Cập nhật điều trị tăng huyết ́áp và vị trí của thuốc chẹn b1 chọn lọc

Blood Pressure BP Thresholds and Recommendations for Treatment and Follow-Up continued on next slide Reassess in 3–6 mo Class I BP goal met Reassess in 3–6 mo Class I Assess and optimiz

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The SPRINT Research Group Published online on November 9, 2015, at NEJM.org.

Các biến cố tim mạch nặng:

RRR 25% (P < 0.001)

Tử vong do mọi nguyên nhân:

RRR 27% (P = 0.003)

Nghiên cứu SPRINT

9361 bệnh nhân có nguy cơ tim mạch cao và HA tâm thu ≥ 130 mm Hg.

Can thiệp: Hạ HA tâm thu < 120 mm Hg hoặc < 140 mm Hg.

VNM/NONCMCGM/0818/0044

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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

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Categories of BP in Adults*

*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

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Blood Pressure (BP) Thresholds and Recommendations for

Treatment and Follow-Up (continued on next slide)

Reassess in 3–6 mo (Class I)

BP goal met

Assess and optimize adherence to therapy

Consider intensification of

Reassess in

1 mo (Class I)

Nonpharmacologic therapy and BP-lowering medication

Nonpharmacologic therapy (Class I)

BP thresholds and recommendations for treatment and follow-up

Nonpharmacologic therapy

and BP-lowering medication†

(Class I)

Stage 2 hypertension

(BP ≥ 140/90 mm Hg)

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Colors correspond to Class of Recommendation in Table 1.

*Using the ACC/AHA Pooled Cohort Equations Note that patients with DM or CKD are automatically placed in the risk category For initiation of RAS inhibitor or diuretic therapy, assess blood tests for electrolytes and renal function 2 to 4 weeks after initiating therapy.

high-†Consider initiation of pharmacological therapy for stage 2 hypertension with 2 antihypertensive agents of different

classes Patients with stage 2 hypertension and BP ≥160/100 mm Hg should be promptly treated, carefully monitored, and subject to upward medication dose adjustment as necessary to control BP Reassessment includes BP measurement,

detection of orthostatic hypotension in selected patients (e.g., older or with postural symptoms), identification of white coat hypertension or a white coat effect, documentation of adherence, monitoring of the response to therapy, reinforcement of the importance of adherence, reinforcement of the importance of treatment, and assistance with treatment to achieve BP target.

BP goal met

No Yes

Assess and optimize adherence to therapy

Consider intensification of therapy

Reassess in

1 mo (Class I)

Nonpharmacologic therapy and BP-lowering medication

Nonpharmacologic therapy (Class I)

BP thresholds and recommendations for treatment and follow-up

Nonpharmacologic therapy

and BP-lowering medication†

(Class I)

Stage 2 hypertension

(BP ≥ 140/90 mm Hg)

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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

Chronic kidney disease ≥130/80 <130/80

Chronic kidney disease after renal transplantation ≥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.

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Choice of Initial Medication

COR LOE Recommendation for Choice of Initial Medication

For initiation of antihypertensive drug therapy, line agents include thiazide diuretics, CCBs, and ACE inhibitors or ARBs.

first-SR indicates systematic review

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Choice of Initial Monotherapy Versus Initial Combination

Drug Therapy

Versus Initial Combination Drug Therapy*

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Hypertension in Patients With Comorbidities

2017 Hypertension Guideline

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Management of Hypertension in Patients With SIHD

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

BP, blood pressure; CCB, calcium channel blocker; GDMT, guideline-directed management and therapy; and SIHD, stable ischemic heart disease.

Hypertension With SIHD

Reduce BP to <130/80 mm Hg with GDMT beta blockers*, ACE inhibitor, or ARBs†

(Class I)

Add dihydropyridine CCBs

if needed (Class I)

Add dihydropyridine CCBs, thiazide-type diuretics, and/or MRAs as needed

(Class I)

Angina pectoris

No

BP goal not met

Yes

Colors correspond to Class of Recommendation in Table 1.

