Cp Cp nht nht 2011 2011

TNG HUYET P CAO TUOI TNG HUYET P CAO TUOI

PGS. TS. Nguyn Vn Tr
Ch nhim b mn Lo Khoa HYD TP.HCM
Ch tich hi Lo Khoa TP.HCM

Cp Cp nht nht 2011: 2011: Tng Tng huyt huyt p p cao cao tui tui
W W c c dim dim no no cn cn Iuu Iuu ? ?
W W Muc Muc tiu tiu diu diu tri tri c c g g khc khc ??
3
c dim THA cao tui
Tn sut THA tng theo tui (NHANES V)
Heart Disease and Stroke Statistics 2004
4
Thay di HA tm thu v tm truong theo tui
The Framingham Heart Study. irculation 1997. 96:308-15.
c dim THA cao tui
5
Nguy Nguy co co bnh bnh tim tim mach mach
Iin Iin quan quan gia gia tui tui v v huyt huyt p p
Denardo et al. 2 J Med 13:719-76, 010
6
Blacher et al. Arch Intern Med. .
HA tm thu v p Ic mach
tin don nguy co tt nht THA cao tu|i
A Meta-AnaIysis
2
-
Y
e
a
r

R
i
s
k

O
f

E
n
d

P
o
i
n
t
SystoIic BIood Pressure (mm Hg)
DiastoIic
Pressure
(mm Hg)
EWPHE (N=840)
Syst-Eur (N=4695)
Syst-China (N=2394)
7
Figure 1
PP
Dy tht tri
Tng huyt p tm thu do cng dng mach
c dim THA cao tui
Nghin cu LIFE
(1)
W 9193 BN THA, tui 55-80, dy
dng tm tht tri
W Losartan hiu qu hon atenolol
trong gim bin c tim mach, dt
qui v gim rung nh mi
1. Lancet.359:9951003.
c dim THA cao tui
9
u u t t nguy nguy co co tim tim mach mach thung thung di di km km
THA THA cao cao tui tui
Chronic kidney disease Chronic kidney disease
ACC 011
Diabetes
Metabolic syndrome
10
Loi Loi ch ch UCMC THA UCMC THA v v T: T:
trong trong c cc c ngh ngh//c c uu UKPDS, ABCD, CAPPP UKPDS, ABCD, CAPPP va va FACET FACET
-24
-43
-63
-51
-70
-60
-50
-40
-30
-20
-10
0
Pahor M, et al. Diabetes Care. 2000;23:888-892.
NMCT cp
Cc bin c
tim mach t qu
T vong do
moi nguyn
nhn
P<0.001
P<0.001
P=0.01
NS
11
RMA: RMA: 90 90 Bn Bn, , nm nm, , rbesartan lm chm qu trnh
tin trin t tiu albumine vi luong dn tiu dam dai
luong
DNT: DNT:1717 1717 Bn Bn, 54 , 54 thng thng, , rbesartan lm gim qu
trnh tin trin dn bnh thn giai doan cui
RENAAL: RENAAL: 1513, 4,5 1513, 4,5 nm nm, , Losartan Losartan gim gim bnh bnh thn thn
giai giai doan doan cui cui, , t t vong vong
RMA: RMA: 90 90 Bn Bn, , nm nm, , rbesartan lm chm qu trnh
tin trin t tiu albumine vi luong dn tiu dam dai
luong
DNT: DNT:1717 1717 Bn Bn, 54 , 54 thng thng, , rbesartan lm gim qu
trnh tin trin dn bnh thn giai doan cui
RENAAL: RENAAL: 1513, 4,5 1513, 4,5 nm nm, , Losartan Losartan gim gim bnh bnh thn thn
giai giai doan doan cui cui, , t t vong vong
'ai 'ai tr tr bo bo v v thn thn B/N T B/N T ca ca ARB ARB
1
Cn Cn Iuu Iuu
THA THA gi gi tao tao
Tut Tut HA HA tu tu th th dng dng
c dim THA cao tui
13
Tng Tng huyt huyt p p gi gi tao tao
W W o o huyt huyt p p cao cao nhung nhung tht tht su su HA HA bnh bnh thung thung
W W ng ng mach mach bi bi cng cng, , xo xo ha ha, , vi vi ha ha
W W Chn Chn don don
W W Du Du OsIer OsIer duong duong tnh tnh
