高血压的预防及控制JNC

按一下以編輯母片標題樣式,按一下以編輯母片,第二層,第三層,第四層,第五層,*,高血壓的預防與控制,JNC7,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 120/75,BP drop 10 to 20% at night if not signs,possible increase risk of CVD,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,心血管疾病的盛行率,CVD account for 30% of death world wild,CVD leading cause of deaths in developed,countries,By 2020 CVD will become #1 killer in developed,Countries/economies in transition,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 2020,Cause 1990 1999 2020,million(%) million(%) million(%),冠狀動脈疾病,6.2 (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,Causes of Hypertension,Essential hypertension,Chronic renal disease,renovascular,dx,Primary,hyperaldosteronism,Pheochromocytoma,cushing,syndrome,Sleep apnea,Drug induced and chronic steroid user,Thyroid or parathyroid disease,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 prevention,1 Primary prevention of HTN may improve,quality of life and costs associated with,medical management and its complication,2.In those higher than optimal120/80mmHg,decrease 3 mmHg decrease 8% stroke,5% CVD risk,3.Individuals at highest risk should be,strongly encouraged to adapt healthy life,張孟源內科診所,Pre-hypertension stage,Pre-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,JNC7,的新遠景和新資訊,即使收縮壓在,120-139,之間舒張壓在,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,Benefits of Lowering BP,Average percent reduction,Stroke incidence 35-40%,Myocardial infarction 20-25%,Heart failure 50%,張孟源內科診所,Benefits of Lowering BP,In stage I hypertension and additional CVD,Risk factors, achieving a sustained 12mmHg,Reduction in SBP over 10 yrs will prevent,1 death for 11 patients,Each increment of 20/10mmHg double the,Risk of CVD across the entire BP range,Starting from 115/75,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,Treatment of hypertension inadult with DM,SBP DBP,Goal 130 mmHg 80 mmHg,張孟源內科診所,Goal of Therapy,Reduce CVD and renal morbidity and,mortality,Treatment of BP 140/90mmHg and,BP 50,years of age,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 1999-2000,Awareness 51 73 68 70,Treatment 31 55 54 59,Control 10 29 27 34,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,Follow-up and Monitor,Patient should returned for follow-up and,adjustment of medications until BP goal,is reached,More frequent visits for stage II HTN and,complicated,comorbid,condition,Serum potassium and,creatinine,monitor,張孟源內科診所,Hypertension in older person,More than two-third of people with 65,with HTN,This population has the lowest rate of BP,control,Treatment including isolated systolic HTN,Lower initial drug dose and then standard,dose will be needed to reach BP target,張孟源內科診所,Hypertension in Women,Oral contraceptives may increase BP and,BP should check regularly ,in contrast HRT Dose not raise BP,Pregnant women with HTN should be,Followed carefully ,BB and vasodilator,張孟源內科診所,Left ventricular hypertrophy,LVH is an independent risk factor that increases the risk of CVD,Regression of LVH with aggressive BP,Measurement and weight loss, exercise,sodium restriction and medication control,張孟源內科診所,Peripheral Arterial Disease,PAD is equivalence in risk to ischemic,Heart disease,Other risk factor should be managed,aggressively ,aspirin should be used.,張孟源內科診所,Dementia,Dementia and cognitive impairment occurred more commonly in people with,hypertension,Reduced progression of cognitive impairment occurs with effective,antihypertensive therapy,張孟源內科診所,Target Organ Damage,Heart : LVH ,angina .coronary revascularization, heart failure,Brain : stroke ,transient ischemic attack,Chronic kidney disease,Peripheral vascular disease,Retinopathy,張孟源內科診所,Hypertensive urgencies and emergencies,Patients with marked BP elevations and,acute TOD ( encephalopathy ,myocardial,infarction unstable angina ,pulmonary edema,eclampsia,.stroke ,head trauma,Aortic dissection required hospitalization,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,Postural hypotension,Decrease in standing SBP 10mmHg,associated with dizziness /fainting ,more,frequent in older SBP,BP in these individuals should be,monitor in upright position,Avoiding volume depletion and excessive,rapid dose titration of drug,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,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,健康的飲食,Weight reduction program, total calories,intake,Healthy diet: low salt, low fat and low,cholesterol , and high fiber diet,Balance diet and heath food with adequate,mineral and vitamin