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1、Clinical Management of Hypertensive Heart Disease: Preventing Heart FailureClyde W. Yancy, MD, FACC, FAHA, FACP Medical Director, Baylor Heart and Vascular Institute Chief, Cardiothoracic Transplantation Baylor University Medical Center Dallas, TexasPrevalence of Heart Failure Increases Prevalence o
2、f Heart Failure Increases With AgeWith Age* *NHANES, 1999-2002. NHANES=National Health and Nutrition Examination Survey. Adapted from American Heart Association. Heart Disease and Stroke Statistics2005 Update. Dallas, TX: American Heart Association; 2005.024681020242534354445545564657475+ Age (yr)Po
3、pulation (%)MaleFemaleAdapted from Dzau V, et al. Am Heart J. 1991;2(4 pt 1):1244-1263.Risk factors Hyperlipidemia Hypertension Diabetes Insulin resistanceAtherosclerosis LVHCADMyocardial ischemiaCoronary thrombosisMyocardial infarctionLoss of muscleArrhythmiaSudden deathRemodelingVentricular dilata
4、tionHeart failureDeathFrom Risk Factors to Heart Failure: The Cardiovascular ContinuumABcD12 4 68 10Risk Factors for CHF Among Hypertensive Subjects*Risk FactorSexAge- and Risk FactorAdjusted Hazard Ratio (95% CI) Myocardial infarctionMFAngina pectorisMFDiabetesMFLeft ventricular hypertrophyMFValvul
5、ar heart diseaseMFCHF=congestive heart failure; CI=confidence interval. * Based on 165 CHF events in 1707 men and 192 events in 2118 women with hypertension prior to CHF. Based on dynamic model with reclassification of hypertension and risk factors at each follow-up examination. Adjusted for myocard
6、ial infarction, angina pectoris, diabetes, left ventricular hypertrophy, and valvular heart disease.Adapted from Levy D, et al. JAMA. 1996;275:15571562.STAGE A At high risk for HF but without structural heart disease or symptoms of HF.STAGE D Refractory HF requiring specialized interventions.STAGE B
7、 Structural heart disease but without signs or symptoms of HF.STAGE C Structural heart disease with prior or current symptoms of HF.At Risk for HFHFeg, Patients with: Hypertension Atherosclerotic disease Diabetes Obesity Metabolic syndrome or Patients Using cardiotoxins With family history of cardio
8、myopathyTherapy Goals Treat hypertension Encourage smoking cessation Treat lipid disorders Encourage regular exercise Discourage alcohol intake, illicit drug use Control metabolic syndrome Drugs ACEI or ARB in appropriate patients for vascular disease or diabetesACEI=angiotensin-converting enzyme in
9、hibitor; ARB=angiotensin receptor blocker.HF AlgorithmJNC 7: The Hypertension Guidelines For persons over age 50, SBP is more important than DBP as CVD risk factor Starting at 115/75 mm Hg, CVD risk doubles with each increment of 20/10 mm Hg throughout the BP range Persons who are normotensive at ag
10、e 55 have a 90% lifetime risk for developing hypertension Those with SBP 120-139 mm Hg or DBP 80-89 mm Hg require health-promoting lifestyle modifications to prevent CVD and should be considered prehypertensiveNew Features and Key MessagesSBP=systolic blood pressure; DBP=diastolic blood pressure; CV
11、D=cardiovascular disease.New Features and Key Messages (contd) Thiazide-type diuretics should be initial drug therapy for most, either alone or combined with other drug classes Certain high-risk conditions are compelling indications for other drug classes Most patients will require 2 antihypertensiv
12、e drugs to achieve goal BP If BP is 20/10 mm Hg above goal, initiate therapy with 2 agents, 1 usually should be a thiazide-type diureticAlgorithm for Treatment of HypertensionNot at Goal BP (160 or DBP 100 mm Hg) 2-drug combination for most (usually thiazide-type diuretic and ACEI or ARB or BB or CC
13、B)Stage 1 Hypertension (SBP 140-159 or DBP 90-99 mm Hg)Thiazide-type diuretics for most. May consider ACEI, ARB, BB, CCB, or combinationWithout Compelling IndicationsNot at Goal BPOptimize dosages or add additional drugs until goal BP is achieved. Consider consultation with hypertension specialistBB
14、=-blocker; CCB=calcium channel blocker.Diabetes Chronic kidney disease Recurrent stroke prevention Compelling Indications for Individual Drug ClassesCompelling Indication Initial Therapy Options Clinical Trial BasisNKF-ADA Guideline, UKPDS, ALLHAT NKF Guideline, Captopril Trial, RENAAL, IDNT, AASK P
15、ROGRESS THIAZ, BB, ACE, ARB, CCB ACEI, ARB THIAZ, ACEI THIAZ=thiazide; NKF-ADA=National Kidney Foundation-American Diabetes Association; UKPDS=UK Prospective Diabetes Study; ALLHAT=Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial; RENAAL=Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan; IDNT=Irbesartan in Diabetic Nephropathy Trial; AASK=African American Study of Kidney Disease and Hypertension; PROGRESS=Perindopril Protection Against Recurrent Stroke Study.Does Treatment of Hypertension Prevent HF?Treatment of H
