KHUYẾN cáo điều TRỊ BỆNH TĂNG HUYẾT áp 2015, hội TĂNG HUYẾT áp CANADA (chep 2015) (sản PHỤ KHOA)

• Assess clinic blood pressures using electronic oscillometric monitors • The diagnosis of hypertension should be based on out-of-office measurements • The management of hypertension is

TĂNG HUYẾT ÁP 2015/

HỘI THA CANADA

(CHEP 2015)

CHEP 2015 Recommendations

What’s new?

• Assess clinic blood pressures using electronic (oscillometric) monitors

• The diagnosis of hypertension should be based on out-of-office measurements

• The management of hypertension is all about global cardiovascular risk

management and vascular protection including advice and treatment for

smoking cessation

• Treatment of atherosclerotic renal artery stenosis is primarily medical

What’s still important?

• Know the BP threshold and treat to target

• Adopting healthy behaviours is integral to the

management of hypertension

• The most important step in prescription of

antihypertensive therapy is achieving patient “buy-in”

CHEP 2015 Recommendations

3

Population SBP > DBP >

Low risk (no TOD or CV risk

khởi đầu điều trị bằng thuốc

TOD = target organ damage

*This higher treatment target for the very elderly reflects current evidence and

heightened concerns of precipitating adverse effects, particularly in frail patients

Decisions regarding initiating and intensifying pharmacotherapy in the very elderly

Treatment consists of health behaviour ±pharmacological management

Mục tiêu điều trị

In patients with coronary artery disease

be cautious when lowering blood pressure

if diastolic blood pressures are < 60mmHg

5

What’s still important?

• Know the BP threshold and treat to the target

• Adopting healthy behaviours is integral to the

management of hypertension

• The most important step in prescription of

antihypertensive therapy is achieving patient “buy-in”

CHEP 2015 Recommendations

Tác dụng của thay đổi lối sống/ huyết áp

Intervention Systolic BP (mmHg) Diastolic BP (mmHg)

Diet and weight control -6.0 -4.8 Reduced salt/sodium intake - 5.4 - 2.8

Reduced alcohol intake (heavy

Tóm tắt các biện pháp thay đổi lối sống

Reduce foods with added

Weight loss BMI <25 kg/m2

Alcohol restriction < 2 drinks/day

Physical activity 30-60 minutes 4-7 days/week

Dietary patterns DASH diet

Smoking cessation Smoke free environment

Waist circumference Men <102 cm Women <88 cm

What’s still important?

• Know the BP threshold and treat to the target

• Adopting healthy behaviours is integral to the

management of hypertension

• The most important step in prescription of

antihypertensive therapy is achieving patient “buy-in”

CHEP 2015 Recommendations

9

đa phương tiện

• Encourage greater patient responsibility/autonomy in regular

monitoring of their blood pressure

• Educate patients and patients' families about their

disease/treatment regimens verbally and in writing

• Use an interdisciplinary care approach coordinating with

work-site health care givers and pharmacists if available

• Encouraging adherence to therapy by healthcare

practitioner-based telephone contact, particularly, over the first three

months of therapy

Cải thiện tuân thủ điều trị bằng tiếp cận tối

đa phương diện b- II

• Assess adherence to pharmacological and health behaviour

therapies at every visit

• Teach patients to take their pills on a regular schedule

associated with a routine daily activity e.g brushing teeth.

• Simplify medication regimens using long-acting once-daily

dosing

• Utilize single pill combinations

• Utilize unit-of-use packaging e.g blister packaging

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• The management of hypertension is all about global

cardiovascular risk management and vascular protection

including advice and treatment for smoking cessation

• Treatment of atherosclerotic renal artery stenosis is primarily

medical

Tổng quan về tiêu chuẩn chẩn đoán THA

và hướng dẫn theo dõi

Measurement using electronic (oscillometric) upper arm devices is preferred over auscultation

ABPM: Ambulatory Blood Pressure Measurement AOBP: Automated Office Blood Pressure

HBPM: Home Blood Pressure measurement OBPM: Office Blood Pressure measurement

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Các phương pháp đo huyết áp

• Office (attended, OBPM)

– Auscultatory (mercury, aneroid) – Oscillometric (electronic)

• Office Automated (unattended, AOBP)

BP measurement methods

Office (attended, OBPM)

Auscultatory (mercury, aneroid) Oscillometric (electronic)

http://www.dableducational.org/sphygmomanometers.html

http://www.bhsoc.org/bp-monitors/bp-monitors/

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Khuyến cáo mới 2015 về đo huyết áp

Office BP measurement (OBPM):

•Measurement using electronic (oscillometric) upper arm devices

is preferred to auscultatory devices (Grade C).

