醫聲論壇

chenyuehchung. 寫:再聊一些觀念:
1.所謂 J curve 並非無限制的將血壓降低來看有無complication or outcome(i.e. SBP降到60mmHg一定會有complication=>因此有 J curve 存在??),這些trial 設計大多以 <110/60 or <120/70 為下限,依次往上加 10/5 or 20/10 為一個 group=>prospective compare outcome,如果在這些 group 中發現有轉折就認定有 "J".
舉例:
SBP:for CAD/MI or CV mortality:
(+)(有 J curve):INVEST,TNT,VALUE,ON-TARGET.
(-):Case-J, ADVANCE,FEVER


2.ACCORD-BP trial 非以 test J curve 為設計的trial, 一般只提觀察到過低的outcome 不佳...

3.thiazide大家一般用hydrochlorothiazide,但2011 NICE 建議:
If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011]
For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011]

4.diuretics 使用,建議thiazide, loop, AA(aldsterone antagonist) 分開,因為indication 不同; 有些guideline甚至把AA 中 spironolactone and eplerenone indication 也分開!! =>因此diuretics usage not a "class effect"(非一人得道,雞犬升天), 此點與其他anti-HTN agents 不同...

給大家參考....

chenyuehchung. 寫:再聊一些觀念:
3.thiazide大家一般用hydrochlorothiazide,但2011 NICE 建議:
If diuretic treatment is to be initiated or changed, offer a thiazide-like diuretic, such as chlortalidone (12.5–25.0 mg once daily) or indapamide (1.5 mg modified-release or 2.5 mg once daily) in preference to a conventional thiazide diuretic such as bendroflumethiazide or hydrochlorothiazide. [new 2011]
For people who are already having treatment with bendroflumethiazide or hydrochlorothiazide and whose blood pressure is stable and well controlled, continue treatment with the bendroflumethiazide or hydrochlorothiazide. [new 2011]

4.diuretics 使用,建議thiazide, loop, AA(aldsterone antagonist) 分開,因為indication 不同; 有些guideline甚至把AA 中 spironolactone and eplerenone indication 也分開!! =>因此diuretics usage not a "class effect"(非一人得道,雞犬升天), 此點與其他anti-HTN agents 不同...

給大家參考....

chenyuehchung. 寫:是的.

sam6840 寫:整理一下J curve:
1.J curve 與Diastolic BP而非systolic BP有關。
2.J curve與MI有關，與stroke無關。與urine protein有關，與preserving kidney function無關。
3.J point在那裡？不同研究都不相同。1991 JAMA 85mmhg;2005 Hypertension 70mmhg; 2011 JACC 65mmhg.
4.易有J curve出現的高危險群： elderly, having LVH and/or CAD, and a wide pulse pressure. (JACC vol.54 no.20,2009)
5.BP>115/75 show a strong graded relationship between BP and cardiovascular events and death的說法，根據的是observational data, targeting experiment data並無類似的發現。(Cleveland clinic J of medicine vol.78,no.2,Feb,2011)
6.clinic BP 有1\3 cases not reflect true blood pressure.如有resistance HT,suspicious of white coat HT, 已達acceptable clinic BP but either has symptoms of hypotension or progressive end organ damage應考慮用其它的血壓測量方法，如24hr ambulatory BP monitoring, home self measuring..

給大家參考。也請指正。

chenyuehchung. 寫:講一些觀念:
1.BP goal:not 120/80!!
130/80:for DM,CAD,CAD equivalent,
PAD,CKD,stroke.
120/75:only for proteinuria>1g/d.
others:<140/90.
*Taiwan guideline:<150/100 for
elderly.

*120/80 for LV dysfunction in 2007
ESC guideline(只有在此有提).
*question about <120/80 for DM p't after ACCORD-BP trial,stroke for DBP本來就認為 no J point,因此兩位說法都對,但overall 以HTN guideline 趨向是贊成有J curve(不宜<120/80)!!


2.DM:BB and diuretics increased sugar and new onset DM, but not contra!!

2007 JNC7:BB and diuretics 均屬compelling indication!!

3.add on 順序(舉2011 NICE cf CHEP)
NICE: <55y/o: ACEI/ARB, >55y/o:CCB, then A+C,then A+C+D,then+low dose spironolactone(25mg).

CHEP:first line: ACEI(non-black)/ARB/D(thiazide without hypoK+)/CCB/B-blocker(<60y/o)=> then combine 2 of them include B-blocker(>60 y/o) or A-blocker.

*因此你要combine BB+D in CHEP 是OK...
(前提:without compelling indication:no DM,CAD,MI,HF,CKD,AF....)

4.BB:
大多不建議>65y/o用(in LIFE trial increase stroke rate),esp. avoid atenolol as monotherapy.
<65 y/o 則無此限制!!

conclusion:
我看來審查醫師不太懂,建議樓主可以用上述一些論點做答覆,希望對您有幫助!

polo 寫:唯有倒扣的修法才能停止這種惡行
申復倒補兩倍, 爭審倒補4倍