*GDMT beta blockers for BP control or relief of angina include carvedilol, metoprolol tartrate, metoprolol succinate, nadolol, bisoprolol, propranolol, and timolol Avoid beta blockers with intrinsic sympathomimetic activity The beta blocker atenolol should not be used because it is less effective than placebo in reducing cardiovascular events.

†If needed for BP control.

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Heart Failure With Reduced Ejection Fraction

COR LOE Recommendations for Treatment of Hypertension

in Patients With HFrEF

Adults with HFrEF and hypertension should be prescribed

GDMT titrated to attain a BP of less than 130/80 mm Hg

III: No

Benefit B-R

Nondihydropyridine CCBs are not recommended in the

treatment of hypertension in adults with HFrEF

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Heart Failure With Preserved Ejection Fraction

COR LOE Recommendations for Treatment of

Hypertension in Patients With HFpEF

In adults with HFpEF who present with symptoms of

volume overload, diuretics should be prescribed to control hypertension

Adults with HFpEF and persistent hypertension after

management of volume overload should be prescribed ACE inhibitors or ARBs and beta blockers titrated to attain SBP of less than 130 mm Hg

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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

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Aortic Disease

COR LOE Recommendation for Management of Hypertension

in Patients With Aortic Disease

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

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Tóm tắt hướng dẫn ACC/AHA 2017

• Định nghĩa lại tăng HA: ≥ 130/80 mm Hg.

• Mục tiêu HA cần đạt khi điều trị: < 130/80 mm Hg.

• Các nhóm thuốc dùng để khởi trị bệnh nhân tăng HA không biến chứng, không có bệnh kèm theo: Ức chế men chuyển, chẹn thụ thể angiotensin, chẹn canxi, lợi tiểu thiazide.

• Phối hợp thuốc ngay từ đầu nếu HA bệnh nhân > 20/10 mm Hg

so với HA mục tiêu

• Thuốc chẹn bêta được chỉ định cho bệnh nhân tăng HA kèm:

- Bệnh mạch vành ổn định

- Suy tim

- Bệnh động mạch chủ ngực

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Vì sao Hướng dẫn ACC/AHA 2018 không xem chẹn bêta là một nhóm thuốc hàng đầu trong điều trị tăng HA?

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Khác biệt giữa các thuốc chẹn  về hiệu quả ngừa đột quị

(phân tích gộp số liệu của 13 TNLS)

ATENOLOL

CHẸN  NGOÀI ATENOLOL

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Hiệu quả ngừa biến cố (chết, NMCT, đột quị)

Thuốc chẹn  so với các thuốc điều trị tăng HA khác

Bệnh nhân trẻ - trung niên

Khan N, McAlister FA CMAJ 2006;174:37-42. VNM/NONCMCGM/0818/0044

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Hiệu quả ngừa biến cố (chết, NMCT, đột quị)

Thuốc chẹn  so với các thuốc điều trị tăng HA khác

Bệnh nhân cao tuổi

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Recommendations for individuals with diastolic and/or systolic hypertension

Canadian guidelines recommend beta-blockers as an

initial antihypertensive therapy1

1 Daskalopoulou SS, Rabi DM, Zarnke KB et al The 2015 Canadian Hypertension Education Program recommendations for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension Can J Cardiol 2015;31(5):549–68.

Initial therapy should be monotherapy with:

• a thiazide/thiazide-like diuretic (Grade A)

• a beta-blocker (in patients <60 years of age, Grade B)

• an ACE inhibitor (in non-black patients, Grade B)

• a long-acting calcium channel blocker (CCB) (Grade B) or

• an angiotensin receptor blocker (ARB) (Grade B)

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Chẹn  không phải là một nhóm thuốc đồng nhất

• Dược động học:

- Khả dụng sinh học

- Bán thời gian loại thải

- Đường đào thải

• Hoạt tính giống giao cảm nội tại (intrinsic sympathomimetic activity – ISA)

• Mức độ ức chế chọn lọc các thụ thể 1

• Tác dụng dãn mạch ngoại biên.