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Đo huyết áp bằng nghe tại PK không

chính xác

• In the real world, the accuracy of auscultatory OBPM

can be adversely affected by provider, patient and

device factors such as:

– too rapid deflation of the cuff – digit preference with rounding off of readings to 0 or 5 – also, mercury sphygmomanometers are being phased out and aneroid devices are less likely to remain calibrated

• Consequence: Routine auscultatory OBPMs are 9/6 mm

Hg higher than standardized research BPs (primarily

• Measurement using electronic (oscillometric) upper

arm devices is preferred over auscultation

• The first reading should be discarded and the latter two

averaged.

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Clinic BP as alternate method

tiện ưu tiên chẩn đoán THA

Home (HBPM)

http://www.dableducational.org/sphygmomanometers.html

Các biện pháp đo huyết áp ngoài PK

• ABPM has better predictive ability than OBPM and is

the recommended out-of-office measurement method.

• HBPM has better predictive ability than OBPM and is

recommended if ABPM is not tolerated, not readily

available or due to patient preference.

• Identifies white coat hypertension (as well as

diagnosing masked hypertension)

ABPM: Đo huyết áp di động 24 giờ HBPM: Đo huyết áp tại nhà

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quan cao với nguy cơ do THA

SBP

DBP

Masked Hypertension

200 180 160 140 120

che giấu

05101520253035

• subjects recently diagnosed with hypertension with a

limited number of routine OBPM

• subjects with mild hypertension

• pregnant women

• subjects without evidence of target organ damage

Franklin SS, et al Hypertension 2013;62:982-7 Lovibond K, et al Lancet 2011;378:1219-30 27

•high normal clinic BPs

• The management of hypertension is all about global

cardiovascular risk management and vascular protection

including advice and treatment for smoking cessation

• Treatment of atherosclerotic renal artery stenosis is primarily

medical

.

Khảo sát nguy cơ tim mạch toàn diện trên tất

cả bệnh nhân THA

8 out of 10 hypertensive patients have at least 1 additional risk factor

 Risk factors =  Global CV risk

Gee ME, Bienek A, McAlister FA, et al Factors Associated With Lack of Awareness and Uncontrolled High Blood Pressure Among

Canadian Adults With Hypertension Can J Cardiol 2012;28:375-382.

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Thông tim cho bệnh nhân về nguy cơ

toàn diện giúp tăng hiệu quả của thay

đổi yếu tố nguy cơ

Hiệu quả điều trị THA khi bàn luận với bệnh

nhân về nguy cơ bệnh ĐMV

Grover SA, et al J Gen Intern Med 2009;24(1);33-9 33

• Total-C/HDL-C ratio of 6 or higher

• Premature Family History of CV disease

• Previous Stroke or TIA

• LVH

• ECG abnormalities

• Microalbuminuria or Proteinuria

• Peripheral Vascular Disease

Statins are recommended in high risk hypertensive patients based on having

established atherosclerotic disease or at least 3 of the following:

Aspirin: bảo vệ mạch máu bệnh nhân THA

Low dose ASA in hypertensive patients >50 years

Caution should be exercised if BP is not controlled.

Hansson L, Zanchetti A, Carruthers SG, et al Effects of intensive blood-pressure lowering and low-dose aspirin in patients with hypertension: principal results of the Hypertension Optimal Treatment (HOT) randomised trial Lancet 1998;351:1755-1762.

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Tobacco use status of all patients should be

updated on a regular basis and health care providers

should clearly advise patients to quit smoking.

Bảo vệ mạch máu: hướng dẫn mới 2015

Advice in combination with pharmacotherapy (e.g.,

varenicline, bupropion, nicotine replacement therapy)

should be offered to all smokers with a goal of smoking

cessation.

