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민성 송
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1 The goal of evidence -basal blood pressure control and management 여의도성모병원 나영

2 Pathogenesis of Hypertension in Diabetes 유전적인자 환경인자, 비만 인슐린저항성 고인슐린혈증 고혈당 혈관평활근세포증식, 세포내나트륨증가 교감신경계활성항진 지질대사이상 나트륨, 수분재흡수촉진 혈관내피손상 고혈압 동맥경화

3 Jonit National Committee ( JNC 7 th Summary): Target BP Goals Type of hypertension BP goal (mmhg) Uncomplicated <140/90 Complicated Diabetes mellitus <130/80 Kidney disease <130/80* Other high risk (stroke, myocardial infarction) <130/80 Task Force of ESH ESC. J Hypertens 2007;25: Chobanian et al. JAMA 2003;289:

4 ADA 당뇨병환자의고혈압목표 1. 수축시혈압은 130mmHg 미만으로조절한다.(C) 2. 이완기혈압은 80mmHg 미만으로조절한다.(B) 3. 환자특성상약물에대한반응에기초하여좀더높거나낮은혈압이적당하다. (B) Diabetes Care, volume 35,supplement 1, january 2012

5 Blood Pressure Control in Diabetic Patients: How important is it?

6 Hypertension in diabetes % with BP 140/90 General population 31.3% All patients with DM Type 1 DM, normal AER Type 2 DM: At Dx Microalbuminuria Macroalbuminuria 65% 30% 50% 40-83% 78-96% Hypertension 2004; 44: 398, Am J Kid Dis 2004; 43 (May Suppl): S142

7 Association of Systolic BP & Cardiovascular Death in T2DM Multiple Risk Factor Intervention Trial(MRFIT) Cardiovascular mortality rate/10,000 person-yr Nondiabetic (n=342,815) Diabetic (n=5,163) < Systolic blood pressure (mm Hg) Stamler J et al. Diabetes Care. 1993;16:

Blood Pressure Reduction of 2 mmhg Decreases the Risk of Cardiovascular Events by 7 10% Meta-analysis of 61 prospective, observational studies 1 million adults 12.

8 Blood Pressure Reduction of 2 mmhg Decreases the Risk of Cardiovascular Events by 7 10% Meta-analysis of 61 prospective, observational studies 1 million adults 12.7 million person-years 2 mmhg decrease in mean SBP 7% reduction in risk of ischaemic heart disease mortality 10% reduction in risk of stroke mortality Lewington et al. Lancet 2002;360:

9 UKPDS 연구결과 in 1,148 Type 2 diabetic patients a tight blood pressure control (144 / 82 mmhg vs. 154/87 mmhg) gave reduced risk for Any diabetes-related endpoint 24% p= Diabetes-related deaths 32% p=0.019 Stroke 44% p=0.013 Microvascular disease 37% p= Heart failure 56% p= Retinopathy progression 34% p= Deterioration of vision 47% p= UK Prospective Diabetes Study Group. BMJ 1998;317:

10 Hypertension Optimal Treatment (HOT ) Rate of Major CV Events Rate/1000 person-years p for trend 0.5 p for trend BP goal mmhg All n=18790 Diabetic n=1501 Hansson et al., Lancet 1998

11 Blood Pressure Target in Diabetic Patients: The lower the better?

12 Hypertension 2004;44;

13 Hypertension 2004;44;

14 Hypertension in diabetes 고혈압은당뇨병환자 20~60% 관찰 비당뇨환자에비해 1.5~3배높은유병률 미세혈관합병증증가 ( 망막증, 신증 ) 대혈관합병증증가 ( 심근경색증, 뇌졸증, 말초혈관질환 ) 심혈관합병증은당뇨환자의사망원인의 80% 이상차지 당뇨환자의고혈압은반드시조기에확인하여 적극적으로치료및관리필요함

개 ( 당뇨병환자 2059 명 ) 61.3 1600 1400 72.6% 38.

