Điều trị Tăng huyết áp trên bệnh nhân có rối loạn …tsc2019.tamduchearthospital.com/pdf/p2/219-dt-tha-tren...Điều trị Tăng huyết áp trên bệnh nhân có

Điều trị Tăng huyết áp trên bệnh nhân có

rối loạn chuyển hóa PGS. TS. Phạm Nguyễn Vinh

Đại học Y khoa Phạm Ngọc Thạch

Đại học Y khoa Tân Tạo

Bệnh viện Tim Tâm Đức

Viện Tim Tp. HCM

1

Điều trị THA trên bn có rối loạn chuyển hóa

Rối loạn chuyển hóa

Hội chứng chuyển hóa

Đái tháo đường

2


Metabolic syndrome

3

- 2014: 19.1% of all Canadian adults met MetS (nearly 1 in 5 people) - 40% of people over 65 have MetS


Metabolic syndrome, diabetes, and prevalence of coronary heart disease

4 TL: Neil B. Ruderman, Gerald I. Shulman, in Endocrinology: Adult and Pediatric, 7th ed, 2016.


Recommendations for the diagnosis of disorders of glucose metabolism

5 TL: Grant PJ, Cosentino F, et al. 2019 ESC Guidelines on diabetes, pre-diabetes, and CVD developed in collaboration with the EASD. European Heart Journal (2019) 00,1-69. Doi:10.1093/eurheartj/ehz486


Cardiovascular risk assessment in patients with diabetes and prediabetes



Categories of BP in Adults*

BP Category SBP DBP

Normal <120 mm Hg and <80 mm Hg

Elevated 120–129 mm Hg

and <80 mm Hg

Hypertension

Stage 1 130–139 mm Hg

or 80–89 mm Hg

Stage 2 ≥140 mm Hg or ≥90 mm Hg *Individuals with SBP and DBP in 2 categories should be

designated to the higher BP category.

BP indicates blood pressure (based on an average of ≥2 careful

readings obtained on ≥2 occasions, as detailed in DBP, diastolic

blood pressure; and SBP systolic blood pressure.


Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension*

Nonpharmacologi

-cal Intervention Dose Approximate Impact on SBP

Hypertension Normotension

Weight loss Weight/body fat

Best goal is ideal body weight, but

aim for at least a 1-kg reduction in

body weight for most adults who are

overweight. Expect about 1 mm Hg for

every 1-kg reduction in body weight.

-5 mm Hg -2/3 mm Hg

Healthy diet DASH dietary pattern

Consume a diet rich in fruits,

vegetables, whole grains, and low-fat

dairy products, with reduced content

of saturated and total fat.

-11 mm Hg -3 mm Hg

Reduced intake

of dietary

sodium

Dietary sodium Optimal goal is <1500 mg/d, but aim

for at least a 1000-mg/d reduction in

most adults.

-5/6 mm Hg -2/3 mm Hg

Enhanced

intake of

dietary

potassium

Dietary potassium

Aim for 3500–5000 mg/d, preferably

by consumption of a diet rich in

potassium.

-4/5 mm Hg -2 mm Hg

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

DASH indicates Dietary Approaches to Stop Hypertension; and SBP, systolic blood pressure.

Resources: Your Guide to Lowering Your Blood Pressure With DASH—How Do I Make the DASH?

Available at: https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to.

Top 10 Dash Diet Tips. Available at: http://dashdiet.org/dash_diet_tips.asp

https://www.nhlbi.nih.gov/health/resources/heart/hbp-dash-how-to







http://dashdiet.org/dash_diet_tips.asp


Best Proven Nonpharmacological Interventions for Prevention and Treatment of Hypertension* (cont.)

Nonpharmacologica

l Intervention

Dose Approximate Impact on SBP

Hypertension Normotension

Physical

activity

Aerobic ● 90–150 min/wk

● 65%–75% heart rate reserve

-5/8 mm Hg -2/4 mm Hg

Dynamic resistance

● 90–150 min/wk

● 50%–80% 1 rep maximum

● 6 exercises, 3 sets/exercise, 10

repetitions/set

-4 mm Hg -2 mm Hg

Isometric resistance ● 4 × 2 min (hand grip), 1 min rest

between exercises, 30%–40%

maximum voluntary contraction, 3

sessions/wk

● 8–10 wk

-5 mm Hg -4 mm Hg

Moderation

in alcohol

intake

Alcohol

consumption

In individuals who drink alcohol,

reduce alcohol† to:

● Men: ≤2 drinks daily

● Women: ≤1 drink daily

-4 mm Hg -3 mm

*Type, dose, and expected impact on BP in adults with a normal BP and with hypertension.