Bảo vệ mạch máu: hướng dẫn mới 2015

Cochrane network meta-analysis 2014

Kate Cahill et al

• Nicotine replacement therapy (NRT), antidepressant

bupropion, and nicotine receptor partial agonist

varenicline

• Impact on long term abstinence- 6 months or longer

• Synthesis of 12 Cochrane reviews

– 267 studies – Over 10,000 participants

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lá bằng thuốc

CHEP 2015 Recommendations

What’s new?

• Clinic blood pressures should be using electronic (oscillometric) monitors

• The diagnosis of hypertension should be based on out-of-office measurements

• The management of hypertension is all about global cardiovascular risk

management and vascular protection including advice and treatment

supporting smoking cessation

• Treatment of atherosclerotic renal artery stenosis is primarily medical

41

Patients with hypertension attributable to

atherosclerotic renal artery stenosis (RAS) should

be primarily medically managed because renal

angioplasty and stenting offer no benefits over

optimal medical therapy alone

CHEP Recommendations 2015: Therapy

Rx for Atherosclerotic RAS

-Composite: Death (CV/renal), stroke, MI,

stroke, HFhosp, prog renal insuff, perm RRT

NEJM 2014; 370; 13-22. 43

for Atherosclerotic RAS

• Conclusion:

– Renal-artery stenting did not confer a significant benefit with respect to the prevention of clinical events when added to comprehensive, multifactorial medical therapy in people with atherosclerotic RAS and HT or CKD.

Nghiên cứu gộp dựa trên các nghiên cứu phân

phối ngẫu nhiên về hẹp động mạch thận

• Summary Estimates of CV Outcomes for

Revascularization vs Medical Therapy:

– Mortality:14.0% vs 15.3% (P = 0.37) – Hospitalization for CHF: 9.4% vs 10.4% (P = 0.40) – Stroke: 4.1% vs 5.1% (P = 0.30)

– Worse renal function: 15.3% vs 16.1% (P = 0.67).

Bavry AA, et al JAMA Intern Med 2014;174(11):1849-1851.

45

Renal artery angioplasty and stenting for atherosclerotic

hemodynamically significant renal artery stenosis could

be considered for patients with uncontrolled hypertension

resistant to maximally tolerated pharmacotherapy,

progressive renal function loss, and acute pulmonary

edema.

CHEP Recommendations 2015: Therapy

with RAS: they included patients

who were not “resistant”

CORAL S≥155 ≥2 drugs ≥60/80% 150 2.1 drugs 67%

ASTRAL n/a n/a ≥70% 149-152 2.8 drugs 75%

STAR “Controlled BP” ≥50% 160-163 2.8-2.9 70-90%

DRASTIC D≥95 ≥2 drugs ≥50% 179-180 2.0 72-76%

SNRASCG D≥95 ≥2 drugs ≥50% 182-190EMMA D≥95 Yes ≥60/75% 158-165 1.33 DDD <75%

#AHT= number of antihypertensive drugs

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Initial therapy

A combination of 2 first line drugs may be considered as initial therapy if the blood pressure is >20 mmHg systolic or >10 mmHg diastolic above target

Điều trị tăng huyết áp trên bệnh nhân mới bị nhồi máu cơ tim

Long-acting Dihydropyridine

CCB*

Beta-blocker and ACEI or ARB

Recent myocardial infarction

Heart Failure

or not effective

*Avoid non dihydropyridine CCBs (diltiazem, verapamil)

TL: 2015 Canadian Hypertension Education Program (CHEP)

bệnh tim thiếu máu cục bộ

• Caution should be exercised when combining a non DHP-CCB and a beta-blocker

• If abnormal systolic left ventricular function: avoid non DHP-CCB (Verapamil or Diltiazem)

• Dual therapy with an ACEI and an ARB are not recommended in the absence of refractory heart failure

• The combination of an ACEi and CCB is preferred

Kết luận

• Chẩn đoán THA: nên dựa vào huyết áp đo tại nhà và

ABPM

• Huyết áp kế điện tử; bảng quấn cánh tay

• Nên ngưng thuốc lá

• THA do hẹp ĐM thận: điều trị nội là chính

• Thuốc đầu tiên không chỉ định bắt buộc: UCMC,

chẹn thụ thể AG II, ức chế calci, lợi tiểu, chẹn beta

• Phối hợp thuốc là cần thiết

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