#1
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ëåãêàÿ àðòåðèàëüíàÿ ãèïåðòåíçèÿ è ðèñê èøåìèèè ìîçãà
Îñòà¸òñÿ î÷åíü íå ïðîñòûì âîïðîñ î äîêàçàòåëüíîñòè ýôôåêòèâíîñòè ëå÷åíèÿ ëåãêîé, äà è óìåðåííîé Àà â ñâÿçè ñ "óëó÷øåíèåì" ìîçãîâîãî êðîâîîáðàùåíèÿ, óìåíüøåíèÿ ðèñêà ðàçâèòèÿ ÕÍÌÊ, èøåìè÷åñêîãî èíñóëüòà. Êàêèå êðèòåðèè óëó÷øåíèÿ ñóùåñòâóþò, êàêîâà ïðàâèëüíàÿ òàêòèêà, èìåííî ñ òî÷êè çðåíèÿ íåâðîëîãà? Êàêèå øèðîêèå èññëåäîâàíèÿ ïðîâîäèëèñü è ïðîõîäÿò ïî ýòîé òåìå? Ïîòîìó ÷òî íà ìîé âçãëÿä ïîãîëîâíîå ñòðåìëåíèå "îïòèìèçàöèè" ÀÄ òåðàïåâòàìè ïðèâîäèò ê óâåëè÷åíèþ áîëüíûõ ñ õðîíè÷åñêèìè è îñòðûìè íàðóøåíèÿìè êðîâîîáðàùåíèÿ ãîëîâíîãî ìîçãà. Ñïàñèáî!
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#2
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Óâàæàåìûé êîëëåãà. Òî÷êà çðåíèÿ íåâðîëîãîâ ñîâïàäàåò ñ òî÷êîé õðåíèÿ êàðäèîëîãîâ, âðà÷åé îáùåé ïðàêòèêè, äà è âñåõ, ÷üè çíàíèÿ - ýòî äîêàçàòåëüíàÿ ìåäèöèíà, à óæå ïîòîì ñîáñòâåííûå óìîçàêëþ÷åíèÿ.
Íà÷íèòå ñ äîêàçàíîãî - "Hypertension is a major problem in nearly all countries around the world, and is the most important modifiable risk factor for stroke. A continuous and linear relationship between blood pressure and risk of stroke has been reported, which holds even in individuals with a normal blood pressure." "Categorizing patients as “hypertensive” or “normotensive” based on an arbitrary blood pressure threshold may not be helpful with respect to secondary stroke prevention for several reasons. First, the relationship between blood pressure and stroke is continuous and graded, with no evidence of a lower blood pressure threshold for stroke risk (Lewington et al, 2002; Rodgers et al, 1996)" - ýòî ïåðâè÷íà ïðîôèëàêòèêà. Âòîðè÷íàÿ ïðîôèëàêòèêà - "several controlled trials have demonstrated that blood pressure reduction benefits patients who would not normally be designated as hypertensive ((HOPE trial, PROGRESS Collaborative Group, 2001)". [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] "The relationship between blood pressure and cardiovascular risk is “continuous, consistent, and independent of other risk factors.”76 The higher the blood pressure, the greater the stroke risk.77" - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Íà ñåãîäíÿøíèé äåíü ñèòóàöèÿ âöåëîì âûãëÿäèò òàê, íî ïðàâèëüíûì áóäåò ïîäõîäèòü ñ óìîì ê ñàìûì ÷òî íè åñòü ýâèäåíò-áåéçåä ðåêîìåíäàöèÿì. [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ëó÷øåãî, ÷åì ÅÁÌ â ñîâðåìåííîé ìåäèöèíå ïîêà íåòó è å¸ ýôôåêòèâíîñòü âïîëíå äîêàçàíà íà ïðàêòèêå ñîâðåìåííîé ìåäèöèíû. Ñ óâàæåíèåì, TARIKAFR. |
#3
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 òîì ÷òî Àà - ôàêòîð ðèñêà äëÿ ðàçâèòèÿ èøåìè÷åñêèõ ïîðàæåíèé ìîçãà íèêòî è íå ñîìíåâàåòñÿ. Íî ïðîáëåìà â òîì ÷òî áîëüíûå ñ ëåãêîé è ïîñòîÿííîé Àà è íå ëå÷àùèåñÿ ãèïîòåíçèâíûìè ïðåïàðàòàìè íå èìåþò çíà÷èòåëüíóþ äîñòîâåðíóþ ðàçíèöó â ïðîãíîçå ðàçâèòèÿ õðîíè÷åñêèìè èøåìè÷åñêèìè çàáîëåâàíèÿìè ìîçãà â ñðàâíåíèè ñ ïîëó÷àþùèìè ãèïîòåíçèâíûå ñðåäñòâà, êîòîðûå â ÷àñòè ñëó÷àåâ óñóãóáëÿþò èøåìèþ ìîçãà. Çà îòâåò ñïàñèáî. Î÷åíü ïîíÿòíî!