†In the United States, one “standard” drink contains roughly 14 g of pure alcohol, which is typically found in 12

oz of regular beer (usually about 5% alcohol), 5 oz of wine (usually about 12%

alcohol), and 1.5 oz of distilled spirits (usually about 40% alcohol).


Phối hợp các loại thuốc THA có thể thực hiện

Chỉ ức chế calci DHP nên phối hợp chẹn beta

Không phối hợp UCMC với chẹn thụ thể AG2

10

TL: Mancia G. et al. 2013 ESH/ESC Guidelines for the management of arterial

hypertension. Eur. Heart. J doi: 10.1093/euroheartj/ eht 151


11

Chiến lược sử dụng thuốc điều trị THA không biến chứng

2 pills


12

Điều trị Tăng huyết áp kèm đái tháo đường

More than 3 drugs may be needed to reach target values for diabetic patients

If Creatinine over 150 µmol/L or creatinine clearance below 30 ml/min ( 0.5 ml/sec), a loop diuretic

should be substituted for a thiazide diuretic if control of volume is desired

Threshold equal or over 130/80 mmHg and TARGET below 130/80 mmHg

Diabetes

with

Nephropathy

> 2-drug combinations

ACE Inhibitor

or ARB

without

Nephropathy

1. ACEInhibitor

or ARB

or

2. Thiazide

diuretic or

DHP-CCB

Monitor serum potassium and creatinine carefully in patients with CKD prescribed an ACEI or ARB

Combinations of an ACEI with an ARB are specifically not recommended in the absence of proteinuria

A combination of 2 first line

drugs may be considered as initial

therapy if the blood pressure is

>20 mmHg systolic or >10

mmHg diastolic above target

TL: 2017 Canadian Hypertension Education Program (CHEP)


Khuyến cáo 2017 ACC/AHA về điều trị THA/ĐTĐ

13

TL: Whelton PK et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/ APhA/ASH/ASPC/NMA/PCNA

Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Am Coll Cardiol 2017.


Điều trị THA trên b/n có bệnh ĐMV

- Mục tiêu HATTh ≤130 mmHg, không thấp hơn 120 mmHg

- B/n cao tuổi (≥ 65t): mục tiêu HATTh 130 – 140 mmHg

- Mục tiêu HATTr < 80 mmHg, không < 70 mmHg

- THA kèm tiền sử NMCT: chẹn bêta + chẹn hệ renin-

angiotensin – aldosterone (RAAS)

- B/n có triệu chứng đau thắt ngực: chẹn bêta và/hoặc ức chế

calci

14 TL: Williams, Mancia et al. J Hypertens 2018 and Eur Heart J 2018, in press


15

Chiến lược sử dụng thuốc điều trị THA có kèm bệnh động mạch vành

2 pills

KHUYẾN CÁO 2018 CỦA ESC/ESH VỀ ĐIỀU TRỊ TĂNG HUYẾT ÁP

CHẸN BETA CÓ GIỐNG NHAU?

2018 ESC/ESH Guidelines for the management of arterial hypertension

Chẹn Beta thế hệ mới Nebivolol đã chứng minh

- KHÔNG tác dụng phụ bất lợi đối với nguy cơ khởi phát đái tháo đường mới mắc và trên rối loạn chức năng tình dục.

- Tác dụng TỐT huyết áp động mạch chủ trung tâm, giảm độ cứng động mạch chủ, giảm rối loạn chức năng nội mô


Các kết hợp hiệu quả

UCMC + lợi tiểu

Chẹn thụ thể AT1 (ARB) + lợi tiểu

UCMC + đối kháng calci

Chẹn thụ thể AT1 (ARB) + đối kháng calci

Phối phợp 3 thuốc:

Lợi tiểu + chẹn beta + đối kháng calci

Lợi tiểu + đối kháng calci + UCMC

Lợi tiểu + đối kháng calci + chẹn thụ thể AT1

(ARB)

18


Lựa chọn thuốc hạ huyết áp/ĐTĐ

‐ Ức chế men chuyển

‐ Chẹn thụ thể AGII

‐ Lợi tiểu giống thiazide

‐ Ức chế calci DHP

Thường cần phối hợp thuốc

ĐTĐ kèm albumin niệu 300 mg/g creatinine niệu

hoặc 30- 299 mg/g creatinine: liều tối đa dung nạp

được UCMC hoặc ARB

19 TL: Diabetes Care 2018 Jan; 41(suppl 1): s86-s104


Chronic Kidney Disease

20

COR LOE Recommendations for Treatment of Hypertension in Patients

With CKD

I

SBP:

B-RSR

Adults with hypertension and CKD should be treated to a BP

goal of less than 130/80 mm Hg.

