抗高血压药物引起的糖尿病不容忽视(英文.ppt

DRUG INDUCED DIABETES DURING ANTIHYPERTENSIVE THERAPY IS IMPORTANT-BUT,CHINESE SOCIETY OF HYPERTENSIONMICHAEL ALDERMANMAY 22,2008,Prevalence of diabetes among Chinese adults aged 3564 years in the 1994 Chinese National Survey(10)and 20002001 InterASIA Study,Gu et al Diabetologia.2003;46:1190.,Percent of deaths,Geiss LS,et al.In:Diabetes in America.National Institutes of Health;1995.,65%of Mortality in people with Diabetes is CVD,Ischemic heart disease,Other heart disease,Diabetes,Malignant neoplasms,Cerebrovascular disease,Pneumonia/influenza,All other,CV mortality rate per10,000 person-years,Systolic BP and CV Death in MRFIT,Nondiabetic(n=342,815),Diabetic(n=5,163),120,120-139,Systolic BP(mmHg),140-159,160-179,180-199,200,Stamler J,et al.Diabetes Care.1993;16:434-444.,BP=blood pressure CV=cardiovascular MRFIT=Multiple Risk Factor Intervention Trial,Annual Incidence of Diabetes in Hypertensive Patients,SHEP untreated controls=2.7%SHEP treated=3.9%,Lancet.2006,368;1673-1679,Am J Cardiol.2005;95:29,Hypertension.2007;50:467,JAMA 2002;288:2981-2997,NHANES 18 year Follow-upNOD in US Women by Baseline BP,Conen,D.et al.Eur Heart J 2007 28:2937-2943,120,120-129,130-139,140,mmHg,.,Conen,D.et al.Eur Heart J 2007 28:2937-2943,Age-adjusted incidence rates(A)and HRs(B)of NOD according to blood pressure category,stratified by baseline body mass index,THE ISSUES,CONSEQUENCES OF NODCVD AND non-CVDHOW DO ANTIHYPERTENSIVE DRUGS EFFECT INCIDENCE OF NOD AND CVD ONSEQUENCES?HOW SHOULD NOD EFFECT MANAGEMENT FOR CVD PROTECTION?,Non-CVD Consequences of NOD,Impaired BP controlBehavioral and PsychologicalMicrovascular consequences(?)Medical care demandsTreatment changes,CVD Consequences,Short and Long termAntihypertensive Drug Related,.,Whelton,P.K.et al.Arch Intern Med 2005;165:1401-1409.,ALLHATIncidence of Coronary heart disease by treatment group according to baseline diabetes mellitus,impaired fasting glucose level,or normoglycemia,Barzilay,J.I.et al ALLHAT.Arch Intern Med 2006;166:2191-2201.,HRs of a 10-mg/dL(0.56-mm)FBG at 2 years for subsequent CVD and Renal Disease,Effect of ACEIs and ARBs on CVD Mortality,Gillespie,et al.Diabetes Care 28:2261-2266,2005,Age-genderadjusted in treatment CVD and non-CVD by baseline FBG among hypertensive patients.,Alderman,Hypertension.1999;33:1130-1134,Myocardial infarction(fatal and nonfatal)in hypertensive patients according to DM status,Aksnes,T.A.et al.Hypertension 2007;50,Diabetes Incidence-4 Years(follow-up FBS 126 mg/dL for those 126 mg/dL at baseline),*,*,*p.05 compared to chlorthalidone,JAMA 2002;288:2981-2997,Ramipril v.Placebo in high risk patients with IGT at baseline,Dream.NEJM;355:1551-1562,2006,Ramipril v.Placebo CVD&non-CVD Outcomes,Dream.NEJM;355:1551-1562,2006,.,Whelton,P.K.et al.Arch Intern Med 2005;165:1401-1409.,ALLHAT:RR(and 6-year rates per 100 for nondiuretic compared with diuretic for diabetes mellitus(A),impaired fasing glucose level(B),and normoglycemia(C)at baseline,for CHD,all-cause mortality,combined CHD,stroke,HF,all CVD,and ESRD,CV death(%),PLACEBO,ACTIVE,*=p 0.05 vs no diabetes,SHEP-14 YEAR FOLLOW-UP,CONCLUSIONS FROM SHEP+,Chlorthalidone Rx of hypertension improves long-term outcomes.The diabetes related to chlorthalidone therapy has better prognosis than diabetes at baseline.The benefit of chlorthalidone-based therapy on long-term total and CV mortality is most pronounced in hypertensive patients with diabetes.,Reduction in major CVD among 6,000 DM in HPS associated with 38/89 LDL/CHOL by Statin,Mazzone,T.The American Journal of Medicine 120;2007,S26-S32,Incidence of MI and Microvascular Endpoints by Mean SBP and HbA1c in UKPDS,Adjusted incidence per 1000 person-years(%),Updated mean HbA1c concentration(%),Mean SBP(mmHg),Adjusted incidence per 1000 person-years(%),5,6,7,8,9,10,11,110,120,130,140,150,160,170,Myocardial infarction,Microvascular endpoints,Microvascular endpoints,Myocardial infarction,Adler AI,et al.BMJ.2000;321:412-419.Stratton IM,et al.BMJ.2000;321:405-412.,MI=myocardial infarction SBP=systolic blood pressure,UNCERTAINTY CONTINUESACCORD AND ADVANCE,ACCORD-Mortality greater with HbAlc 6.4 v.7.0-7.9%ADVANCE-No evidence of mortality with HbAlc 6.4 v.7,5%,Major CV Event Rate In HOT,HOT,Lancet 1998;351:1755,p=0.00551%riskreduction,Goal Diastolic mmHg,Diabetic population,Non-Diabetic subjects,CONCLUSIONS,DM serious whenever it occursMore common in hypertensive Rx Particularly with diureticsNOD has consequences Non-CVD in short termCVD long termNeither fear of,nor NOD,requires D/C Diuretic,CLINICAL IMPLICATIONS,SCREEN FOR NODATTEMPT TO REVERSE HYPERGLCEMIACORRECT HYPOKAELMIAK SPARING DIURETICADD ACE OR ARBOPTIMIZE BP AND LIPID CONTROLTREAT HYPERGLYCEMIA(?)NO EVIDENCE OF CVD BENEFITPREVENTION OF MICROVASCULAR EFFECTS,