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指点迷津:糖尿病患者高血压管理的临床实践
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 关键字:糖尿病 高血压 

编者按:随着生活方式的改变,糖尿病患病人数增长趋势日益明显。截止2022年,中国糖尿病患病人数约1.7亿人,是全世界糖尿病患者最多的国家。作为同是慢性代谢性疾病的高血压与糖尿病常常如影随行,在1型或2型糖尿病患者中高血压均很常见,高血压定义为血压持续≥140/90 mmHg。糖尿病合并高血压使大血管与微血管并发症的发生和进展风险明显增加,也使患者死亡风险增加。研究认为1型糖尿病(T1DM)合并高血压常与肾脏损害加重相关,而2型糖尿病(T2DM)患者合并高血压常并存多种心血管代谢危险因素。此外,大量研究表明降压治疗可减少动脉粥样硬化性心血管疾病(ASCVD)事件、心力衰竭和微血管并发症发生的风险[1]。本期,《国际循环》特别邀请了西南医科大学附属医院徐勇教授就“糖尿病人群的高血压管理实践”指点迷津。

 

筛查和诊断

 

针对糖尿病患者,每次常规临床随访均应进行血压测量,需注意:测量前休息5分钟,坐位测量,并注意正确的测量操作。若发现血压升高(≥140/90 mmHg),应通过多次测量读数确认血压,包括在另一天进行测量或行24小时血压监测,以诊断高血压。所有糖尿病高血压患者还应在居家期间进行血压监测[1]。

 

治疗目标

 

研究表明,高血压患者将血压控制在低于140/90 mmHg可减少心血管事件和微血管并发症[2-8]。因此,患有高血压的1型和2型糖尿病患者至少应将血压控制在140/90 mmHg以下。同时,不同心血管疾病风险患者,血压水平应该个体化。针对有较高心血管风险(现有动脉粥样硬化性心血管疾病[ASCVD]或10年ASCVD风险>15%)的糖尿病合并高血压患者,在安全达标的前提下,血压目标<130/80 mmHg可能更合适;而对于心血管疾病风险较低(10年ASCVD风险<15%)的糖尿病合并高血压患者,应将血压控制在<140/90 mmHg。对于患有糖尿病和原发性高血压的孕妇,建议将血压控制在<135/85 mmHg,以降低加速孕妇高血压的风险,并尽量减少胎儿生长受损[9,10]。但需要注意的是,目前尚缺乏高质量的研究数据来指导1型糖尿病患者的血压目标。

 

需要注意的是降压治疗时还需要考虑潜在不良反应(如低血压、晕厥、跌倒、急性肾损伤和电解质异常)[9-11],尤其是年龄较大、合并慢性肾脏疾病和体质差的患者[9]。此外,具有直立性低血压、重大疾病、功能受限或多药治疗的患者,发生不良反应的风险也更高

 

治疗策略

 

01、生活方式干预

 

生活方式管理是高血压治疗的一个重要组成部分,其可以降低血压,提高一些降压药的疗效,促进代谢和血管健康的其他方面,并且通常不良反应很少。因此,对于糖尿病患者合并血压轻度升高(收缩压>120 mmHg或舒张压>80 mmHg)均应进行生活方式管理[1]。

 

生活方式干预包括[12,13]:

通过限制热量来减少超重

限制钠盐的摄入量(< 200-300mg/d)

增加水果和蔬菜的摄入量

低脂乳制品的摄入量

避免过量饮酒

增加体力活动。

 

02、药物干预

 

糖尿病患者确诊为高血压(BP≥140/90 mmHg)除生活方式治疗外,应及时开始给予药物治疗以达到血压目标。初始治疗药物的选择应该根据高血压的严重程度,血压在140/90—159/99mmHg之间可以从单一药物开始;血压≥160/100 mmHg的患者,建议使用两种降压药物启始治疗,以减少糖尿病患者的心血管事件[14-16]。单片复方降压药可以改善一些患者的药物依从性[17]。

 

研究表明,高血压的起始治疗应选择可以降低糖尿病患者心血管事件的降压药物:ACEI/ARB,噻嗪类利尿剂,或二氢吡啶钙通道阻滞剂(CCB)[18-21]。对于患有糖尿病和已确诊的冠状动脉疾病的患者,ACEI/ARB是推荐一线降压药物;合并蛋白尿(尿白蛋白/肌酐比值[UACR] ≥30 mg/g)的糖尿病患者,为降低肾病进展的风险,首选ACEI或ARB[22-24]。没有蛋白尿的糖尿病患者,起始治疗可选择噻嗪类利尿剂、CCB、ACEI或ARB类降压药物。β-受体阻滞剂对既往有心肌梗死,活动性心绞痛或心力衰竭的糖尿病患者有更多获益[1]。部分难治性高血压患者,使用三种或以上降压药(包括利尿剂)仍不能达到血压目标,应考虑使用盐皮质激素受体拮抗剂治疗,使用期间需定期监测患者的血清肌酐和血清钾[22](图1)。

图1. 糖尿病合并高血压的治疗策略

 

对于较多糖尿病患者合并血压较高的患者,通常需要多种药物联合应用才能达到理想血压控制目标,尤其是合并糖尿病肾病的患者。需要注意的是,不建议同时选择ACEI和ARB制剂[23-25]。针对同时口服多个降压药物的患者,目前有少量研究认为将部分降压药物在睡前使用可以降低了心血管事件,但研究数据较少[19]。另外,使用ACEI、ARB或利尿剂治疗期间,需注意监测血清肌酐/估计的肾小球滤过率(eGFR)和血清钾水平,特别是在肾小球滤过率降低且高钾血症和急性肾损伤风险增加的患者[23-25]。

 

妊娠期间有效且安全的降压药物包括甲基多巴、拉贝洛尔和长效硝苯地平,而肼苯哒嗪可用于妊娠期高血压或严重先兆子痫的急性处理[26],而ACEI、 ARB和螺内酯是禁忌选择。不建议使用利尿剂用于妊娠期的血压控制,但需要进行容量控制的患者,可在妊娠晚期使用[26-27]。

 

参考文献

[1] American Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S125-S150. doi: 10.2337/dc21-S010.