W W Khng Khng tn tn thuong thuong co co quan quan dch dch
W W iu iu tri tri thuc thuc ha ha p p gy gy chng chng mt mt, , i i ma ma, , tiu tiu
t t, , I I In In, , m m mt mt
W W o o HA HA ngn ngn tay tay
W W o o HA HA ni ni mach mach
W W iu iu tri tri: : diu diu chinh chinh Ii Ii sng sng
14
Tut Tut Huyt Huyt p p tu tu th th
HA HA dng dng 5 20/10 mmHg HA 5 20/10 mmHg HA ngi ngi
Dua Dua HA HA dng dng m m thp thp hon hon d d
diu diu chinh chinh thuc thuc
Muc Muc tiu tiu diu diu tri tri THA THA cao cao tui tui
16
Muc tiu diu tri THA ngui cao tui
iu tri
Khng c di tho dung v bnh thn man:
- 60-79 tui < 140/90 mmHg
- < 80 tui: 130 dn < 150
C di tho dung v/hoc bnh thn man: < 130/80 mmHg
ACC 011
Mark A. Supiano (009). Hypertension. n: Jeffrey B. Halter, Joseph G. Ouslander.
Hazzard's geriatric medicine and gerontology 6
th
, 975-983. McGraw-Hill.
17
Nghin cu H'ET
Chn don diu tri
W 3845 bnh nhn > 80 tui (trung bnh 84 tui)
W Nhm 1: indapamide + perindopril
W Nhm : gi duoc
W Mc HA muc tiu l 150/80 mmHg
Sau nm: diu tri THA bn > 80 tui lm gim t l dt quy
(1,4% vs 17,7%) v t l t vong (47,% vs 59,6%).
Treatment of hypertension in patients 80 years of age or older. Engl J Med. 358:1887.
$tage 1 Hypertension
SBP 140-159 mmHg or
DBP 90-99 mmHg
ACEI, ARB, CA, diuretic,
or combination
$tage 2 Hypertension
SBP >160 mmHg or
DBP >100 mmHg
Maiority will require >2 drugs to
reach goal iI >20 mmHg above
target. Initial combinations
should be considered. The
combination oI amlopidine with
an RAS blocker may be preIerred
to a diuretic combination, though
either is acceptable.
Compelling Indication
Heart Failure
Post myocardial inIarction
CAD or High CVD risk
Angina Pectoris
Aortopathy/Aortic Aneurysm
Diabetes
Chronic kidney disease
Recurrent stroke prevention
Early dementia
Initial Therapy Options`
THIAZ, BB, ACEI, ARB, CA,
ALDO ANT
BB, ACEI, ALDO ANT, ARB
THIAZ, BB, ACEI, CA
BB, CA
BB, ARB, ACEI, THIAZ, CA
ACEI, ARB, CA, THIAZ, BB
ACEI, ARB
THIAZ, ACEI, ARB, CA
Blood pressure control
*Combination therapy
PrincipIes of Hypertension Treatment in the EIderIy
Not at Target BP
Optimize dosages or add additional drugs until goal BP is achieved.
Refer to a clinical hypertension specialist if unable to achieve control.
LifestyIe Modifications
InitiaI Drug Choices
Not at Target BP
With CompeIIing Indications Without CompeIIing Indications
18
1
Kt Kt Iun Iun: THA : THA cao cao tui tui
C C dc dc dim dim ring ring
Tn Tn sut sut rt rt cao cao
THA THA tm tm thu thu vi vi p p Iuc Iuc mach mach cng cng rng rng th th nguy nguy co co
tim tim mach mach cng cng cao cao
Thung Thung km km dy dy tht tht tri tri, HCCH, T, , HCCH, T, bnh bnh thn thn man man
Thung Thung gp gp THA THA gi gi tao tao, , tut tut HA HA tu tu th th
HA HA muc muc tiu tiu 2 80 2 80 tui tui: 130 : 130 dn dn < 150 mmHg < 150 mmHg