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#4
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Íàøåë óáåäèòåëüíîå èññëåäîâàíèå PROGRESS ñ äîêàçàòåëüñòâîì ñíèæåíèÿ ðèñêà ïîâòîðíîãî èíñóëüòà ó áîëüíûõ ïåðåíåñøèõ èíñóëüò, êàê ñ ÀÃ, òàê è áåç íå¸ ïðè ïðè¸ìå ïåðèíäîïðèëà 4ìã â ñóò + èíäàïàìèä 2,5ìã/ñóò;
èññëåäîâàíèå HOPE ñ ïðèåìîì ðàìèïðèëà 2,5ìã/ñóò, ó áîëüíûõ ñ âûñîêîé ñòåïåíüþ ðèñêà îñëîæíåíèé ñåðäå÷íî-ñîñóäèñòûõ çàáîëåâàíèé, â òîì ÷èñëå è áåç Àà - ñî ñíèæåíèåì ðèñêà ðàçâèòèÿ èíñóëüòà; èññëåäîâàíèå ELSA ñ ïðè¸ìîì ëàöèäèïèíà äîêàçûâàþùåå òîðìîæåíèå àòåðîñêëåðîòè÷åñêîãî ïðîöåññà â ÌÀà ó áîëüíûõ ñ ÀÃ. Ïîêà âñ¸. Íî èìåííî íà ìîé âîïðîñ - ñðàâíåíèå ðèñêîâ ëå÷åííîé ( è ÷åì ëå÷åííîé) ëåãêîé è ñòàáèëüíîé áåçêðèçîâîé Àà è íåëå÷åííîé ëåãêîé Àà - òàêèõ èññëåäîâàíèé ÿ íå íàøåë. Ïîìîãèòå êîëëåãè. Âåäü ïðèõîäÿò ýòè áîëüíûå ê íåâðîëîãó ïîñëå íàçíà÷åííîãî èì òåðàïåâòàìè ëå÷åíèÿ ñ öåëüþ íîðìàëèçàöèè ÀÄ, âûÿâëåííîãî ó íèõ ïðè ïðîôîñìîòðàõ, ñ æàëîáàìè, êîòîðûõ ó íèõ íå áûëî è ñ ÿâëåíèÿìè ðàññåÿííîãî ìèêðîî÷àãîâîãî íåéðîäåôèöèòà, êîòîðîãî òîæå íå áûëî. Ñïàñèáî! |
#5
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Öèòàòà:
Ìîæåò êàêîé íèáóäü êëèíè÷åñêèé ïðèìåð îáñóäèì? |
#6
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Óâàæàåìûé,servadol. Äåéñòâèòåëüíî, íèêàêèõ õðîíè÷åñêèÿ èøåìèé âñëåäñòâèè ëå÷åíèÿ ÃÁ ÿ íèãäå íå âñòðå÷àë. Áîëüøå - äàæå â ñëó÷àå íåêëèíè÷åñêèõ êàðîòèäíûõ ñòåíîçîâ íèêàêèõ ðåêîìåíäàöèé ïî íåëå÷åíèþ ÃÁ íåò, õîòÿ âûãëÿäèò ýòî íå ñîâñåì ëîãè÷íî. Äîñòàòî÷íî áîëüøîå êîëè÷åñòâî ñïåöèàëèñòîâ â ýòîé ñôåðå ïðèäåðæèâàþòñÿ ìíåíèÿ, ÷òî ïîäõîä ê ÃÁ è â ýòèõ ñëó÷àÿõ äîëæåí áûòü äîñòàòî÷íî æ¸ñòêèì, õîòÿ íèêàêèõ èññëåäîâàíèé â ýòîì íàïðàâëåíèè åù¸ íåò.