[2] Emdin CA, Rahimi K, Neal B, Callender T, Perkovic V, Patel A. Blood pressure lowering in type 2 diabetes: a systematic review and meta-analysis. JAMA 2015;313:603–615.

[3] Arguedas JA, Leiva V, Wright JM. Blood pressure targets for hypertension in people with diabetes mellitus. Cochrane Database Syst Rev 2013;10:CD008277

[4] Ettehad D, Emdin CA, Kiran A, et al. Blood pressure lowering for prevention of cardiovascular disease and death: a systematic review and meta-analysis. Lancet 2016;387:957–967.

[5] Brunstr¨om M, Carlberg B. Effect of antihypertensive treatment at different blood pressure levels in patients with diabetes mellitus: systematic review and meta-analyses. BMJ 2016;352:i717

[6] Bangalore S, Kumar S, Lobach I, Messerli FH. Blood pressure targets in subjects with type 2 diabetes mellitus/impaired fasting glucose: observations from traditional and Bayesian random-effects meta-analyses of randomized trials. Circulation 2011;123:2799–2810

[7] Thomopoulos C, Parati G, Zanchetti A. Effects of blood-pressure-lowering treatment on outcome incidence in hypertension: 10 - Should blood pressure management differ in hypertensive patients with and without diabetes mellitus?Overview and meta-analyses of randomized trials. J Hypertens 2017;35:922–944

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[9] Sink KM, Evans GW, Shorr RI, et al. Syncope, hypotension, and falls in the treatment of hypertension: results from the randomized clinical systolic blood pressure intervention trial. J Am Geriatr Soc 2018;66:679–686

[10] Cushman WC, Evans GW, Byington RP, et al.; ACCORD Study Group. Effects of intensive bloodpressure control in type 2 diabetes mellitus. NEngl J Med 2010;362:1575–1585

[11] Whelton PK, Carey RM, Aronow WS, et al. 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: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018;71:e127–e248

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[13] James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for themanagementof high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA 2014;311: 507–520.

[14] 50. Bakris GL, Weir MR; Study of Hypertension and the Efficacy of Lotrel in Diabetes (SHIELD) Investigators. Achieving goal blood pressure in patients with type 2 diabetes: conventional versus fixed-dose combination approaches. J Clin Hypertens (Greenwich) 2003;5:202–209.

[15] FeldmanRD,ZouGY, VandervoortMK,Wong CJ, Nelson SAE, Feagan BG. A simplified approach to the treatment of uncomplicated hypertension: a cluster randomized, controlled trial. Hypertension 2009;53:646–653.

[16] Webster R, Salam A, de Silva HA, Selak V, Stepien S, Rajapakse S, et al. Fixed low-dose triple combination antihypertensive medication vs usual care for blood pressure control in patientswithmild to moderate hypertension in Sri Lanka: a randomized clinical trial. JAMA 2018;320:566–579.

[17] Bangalore S, Kamalakkannan G, Parkar S, Messerli FH. Fixed-dose combinations improve medication compliance: a meta-analysis. Am J Med 2007;120:713–719

[18] Catal′a-L ′ opez F, Mac′?as Saint-Gerons D, Gonz′alez-Bermejo D, et al. Cardiovascular and renal outcomes of renin-angiotensin system blockade in adult patients with diabetes mellitus: a systematic review with network meta-analyses.PLoS Med 2016;13:e1001971

[19] Palmer SC, Mavridis D, Navarese E, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes andkidney disease: a network meta-analysis. Lancet 2015;385:2047–2056

[20] Barzilay JI, Davis BR, Bettencourt J, et al.; ALLHAT Collaborative Research Group. Cardiovascular outcomes using doxazosin vs. chlorthalidone for the treatment of hypertension in older adults with and without glucose disorders: a report from the ALLHAT study. J Clin Hypertens (Greenwich) 2004;6:116–125

[21] Weber MA, Bakris GL, Jamerson K, et al.; ACCOMPLISHInvestigators. Cardiovascular events during differing hypertension therapies inpatients with diabetes. J Am Coll Cardiol 2010;56:77–85

[22] Telmisartan Randomised AssessmeNt Study in ACE iNtolerant subjects with cardiovascular Disease (TRANSCEND) Investigators, Yusuf S, Teo K, et al. Effects of the angiotensin-receptor blocker telmisartan on cardiovascular events in high-risk patients intolerant to angiotensinconverting enzyme inhibitors: a randomised controlled trial. Lancet 2008;372:1174–1183

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[26] American College of Obstetricians and Gynecologists; Task Force on Hypertension in Pregnancy. Hypertension in pregnancy. Report of the American College of Obstetricians and Gynecologists' Task Force on Hypertension in Pregnancy. Obstet Gynecol 2013;122:1122–1131

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