15 당뇨환자의고혈압의실제목표도달정도는? 당뇨환자혈압조절달성율 (%) ( 당뇨환자 3936 명 ) 2012 년 3 월일개종합병원 10 개 ( 당뇨병환자 2059 명 ) % % 44.5% % 400 달성함 (%) 달성못함 (%) 대한당뇨병학회, 2011 SBP DBP 도달 도달 x

16 Diabetes and hypertension Awareness 한국 1998 년 2001 년 2005 년 유병률 일차의료의의고혈압환자치료를위한목표혈압수치에대한지식조사 (87 개의원대상 ) 인지율 단순고혈압 당뇨가있는고혈압 치료율 보건복지부, 국민건강영양조사검진표 미국 1988년 1994년 2000년 유병률 성별 남여 연령 <45 >45 SBP DBP SBP DBP 정답자수 (%) 정답자수 (%) 50(70.4) 14(87.5) 57(86.3) 7(33.3) 63(100) 15(100) 58(100) 20(100) 43(60.6) 12(75.0) 47(71.2) 8(38.0) 15(30.0) 4(44.4) 16(37.2) 3(18.7) 인지율 치료율 과별가정의학과내과한의원 26(92.9) 23(79.3) 15(50.0) 23(100) 25(100) 30(100) 20(71.4) 25(86.2) 10(33.3) 7(46.7) 7(36.8) 5(20.0) Hajjar l,kotchen TA. JAMA 290 : 성대현외. 가정의학회지, 26: , 2005

17 Recommendation for hypertension management in diabetic patients Systolic Diastolic recommendation Goal (mmhg) < 130 < 80 C Behavioral therapy alone(maximum 3months) then add pharmacologic treatment E Behavioral therapy + pharmacologic treatment A Diabetes Care, volume 35,supplement 1, january 2012

18 Screening and Diagnosis BP measured at every routine visit ( C ) SBP 130 mmhg or DBP 80 mmhg Repreat SBP 130 mmhg or DBP 80 mmhg Diabetes Care, volume 35,supplement 1, january 2012

6mmHg 높다ㆍ다리를꼰자세 : 수축기혈압 2~8mmHg 높다ㆍ팔을뻗지않고지지되지않은상태로측정 : 이완기혈압 10% 이상높게측정 올바른자세

19 Screening and Diagnosis Measurement of blood pressure ㆍ혈압측정전최소 5분동안안정ㆍ 1~2분시간간격을두고, 최소 2회이상측정ㆍ환자의심장높이에서측정띠를둠ㆍ처음에는양팔에서측정하고, 이후높은쪽측정 ㆍ등받이없는의자 : 이완기혈압 6mmHg 높다ㆍ다리를꼰자세 : 수축기혈압 2~8mmHg 높다ㆍ팔을뻗지않고지지되지않은상태로측정 : 이완기혈압 10% 이상높게측정 올바른자세 팔걸이와등받이가있는의자, 발은바닥에대고, 편안히앉아안정을취한후측정 잘못된자세 팔걸이와등받이가없는의자, 다리를꼰상태, 팔리지지되지않은상태 대한고혈압학회혈압모니터지침. 2007

20 Screning and Diagnosis 가정혈압과 24 시간활동중혈압측정 가정혈압 (Home blood pressure self-monitoring) - 아침기상후 1시간이후배뇨이후에, 저녁취침전안정후측정 - 혈압이안정된경우주 3회, 하루 2회측정 - 가정혈압은진료실에서측정한것보다평균 12/7mmHg 낮다. 24 시간활동중혈압 (Ambulatory blood pressure monitoring) - 백의고혈압 (white coat), 가면고혈압 (masked hypertension) 파악 - 낮시간활동할때와수면중의혈압에대한정보확인 - 여러번측정한혈압의평균이개인고유의혈압정도를보다잘반영하여환자의심혈관질환과예후를보다잘예측할수있다. 우리나라고혈압진료지침. 2004