Ïîêà äîêàçàíî, ÷òî ÷åì âûøå ÀÄ - òåì âûøå ðèñê ÎÍÌÊ. Äû Âû æå ñàìè âèäåëè, ÷òî ïîçèòèâíûé ýôôåêò ãèïîòåíçèâíîé òåðàïèè îáíàðóæåí äàæå â íîðìîòîíèêîâ. À ïðè ë¸ãêîé Àà è òåì áîëåå, ÷òî âïîëíå ëîãè÷íî. À äàëåå, æàëîáû â ïîäîáíûõ ñëó÷àÿõ ìîãóò áûòü ñâÿçàíû ñ îðòîñòàòè÷åñêîé ãèïîòåíçèåé, ïîáî÷íûìè äåéñòâèÿìè è âçàèìîäåéñòâèÿìè ïðåïàðàòîâ, à íåâðîëîãè÷åñêèé äåôèöèò âïîëíå ìîæåò áûòü ñëåäñòâèåì ãèïåðòîíè÷åñêîé ëåéêîýíöåôàëîïàòèè è ëàêóíàðíûõ èíôàðêòîâ áîëåçíè ìàëåíüêèõ ñîñóäîâ, êîòîðàÿ ïî÷òè íåèçáåæíà ïðè õðîíè÷åñêîé ÀÃ. Íó è êîíå÷íî äåéñòâèòåëüíî çäåñü íóæíî ñìîòðåòü êàæäûé ñëó÷àé â îòäåëüíîñòè.  öåëîì, íà äàííîì ýòàïå çíàíèé äàæå ë¸ãêóþ ÃÁ íóæíî ëå÷èòü, íî âíà÷àëå íåìåäèêàìåíòîçíûìè ìåòîäàìè, ÷üÿ ýôôåêòèâíîñòü èíîãäà äàëåêî íå ìåíüøå ìåäèêàìåíòîçíûõ. Íî ýòî óæå ïåñíÿ ñ äðóãîé îïåðû. Ñ óâàæåíèåì, TARIKAFR. |
#7
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äà ÿ ñîãëàñåí, ñêîðåå âñåãî âñå óõóäøåíèÿ ñâÿçàíû ñ ñëèøêîì àãðåññèâíîé òàêòèêîé íà÷àëà òåðàïèè. Áóäó îòñëåæèâàòü, ÷òî, â êàêèõ äîçàõ ñ êàêèì êîíòðîëåì ëå÷åíèÿ ïðèõîäÿò òàêèå ïàöèåíòû. Ñ áëàãîäàðíîñòüþ è óâàæåíèåì!
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#8
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Óâàæàåìûé TARIKAFR!