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Criteria Bisoprolol Atenolol Metoprolol Carvedilol Nebivolol*

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MetoprololBetaxololNebivolol#

AcebutololCeliprololBETA-BLOCKER

ISA: Intrinsic sympathomimetic activity

* : mild alpha-blocking activity

#: vasodilator effect

+ISA -ISA

Cardioselective (β1) Noncardioselective (β1, β2)

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A: giá trị ban đầu

B: sau 2 tuần điều trị bằng bisoprolol C: sau 2 tuần dùng placebo

ở bệnh nhân ĐTĐ týp 2 có tăng HA

Janka HU et al J Cardiovasc Pharmacol 1986;8(Suppl 11):96-99. VNM/NONCMCGM/0818/0044

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Ảnh hưởng của các thuốc chẹn  trên HDL-C

cholesterol

BisoprololPropranololAtenolol

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2018 ESC/ESH Guidelines for the treatment of hypertension

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2018 ESC/ESH Guidelines for the treatment of hypertension

Screening and diagnosis of hypertension

Optimal BP

< 120/80

Normal BP120-129/80-84

High-normal BP130-139/85-90

Repeat BP at least annually

Repeated visits for office BP measurements

Out of office BP measurements (ABPM or HBPM)

Use either to confirm diagnosis

Consider masked hypertension

Out of office BP measurements (ABPM or HBPM)

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Mục tiêu HA cần đạt khi điều trị (ESC/ESH 2018)

• HA < 140/90 mm Hg là mục tiêu đầu tiên cần đạt đối với tất cả bệnh nhân tăng HA.

• HA tâm trương < 80 mm Hg là mục tiêu được khuyến cáo đối với tất cả bệnh nhân tăng HA được điều trị bằng thuốc.

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Mục tiêu HA tâm thu cần đạt đối với những đối tượng khác nhau (ESC/ESH 2018)

Class/Level

Đái tháo đường 130 mm Hg hoặc thấp hơn** (được khuyến cáo) IA

Bệnh mạch vành 130 mm Hg hoặc thấp hơn (được khuyến cáo) IA

*Theo dõi sát các biến cố ngoại ý /**Nếu dung nạp được

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Điều trị tăng huyết áp (ESC/ESH 2018)

Tất cả các nhóm thuốc điều trị tăng HA gồm ƯCMC, chẹn thụ thể AT, chẹn

bêta, chẹn canxi và lợi tiểu (thiazide và giống thiazide như chlorthalidone và

indapamide) đều có hiệu quả hạ HA và giảm biến cố tim mạch được chứng

minh trong các TNLS, và do vậy đều được chỉ định như là nền tảng của các

chiến lược điều trị tăng HA

Phối hợp thuốc được khuyến cáo khởi trị cho hầu hết bệnh nhân tăng HA

Các phối hợp thuốc được ưa chuộng gồm một thuốc ức chế hệ RA (ƯCMC

hoặc chẹn thụ thể AT) với một thuốc chẹn canxi hoặc lợi tiểu Những phối

hợp khác của 5 nhóm thuốc chính đều có thể được dùng

Thuốc chẹn bêta được khuyến cáo phối hợp với bất cứ thuốc nào trong số

các nhóm thuốc chính khác khi có các chỉ định đặc hiệu như đau thắt ngực,

sau NMCT, suy tim hoặc để kiểm soát tần số tim

Chiến lược điều trị bằng thuốc

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Điều trị tăng huyết áp (ESC/ESH 2018)

Nên khởi trị tăng HA bằng phối hợp 2 thuốc, tốt nhất là với viên 2 trong 1

(Các trường hợp ngoại lệ là bệnh nhân cao tuổi suy yếu và bệnh nhân tăng

HA độ 1, nhất là nếu HA tâm thu < 150 mm Hg)