c c ch ch beta beta khng khng chi chi dinh dinh buc buc du du nhung nhung c c mt mt
hu hu ht ht trong trong cc cc chi chi dinh dinh bt bt buc buc
Cm Cm on on qu qu dng dng nghip nghip
3
Tng Tng huyt huyt p p o o chong chong trng trng
o o HA HA phng phng khm khm tng tng
o o HA HA tai tai nh nh bnh bnh thung thung
4
Cc thay di ngui THA cao tui
1. Thanh dng mach xo cung
2. Giam nhay cam thu th ap sut
3. Tng hoat h thn kinh giao cam
4. Thay di dap ung cua thu th alpha va beta adrenergic
5. Ri loan chuc nng ni mac
6. Giam thai tru mui nuoc tai thn
7. Hoat tinh renin huyt tuong thp
8. D khang insulin trn chuyn hoa duong
9. Beo phi vung bung
Mark A. Supiano (009). Hypertension. n: Jeffrey B. Halter, Joseph G. Ouslander.
Hazzard's geriatric medicine and gerontology 6
th
, 975-983. McGraw-Hill.
5
Chn don diu tri
W Nghin cu The Strong Heart
Tri s p luc mach trung tm c mi lin quan
manh vi su ph dai t bo ni mach mach
mu, xo va dng mach, bin c tim mach
hon tri s p luc mach cnh tay
W Nghin cu CAFE
Mc d c cng mc HA tm thu cnh tay,
amlodipine + peridopril hiu qu hon atenolol
+ thiazide trong gim HA tm thu MC trung
tm v p luc mach MC trung tm
HA MC trung tm c th l yu t quyt dinh
dc lp quan trong ca cc kt cuc lm sng
Hypertension. 50;197-03.
irculation. 113:113-15.
6
Chn don diu tri
Nghin cu SHEP (Systolic Hypertension in the Elderly Program)
W 4376 bnh nhn THA > 60 tui (trung bnh 7 tui)
W Nhm 1: chlorthalidone + atenolol, reserpine
W Nhm : gi duoc
iu tri THA ngui cao tui
lm gim dt quy 36%
suy tim 54%
NMCT 7%
5,%
8,%
(p=0,0003)
Systolic Hypertension in the Elderly Program (SHEP). JM. 65:355-64.
7
Chn don diu tri
W 4695 bnh nhn > 60 tui (trung bnh 70 tui)
W THA tm thu don dc
W Nhm 1: nitrendipine + enalapril, hydrochlorothiazide
W Nhm : gi duoc
The Systolic Hypertension in Europe (Syst-Eur) Trial nvestigators. Lancet. 350:757.
Nghin cu Syst-EUR (Systolic Hypertension in Europe)
Sau 4 nm: diu tri THA ngui cao tui lm gim
t l dt quy 41%, bin c tim mach chung 31%
8
Nghin cu STOP-2
Chn don diu tri
W 6614 bnh nhn THA, tui t 70-84
W Nhm 1: atenolol, metoprolol, pindolol, hydrochlorothiazide
hoc amiloride
W Nhm : enalapril, lisinopril, felodipine hoc isradipine
Kt qu: mc HA gim, t l dt quy, NMCT, bin c tim mach,
t vong tuong duong cc nhm
Cardiovascular mortality and morbidity the Swedish Trial in Old Patients with Hypertension- study.
Lancet. 354:1751-6.
9
Nghin cu ALLHAT
(1)
Chn don diu tri
W Thuc loi tiu, chen knh canxi v UCMC gim cc bin c
tim mach tuong duong nhau nhm bnh nhn > 65 tui.
1. JM. 88:981997.
30
Cc dim luu khi diu tri THA ngui cao tui
iu tri
1. Truc khi bt du dng thuc ha p, khm tm sot ha HA tu th dng
. Gim cn, gim nhp mui, han ch ruou
3. Khi du dng thuc vi liu thp (khong so vi liu ca ngui tr)
4. Vic ha p cn t t, khng nng vi