IMHO, Âû íåñêîëüêî ïðåóâåëè÷èëè óðîâåíü äîêàçàòåëüíîñòè êàñàòåëüíî äàííîé êîíêðåòíîé òåìû. Õîòÿ ïîâûøåíèå ðèñêà èøåìè÷åñêîãî èíñóëüòà (ÈÈ) â öåëîì äåéñòâèòåëüíî íàïðÿìóþ çàâèñèò îò ñòåïåíè âûðàæåííîñòè ÀÃ, äîêàçàííûé îïàñíûé óðîâåíü íà÷èíàåòñÿ ñî çíà÷åíèé, ïðåâûøàþøèõ îïòèìàëüíûé óðîâåíü (115/75 äëÿ âîçðàñòà 40-89 ëåò) íà 20 ìì ðò.ñò. ñèñò. è 10 - äèàñò. Ñîãëàñíî äàííûì 7-ãî îò÷åòà JNC: Prevention, Detection, Evaluation, and Treatment of High Blood Pressure ( [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] ) ýòè ãðàíèöû êàê ðàç è îïðåäåëÿþò ïîíÿòèå ëåãêàÿ Àà (èëè ïðåãèïåðòåíçèÿ), îòíîñèòåëüíî êîòîðîé íå ïîëó÷åíî óáåäèòåëüíûõ äàííûõ çà ïîâûøåíûé ðèñê (ÈÈ) è êîòîðàÿ íå òðåáóåò ëå÷åíèÿ. |
#9
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ðåêîìåäóåòñÿ ïîääåðæèâàòü ÀÄ íà óðîâíå 135-150
[Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] |
#10
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Ñòðîãî ãîâîðÿ ýòî âñåãî ëèøü ìíåíèå À.Ñ.Êàäûêîâà è Í.Â.Øàõïàðîíîâîé, ïðèòîì áåç ññûëîê íà êàêèå ëèáî èññëåäîâàíèÿ. Ê òîìó æå òàì ÿâíàÿ ðåêëàìà îäíîé èç ôîðì àöåòèëñàëåöèëîâîé ê-òû, ÷òî íå äîáàâëÿåò ñîëèäíîñòè ñòàòüå. Ïðî ðåêîìåíäàöèè âàçîàêòèâíûõ ïðåïàðàòîâ è ìåêñèäîëà ïðîñòî ïðîìîë÷èì.
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#11
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????? Do six por dumayut:
Effects of treatment for hypertension on cerebral haemorrhage and infarction. D G Black, A M Heagerty, R F Bing, H Thurston, J D Swales One hundred and sixty nine patients admitted to hospital for stroke over 30 months were examined to see whether treating hypertension had influenced the incidence of cerebral haemorrhage and infarction. Seventy eight (46%) of them had normal blood pressure, 47 (28%) previously diagnosed hypertension for which they were receiving treatment, and 44 (26%) previously undiagnosed and untreated hypertension. Haemorrhagic stroke was commoner among patients with untreated hypertension, whereas infarction was commoner in patients with treated hypertension. Infarction and haemorrhage were equally prevalent in patients with normal blood pressure. Effective treatment in this population seemed to have had a substantially different impact on vascular disease, giving rise to cerebral haemorrhage as opposed to infarction. This is consistent with evidence from other studies that treatment for hypertension has little or no effect on the progression of atheroma. Br Med J (Clin Res Ed)289:156-159 |
#12
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Óâàæàåìûé, Hard. Êîíå÷íî, ðå÷ü çäåñü èä¸ò î ïîãðàíè÷íîì ñîñòîÿíèè, ëèìèò ãèïåðòåíçèè è ïîêàçàíèÿ ê ëå÷åíèþ, ãäå òðóäíî ïîëó÷èòü óáåäèòåëüíûå ðåêîìåíäàöèè. Íî êàê Âàì èçâåñòíî, íà ïðîòÿæåíèè ìíîãèõ ëåò íèæíÿÿ ãðàíèöà Àà òîëüêî ïàäàåò è íà äàííûé ìîìåíò íåò óáåäèòåëüíûõ äàííûõ, ÷òî îíà íå óïàä¸ò è äàëüøå. Íî óæå íà îñíîâàíèè ïîëó÷åíûõ äàííûõ êàòåãîðè÷åñêîå óòâåðæäåíèå, ÷òî