Nếu HA không được kiểm soát với phối hợp 2 thuốc, nên tăng cường điều trị

bằng phối hợp 3 thuốc, thường là một thuốc ức chế hệ RA + một thuốc chẹn

canxi + một thuốc lợi tiểu thiazide/giống thiazide, tốt nhất là ở dạng viên 3

trong 1

Nếu HA không được kiểm soát với phối hợp 3 thuốc, nên tăng cường điều trị

bằng cách phối hợp thêm spironolactone, hoặc nếu thuốc này không dung

nạp được, với amiloride hoặc lợi tiểu khác liều cao hơn hoặc một thuốc

chẹn bêta hoặc một thuốc chẹn alpha

Chiến lược điều trị bằng thuốc

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Chống chỉ định với thuốc điều trị tăng huyết áp (ESC/ESH 2018)

Lợi tiểu thiazide/giống

thiazide (chlorthalidone,

indapamide)

- Gout - Hội chứng chuyển hóa

- Rối loạn dung nạp glucose

- Có thai

- Tăng canxi máu

- Hạ kali máu Chẹn bêta - Hen phế quản

- Bloc xoang nhĩ /nhĩ thất độ cao

- Nhịp chậm (tần số tim < 60/phút)

- Hội chứng chuyển hóa

- Rối loạn dung nạp glucose

- Vận động viên

- Suy tim (HFrEF, NYHA III hoặc IV)

- Phù chân nặng đã có sẵn Chẹn canxi không DHP

Ức chế men chuyển - Có thai

- Tiền sử phù mạch

- K máu > 5,5 mmol/l

- Hẹp động mạch thận 2 bên

- Phụ nữ tuổi sinh đẻ không có biện pháp ngừa thai đáng tin cậy

Chẹn thụ thể angiotensin - Có thai

- K máu > 5,5 mmol/l

- Phụ nữ tuổi sinh đẻ không có biện pháp ngừa thai đáng tin cậy

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Điều trị tăng HA không biến chứng (ESC/ESH 2018)

ƯCMC hoặc CTTA + chẹn canxi hoặc lợi tiểu

ƯCMC hoặc CTTA + chẹn canxi + lợi tiểu

Tăng HA kháng trị

Thêm spironolactone (25-50 mg/ngày) hoặc lợi tiểu khác, chẹn alpha hoặc chẹn bêta

Xem xét dùng thuốc chẹn bêta ở tất cả các bước điều trị khi có chỉ định đặc hiệu như suy tim, ĐTN, sau NMCT, rung nhĩ

hoặc phụ nữ trẻ đang có thai hoặc định có thai

Phác đồ điều trị này cũng thích hợp cho những bệnh nhân có tổn thương cơ quan đích

do tăng HA, bệnh mạch máu não, đái tháo đường hoặc bệnh động mạch ngoại vi

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Điều trị tăng HA kèm bệnh mạch vành (ESC/ESH 2018)

ƯCMC hoặc CTTA + chẹn  hoặc chẹn canxi hoặc chẹn canxi + lợi tiểu hoặc chẹn 

hoặc chẹn  + lợi tiểu

Phối hợp 3 thuốc trong số các thuốc trên

Thêm spironolactone (25-50 mg/ngày) hoặc lợi tiểu khác, chẹn alpha hoặc chẹn bêta

Xem xét khởi trị khi HATT ≥ 130 ở BN nguy cơ rất cao có bệnh

TM do XVĐM

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Điều trị tăng HA kèm bệnh thận mạna (ESC/ESH 2018)

ƯCMC hoặc CTTA + chẹn canxi hoặc ƯCMC hoặc CTTA + lợi tiểu (hoặc

lợi tiểu quai)b

ƯCMC hoặc CTTA + chẹn canxi + lợi tiểu

(hoặc lợi tiểu quai)b

Thêm spironolactone (25-50 mg/ngày)hoặc lợi tiểu khác, chẹn alpha hoặc chẹn bêta

a Bệnh thận mạn được định nghĩa là eGFR < 60 ml/min/1,73m 2 có hoặc không kèm đạm niệu.

b Dùng lợi tiểu quai khi eGFR < 30 ml/min/1,73m 2 Lợi tiểu thiazide ít hiệu quả ở mức eGFR này.

c Thận trọng: nguy cơ  K máu với spironolactone, nhất là khi eGFR < 45 hoặc K + nền ≥ 4,5 mmol/l.

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