DBP:

C-EO

IIa B-R

In adults with hypertension and CKD (stage 3 or higher or stage

1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-

creatinine ratio or the equivalent in the first morning void]),

treatment with an ACE inhibitor is reasonable to slow kidney

disease progression.

IIb C-EO

In adults with hypertension and CKD (stage 3 or higher or stage

1 or 2 with albuminuria [≥300 mg/d, or ≥300 mg/g albumin-to-

creatinine ratio in the first morning void]), treatment with an ARB

may be reasonable if an ACE inhibitor is not tolerated.

SR indicates systematic review.

TL: Whelton PK et al. JACC 13 Nov 2017. www.acc.org

Điều trị THA trên BN có chỉ định đặc biệt

21

Management of Hypertension in Patients With CKD

•Colors correspond to Class of Recommendation in Table 1.

•*CKD stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d or ≥300 mg/g

creatinine.

•ACE indicates angiotensin-converting enzyme; ARB, angiotensin receptor blocker; BP

blood pressure; and CKD, chronic kidney disease. .

Treatment of hypertension in patients with CKD

Albuminuria (≥300 mg/d or ≥300 mg/g

creatinine)

ACE inhibitor*(Class IIa)

Yes

Usual “first-line” medication choices

ACE inhibitor(Class IIa)

ARB*(Class IIb)

No

Yes

ACE inhibitor intolerant

No

BP goal <130/80 mm Hg(Class I)

BP goal <130/80 mmHg (Class I)


Aortic Disease

22

COR LOE Recommendation for Management of Hypertension in

Patients With Aortic Disease

I

C-EO

Beta blockers are recommended as the preferred antihypertensive agents in patients with hypertension and thoracic aortic disease.



Age-Related Issues

23

COR LOE Recommendations for Treatment of Hypertension in

Older Persons

I

A

Treatment of hypertension with a SBP treatment goal of less

than 130 mm Hg is recommended for noninstitutionalized

ambulatory community-dwelling adults (≥65 years of age) with

an average SBP of 130 mm Hg or higher.

IIa C-EO

For older adults (≥65 years of age) with hypertension and a

high burden of comorbidity and limited life expectancy, clinical

judgment, patient preference, and a team-based approach to

assess risk/benefit is reasonable for decisions regarding

intensity of BP lowering and choice of antihypertensive drugs.



BP Thresholds for and Goals of Pharmacological Therapy in Patients With Hypertension According to Clinical Conditions

Clinical Condition(s)

BP

Threshold,

mm Hg

BP Goal,

mm Hg

General

Clinical CVD or 10-year ASCVD risk ≥10% ≥130/80 <130/80

No clinical CVD and 10-year ASCVD risk <10% ≥140/90 <130/80

Older persons (≥65 years of age; noninstitutionalized,

ambulatory, community-living adults)

≥130 (SBP) <130 (SBP)

Specific comorbidities

Diabetes mellitus ≥130/80 <130/80

Chronic kidney disease ≥130/80 <130/80

Chronic kidney disease after renal transplantation ≥130/80 <130/80

Heart failure ≥130/80 <130/80

Stable ischemic heart disease ≥130/80 <130/80

Secondary stroke prevention ≥140/90 <130/80

Secondary stroke prevention (lacunar) ≥130/80 <130/80

Peripheral arterial disease ≥130/80 <130/80

ASCVD indicates atherosclerotic cardiovascular disease; BP, blood

pressure; CVD, cardiovascular disease; and SBP, systolic blood pressure.



Recommendations for lifestyle

modifications in patients with

diabetes and pre-diabetes



Blood pressure control



Recommendations for the management of BP in patients with diabetes and pre-diabetes (1)



Recommendations for the management of BP in patients with diabetes and pre-diabetes (2)



Recommendations for the management of dyslipidaemia with lipid-lowering drugs (1)



Recommendations for the management of dyslipidaemia with lipid-lowering drugs (2)



Recommendations for the use of antiplatelet in primary prevention in patients with diabetes



Treatment targets for the management of patients with diabetes



Kết luận Hai rối loạn chuyển hóa chính trên bn THA:

Béo phì và ĐTĐ 2

Điều trị THA/RLCH: toàn diện

Mục tiêu HA ≤ 130 mmHg

Mục tiêu ĐTĐ: HbA1c < 7%

LDL-c < 55 mg/dL/ bn nguy cơ rất cao

Chống kết tập tiểu cầu: ĐTĐ nguy cơ cao hoặc rất cao

Thay đổi lối sống: chỉ định loại I

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