Öèòàòà:
Äàæå íå âñïîìèíàÿ äîñòàòî÷íî ÷¸òêèé ïîçèòèâíûé ýôôåêò ãèïîòåíçèâíûõ ïðåïàðàòîâ ïðè âòîðè÷íîé ïðîôèëàêòèêå íîðìîòåíçèâíûõ ïàöèåíòîâ/PROGRESS, HOPE/, àìåðèêàíñóèé ãàéä ñòèïóëèðóåò òàê Because the risk of stroke increases progressively with increasing blood pressure and because a substantial number of individuals have a blood pressure level below current drug treatment thresholds, nondrug or lifestyle approaches have been recommended as a means to reduce the risk of stroke in nonhypertensive individuals.93 - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ], ÷òî óæå ñàìî ïî ñåáå çíà÷èò, ÷òî ëå÷èòü òàêèõ ïàöèåíòîâ íàäî, äðóãîé âîïðîñ, ÷òî íåìåäèêàìåíòîçíî è ýòî âàæíî. Åâðîïåéñêèå ðåêîìåíäàöèè ïåðâè÷íîé ïðîôèëàêòèêè íà÷èíàþòñÿ òàê - Blood pressure should be checked regularly. It is recommended that high blood pressure should be managed with lifestyle modification and individualized pharmacological therapy (Class I, Level A) aiming at normal levels of 120/80 mmHg (Class IV, GCP). For prehypertensive (120-139/80-90 mmHg) with congestive heart failure, MI, diabetes, or chronic renal failure antihypertensive mediation is indicated (Class 1, Level A) êàê A high (> 120/80 mmHg) blood pressure (BP) is strongly and directly related to vascular and overall mortality without evidence of any threshold Íåñìîòðÿ íà òî, ÷òî âîïðîñ äåéñòâèòåëüíî äèñêóòàáåëüíûé, â äàííîì ñëó÷àå ðàçóìíî ñëåäîâàòü ðåêîììåíäàöèÿì è ëå÷èòü â çàâèñèìîñòè îò êîëè÷åñòâà ôàêòîðîâ ðèñêà, ïðèíèìàÿ âåðõíèé ëèìèò 129 ïðè íàëè÷èè äèàáåòà, ïî÷å÷íîé èëè ñåðäå÷íîé íåäîñòàòî÷íîñòè, è äàæå íèæå ïðè èõ ñî÷åòàíèè îñîáåííî âî âòîðè÷íîé ïðîôèëàêòèêå, ãäå - absolute target BP level and reduction are uncertain and should be individualized, but benefit has been associated with an average reduction of about 10/5 mmHg, and normal BP levels have been defined as <120/80 mmHg / - [Ññûëêè äîñòóïíû òîëüêî çàðåãèñòðèðîâàííûì ïîëüçîâàòåëÿì ] Ñ óâàæåíèåì, TARIKAFR. |
#13
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Äàâàéòå âñå-òàêè îïðåäåëèìñÿ ñ öåëåâûìè çíà÷åíèÿìè. Åâðîïåéñêèå ðåêîìåíäàöèè â äàííîì ñëó÷àå íè÷åì íå îòëè÷àþòñÿ îò àìåðèêàíñêèõ: 140/90 ìì ðò.ñò. ó áîëüøèíñòâà ïàöèåíòîâ ñ Àà è 130/80 - ó ïàöèåíòîâ ñ ñàõàðíûì äèàáåòîì è ïî÷å÷íîé íåäîñòàòî÷íîñòüþ. Ýòî òîò óðîâåíü, êîòîðûé íå òðåáóåò ëå÷åíèÿ.
Öèòàòà:
Öèòàòà:
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#14
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__________________
Êîãäà çíàåøü ïî÷åìó íåëüçÿ, òî óæå ìîæíî (ñ) Ñ óâàæåíèåì, Ãóñåéíîâ Òèìóð Þñóôîâè÷ Ñàéò dr-timur.ru |
#15
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Öèòàòà:
Ïîëàãàþ, êàê íåäàâíåìó æèòåëþ Êàëèôîðíèè, åìó áóäåò èíòåðåñíà ýòà ïóáëèêàöèÿ: Öèòàòà:
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