade

Heart blockHeart failure

Thiazide/thiazide-like diuretics ElderlyISHHeart failure2 o strokeprevention

Gout

ESH

2007 ESH/ESC Guidelines

Combination between some classes of


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Thiazide diuretics

ACE inhibitors

Calcium antagonists

-blockers AT1-receptor antagonists

-blockers

Combination between some classes ofantihypertensive drugs

J Hypertens. 2007;25:1105-1187.


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Bnh nhn ln tui

Nnbt u iu tr bng thay i li sng.

Nn khi u dng thuc vi liu thp.

HA mc tiu < 140/90 mm Hg.

Nhm thuc c ch knh Ca l mt trongnhng thuc chn la u tin.

JNC 7.

Tng HA v cn ph bin nht:

Hng dn iu tr tng HA theo Hi


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Hng dn iu tr tng HA theo HiTng HA Canada 2010

Hng dn iu tr tng HA theo Hi


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Hng dn iu tr tng HA theo HiTng HA Canada 2010


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V. KT LUN Tng huyt p ngi ln tui rt thng gp.

Thng l tng huyt p tm thu n c.

Tng huyt p tm thu cng gy ra nhng bin c v

tim mch trm trng v t vong. iu tr tt tng HAtm thu lm gim quan trng t xut v ccbin chngtng HA.

Nhm thuc c ch knh calci dihydropyridines tcdng ko di (nh Felodipine - Plendil) c vai trquan trng trong kim sot tt HA ngi ln tui.

Chn thnh cm n s ch


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Chn thnh cm n s ch ca Qu v

T L NHP VIN V T VONG


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Number of Admissions Deaths

Total Age > 65 Age > 65

Acute MI 858 562 (65.5%) 63 (81.2%)

Coronary disease 1280 685 (53.5%) 12 (85.7%)Arrhythmias 731 519 (71.0%) 11 (73.3%)

Heart failure 1040 805 (77.4%) 38 (92.7%)

Cerebrovascular Dz 1044 758 (72.6%) 47 (74.6%)

(numbers in thousands)> 65 yo 13% population

National Hospital Discharge Survey, 2000.

T L NHP VIN V T VONG

V BNH L TIM MCH


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Thay i tim

Dy thnh tm tht tri nng ln khi ckm tng huyt p.

Ph i tm tht tri c th gy chm th gintrong thi k tm trng.

Gin nh tri th pht sau ph i tm tht tri.

Sites of Clinical Centers of FEVER


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Sites of Clinical Centers of FEVER

Al ith f T t t f H t iJNC 7.


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Algorithm for Treatment of Hypertension

Not at Goal Blood Pressure (100 mmHg)

2-drug combination for most (usuallythiazide-type diuretic and

ACEI, or ARB, or BB, or CCB)

Stage 1 Hypertension(SBP 140159 or DBP 9099 mmHg)

Thiazide-type diuretics for most.May consider ACEI, ARB, BB, CCB,

or combination.

Without CompellingIndications

Not at GoalBlood Pressure

Optimize dosages or add additional drugsuntil goal blood pressure is achieved.

Consider consultation with hypertension specialist.

FEVER: TIU CH NGHIN CU


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1345 Z

Chnh:

Ph :

t qu (fatal and nonfatal)

1)

2)

3)

4)

5)

6)

Total cardiovascular events (composite of CV death, non-fatalstroke, non-fatal MI, dissecting aortic aneurysm, HF requiringtreatment, PTCA, CABG, interventions for PAD, s. creatinine >355 mol/l)Total cardiac events (composite of death by CHD, non-fatal MI,death by HF, HF requiring treatment, PTCA, CABG)

Death by any cause (composite of CV death and non-CV death)

Any of the event categories in composite outcomesa) fatal stroke, b) non-fatal stroke, c) CHD events (fatal and non-

fatal MI and sudden death), d) HF, e) CV death, f) renal failure

New onset diabetes (FBG > 7.0 mmol/l or treatment)

Cancer



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1345 Z

Chnh:

Ph :


1)

2)

3)

4)

5)

6)






Cancer

FEVER: THIT K V S NC


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FEVER: THIT K V S NC

1344 Z

+ Felodipine 5 mg/d

+ Placebo

HCTZ

12.5 mg/d

visits

weeks

1

-6

2

-4

3

-2

4

0

5

1

6

2

7

3

8

4

9

5

10

6

11

9

12

12

16

24

20

36

24

48

28

60 months

Screening Randomization

Add-on diuretic or other agents (not CA)

if BP > 160/90 mmHg, at investigators discretion



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Chnh:

Ph :


1)

2)

3)

4)

5)

6)






Cancer

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04.Cong-Thuoc Chen Calci