supple,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,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膜破壞,-,反而降低胰島素敏感度,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,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,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,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,對,-,藥物研究和發展已驅成熟,張孟源內科診所,Life style modification,Diet,Exercise,Weight reduction,Stress relief,Quit smoking,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,Treatment overview,Goals of therapy,Lifestyle modification,Pharmacologic treatment,Classification and management of BP for,adult,Follow-up and monitor,張孟源內科診所,冠狀動脈疾病的預防,張孟源醫師主講,Case1:,謝陳,OO.54yr old lady,CC: Severe chest pain ,cold sweating,PE:,cons;clear,acute illness looking,BP:136/86mmHg ,heart;regular,heart,chest;clear,Lab:,chole,176mg/dl,Glu 106, Tg132,EKG:acute,myocardial infarction,PH: smoking( 2PPD/day).HTN,Case1:,謝陳,OO .54yr old lady,She admitted at NTUH ICU immediately,Then received CABG surgery.,2 months later she discharged from Hospital,She never smoke until now.,心血管疾病的危險因子,Sex : male gender,vs,female gender,Age: male 40 and female 50 yrs of age,Heriditary,: family history,張孟源內科診所,心血管疾病的危險因子,High blood pressure,Smoking,Hypercholesterolemia,Diabetes mellitus,Obesity (BMI27),Physical inactivity,Stress,張孟源內科診所,冠狀動脈疾病的預防,Hypertension control,Cessation smoking,Hypercholesterolemia control,DM control,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,3,腦中風,張孟源內科診所,未抽菸者,抽菸者,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,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,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,二手煙與心血管疾病,20% to 40% increase in cardiovascular,morbidity and mortality (home ,workplace),Adverse cardiovascular effects:,Production of,artherosclerotic,lesion,Vascular endothelium injury and dysfunction,Deminish,HDL and oxygen transport,Increase oxidation portion of LDL,張孟源內科診所,Positive associations with smoking,Cancers of mouth ,esophagus,pharynx,Lung Ca, pancreas Ca and bladder Ca,Chronic obstructive lung disease,Vascular disease,Peptic ulcer,Cirrhosis ,poisoning,Negative association was confirm with,parkinsonism,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,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，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,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 disorder,Meeting criteria for drug dependent,Psychoactive effect,Compulsive use,Self-reinforcing behavior,Withdraw syndrome,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,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,冠狀動脈疾病的預防,Hypertension control,Cessation smoking,Hypercholesterolemia control,DM control,張孟源內科診所,National Cholesterol educationprogram ATP III,Adult treatment panel I (1988),Adult treatment Panel II(1993),Adult treatment Panel III(2001),LDL should 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,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,Major emphasis of ATPIII,Assessing diet and lifestyle behaviors,and using behavior strategies to enhance adherence is important,Intensified therapeutic lifestyle changes,Diagnosis of multiple syndrome should,be a secondary target of therapy,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,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,健康的飲食,Cut down the total amount of fat,Replace animal fat with vegetable oil,Eat more fresh fruit and vegetables,Go on a sensible weight reducing diet if,necessary,張孟源內科診所,Classification of triglyceride,Normal TG 500 mg/dl,in ATPIII the cut point are lower for TG,level.,張孟源內科診所,Trans fatty acid,Being another LDL-C raising fat that,Should be kept at low intake,Cookies and crackers made from partial,Hydrogenated vegetable oil contain 3%,to 9 % TFA and many snack foods,contain 8% to 10 % .,張孟源內科診所,冠狀動脈疾病的預防,Hypertension control,Cessation smoking,Hypercholesterolemia control,DM control,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,glucorecorecognition,Deterioration 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,減少體重,增加體能活動,抗高血壓藥物,服用降,LDL,藥物,e.g.,statin,fibrate,，,nicotinic acid,低劑量阿斯匹靈,抗胰島素藥物,張孟源內科診所,Public health challengesand community program,Public health approach e.g. reduce,Calories ,saturated fat, and salt restriction,Increase physical activity could downward,Shift in the distribution of hypertension,Reduce morbidity , mortality and lifetime Risk of an individual becoming HTN,Public health can prevent continuing,Costly cycle of management HTN,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祝大家身體健康,張孟源內科診所,.,