21 Management Lifestyle Modifications. Chobanian, A. V. et al. JAMA 2003;289:

22 Management Pharmacologic therapy 안지오텐신전환효소억제제 (Angiotensin converting enzyme inhibitor : ACEi) - 심부전환자의이환율과사망률감소, 신부전진행억제 - 칼륨과신기능은투여전, 후검사, - 임신중 (2-3분기) 여성금기 : 영아사망및태아기형 안지오텐신 II 수용체차단제 (Angiotensin receptor blocker : ARB) - ACEi 억제제와비슷하나 24 시간지속적으로부드러운강압을보임 이뇨제 (Diuretics) : 신장세뇨관에서 sodium 흡수를감소시켜혈압을낮춘다. 베타차단제 (Beta blocker) : 협심증, 심근경색, 빈맥성부정맥사용 칼슘길항제 (Calcium channel blocker, CCB) : 수축기고혈압에효과적 Diabetes Care, volume 35,supplement 1, january 2012

23 Management Pharmacologic therapy 첫약물요법제 : ACE 차단제, ARBs (C) ACE 차단제나 ARBs 를사용할때에는신장기능과혈청 K + 농도를측정한다. (E) 목표혈압도달을위해 2 가지이상의약제를사용하는병합요법이필요하다. (B) 당뇨병성신증환자 ( 미세알부민뇨, 단백뇨 ) : ACE 억제제나 ARBs 사용. 55 세이상, 심혈관계질환의과거력, 고지혈증, 미세알부민뇨, 흡연 : 고혈압유무와상관없이 ACE 억제제의사용 최근심근경색증이있었던환자 : 베타수용체차단제사용고려 고령의고혈압환자들에서는합병증을막기위하여혈압을점진적으로낮추어야한다. Diabetes Care, volume 35,supplement 1, january 2012

24 Management Administer one or more antihypertensive medication at bedtime. (A) Influence of Time of Day of Blood Pressure Lowering Treatment on Cardiovascular Risk in Hypertensive Patients With Type 2 Diabetes Hermida R C et al. Dia Care 2011;34:

25 Management - Gestational diabetes & Children and adolescents Pregnant patients with DM and HTN. (E) target goal /65-79mmHg ACEi and ARBs are contraindicated : fetal damage Children-adolescents with DM and HTN.(E) target goal : < 130/80mmHg ACEi considered : potential teratogenic effect counseling Ellen W et al. NEJM 2011;365:

26 당뇨병환자의고혈압관리 (1) A. 선별검사및진단매방문시마다혈압측정수축기 130 mmhg 혹은이완기 80 mmhg 재검 B. 혈압조절의목표 SBP < 130mmHg & DBP <80mmHg C. 치료 a. 수축기 mmHg 혹은이완기 80-89mmHg 첫 3개월간은식생활습관개선 이후목표에도달하지않을경우약제시작

27 당뇨병환자의고혈압관리 (2) b. 수축기 140 혹은이완기 90mmHg : 식생활습관개선 + 고혈압약제로치료 c. 생활습관개선 : 체중초과일경우체중감량, 식이섭취 ( Na, K ), 금주, 신체활동량 d. 약물요법 ACE inhibitor 혹은 ARB Thiazide GFR 30 ml/min per 1.73 m² loop diuretic GFR <30ml/min per 1.73 m²

28 Take Home Messages 당뇨병환자가고혈압이동반되면심혈관합병증의위험이증가된다. 따라서혈당과함께혈압조절이필요하다. 아직까지혈압관리에대한인식도와치료율이낮은상태이다. 임상에서는여러근거자료를통해환자의치료에대한인식도를높여주고, 지속적인혈압관리를할수있도록관심과교육이필요하다.

29 경청해주셔서감사합니다.

Risk of Developing Hypertension by Daily Intake of Alcohol

Risk of Developing Hypertension by Daily Intake of Alcohol JNC 7 ESH/ESC (Guidelines) Guidelines 2003. 5 JNC 7 Guidelines ; The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure JAMA. 2003;289:2560-2572.