5. Luu chc nng gan thn trong vic lua chon thuc
6. Muc tiu diu tri tuong tu ngui tr nu < 80 tui
7. C th kt hop thuc d kim sot HA.
8. Lua chon thuc ha p ph hop khi c bnh l khc di km.
9. Trong diu tri THA tm thu don dc, dc bit xc nhn vai tr ca thuc
chen knh canxi, loi tiu thiazide v chen thu th angiotensin.
31
Muc tiu diu tri THA ngui cao tui
iu tri
Khng c di tho dung v bnh thn man:
- 60-79 < 140/90 mmHg
- < 80: 130 dn < 150
C di tho dung v/hoc bnh thn man: < 130/80 mmHg
Mark A. Supiano (009). Hypertension. n: Jeffrey B. Halter, Joseph G. Ouslander.
Hazzard's geriatric medicine and gerontology 6
th
, 975-983. McGraw-Hill.
3
iu tri dng thuc
iu tri
Lua chon thuc ha p trn bnh nhn cao tui cn dua trn:
1. Cc nghin cu v cc khuyn co trn bnh nhn cao tui
. Tc dung phu v tuong tc thuc
3. Cc bnh l khc di km
Figure 1
L'L
PP
Stroke
LVH
Coronary
Events (M..)
ng mach bi cng lm THA tm thu
TNH TRANG NGUY CO
CAO V CH |NH BT
BUOC
THUC UOC KHUYN CO
LO TU CHEN BETA UCMC UCTT CHEN CANX KHNG
ALDO
SU TIM
SAU NMCT
BENH MACH 'NH
I THO UNG
BENH THAN MAN
PHNG NGA OT QUY
TI PHT
CAC TH NGHIEM LAM SANG 'A
C S HNG DAN CHO NHNG CH
NH BAT BUOC OI 'I TNG
NHOM THUOC (7)
34
35
THA THA cao cao tui tui thung thung km km T T v v bnh bnh thn thn
36
Khuyn Khuyn co co CHEP 2011 CHEP 2011
diu diu tri tri THA THA bnh bnh nhn nhn T T
C khi cn trn 3 thuc d dat dch HA trn BN T
Nu Creatinine > 150 mol/L( 1,7mg/%) hay d thanh thi creatinine < 30 ml/min ( 0,5 ml/giy), nn
thay th loi tiu Thiazide bng loi tiu quai nu mun kim sot th tch
ThreshoId equaI or over 130/80 mmHg and TARGET beIow 130/80 mmHg
T
c
Bnh thn
Kt hop > 2-thuc
UCMC hay
CTTAII
Khng c
Bnh thn
1. UCMC hay
CTTAII
hay
2. UCC TD di hay
Ioi tiu Thiazide
Theo di cn thn Kali v creatinine huyt thanh trn BN c bnh thn man c k toa UCMC hay CTTA
Kt hop mt ACE vi mt ARB khng duoc khuyn co khi khng c tiu protein
Kt hop thuc buc 1 nn
duoc xem xt nhu l diu tri ban
du nu HA tm thu >0 mmHg
hay HA tm truong > 10
mmHg so vi dch. Khuyn co
kt hop UCMC vi mt UC
calcium nhm DHP.
Cp nht tng huyt p cao tui 2011
W %O2 tc v kt lun
Tn sut rt cao
u t nguy co tim mach chnh nhung c th diu tri
Huyt p tm thu cao km HA tm truong thp ("cng dng
mach")
Nhiu bnh khc km Im diu tri THA phc tap Many
iu chinh Ii sng c Ioi km vi thuc
Khi tri Iiu thp, tng Iiu chm(Iow doses and titrate
sIowIy)
BN 2 80 tui, muc tiu HAtt 140-145 mmHg
38
iu tri dng thuc
iu tri
W Loi tiu thiazide, chen knh canxi, UCMC, chen thu th
angiotensin: hiu qu diu tri THA ngui cao tui.
W Chen beta khng hiu qu nhu loi tiu thiazide hoc
chen thu th angiotensin v mt gim t vong do dt quy,
bin c tim mach v t vong chung ngui cao tui.
W trnh tc dung phu ha HA tu th ngui cao tui
trnh thuc dn mach truc tip (prazosin, hydralazine)
W trnh tc dung phu thn kinh tm thn ngui cao tui
trnh thuc tc dung TKTU (clonidine, reserpine)