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חוברת סיכומים במשפחה 2008-2009
חוברת סיכומים במשפחה 2008-2009
2008-2009
:
JNC -
) +
13(20-
:
Primary care medicine
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CeorgeL. Llakris.MD
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L. Iz.zu^.1r.
h{D
Jor-trrrlr
Dani*l V. .ir.rnt:s.
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Rurn'.1.il[aterson"i\lD. i\11].1
-Srrzanne
Oparil. l\{D
'I'.
.lar:l;son \[iriglrt .h'.t{D. I'jhl)
Ii,lrrru'rl.[. llo<:t:r:ll:r"
PlrIl. I\lltl I
a n c[llt t "Nir t ionalllig h l -i l o o rl
Irressrr
rc [drrr;llion Progr:rrrr
Coorrlinat.ingConrnrittcr:
oR N,toRE
Ttilt.t 3 nrc,tpt s. t't-tE
National Iieart, Lung. and
B lood I ns t it u re (N H L B I) h a s
a d m i n i s t e r e dr h e N a r i o n a l
I i i g h B l o o d P r e s s u r eE d u c a t i o n
Program (NHBPEP) Coordinating
Co mm it t ee.a' cr oali ti o n o f 3 9 m a i o r
i rro fes s ional,it ubli c , a n d to l r" rn ri .,,
organizationsand 7 fedcral;rgencies.
On c im por t alnt f un c ri o n i s to i -s s u c
guideiinesirnd advisoriesdcsignedro
increasca\\:areness,
llrevcntion. Lrealtn 1 e nL,; r nd c c r nt r olo f h 1 ' p e rte
nsion
(high blood pressurefBPl). Sincethe
i
JAMA.2Q03:289:2550-ZSZZ
publiczrticrnof "The Si.xthRepclrtoI
the _]ointNationai Committcer:n tire
Prevcntion,Detection.Evaluettion,
ancl U N C V I) rel easecli n L997,r manv
TrezrtnrentclflI-ligh Blood Pressrire" large-scalech.n.icaltrials have been
published.
The decisionro appoint a commilSee also pp 2534 and 2573.
teelor "The Seventh.Report
of rheJoint
2560
www.jama.com
:l
TIIEJNC 7 REPORT
u
to com- iectecl,r which cizrssitiesstudies in
Ni-lLBI \\reb site.: in zrgreering
Last anci
mission a nel\' rcport, the director rc- a p r o c e s s a < l a P t e cflr o m
that the CoorclinatingComnrit- Abramson.5
cluestc:ci
The executive committee met on 6
teemembersproviclc'in u'nting a deuriicci
included meetrationale explaining ti'renec.essitvto up- occasions,2 o[ u'hich
ConrCoordinating
eutire.
tlte
u'ith
clate.the.guidelines and to dsscribethe ings
b1'
rnet
also
tcams
u't'iting
Tile
critical issuesand conceptsto'be con- .,',i,t"..
conre]ecn-onic
uscd
and
sidercd lbr a neu're.port.The]'iC 7 charir telcconlerence
the.rcport'
rvamselectedin irddition to a 9-rnenrber nruniczrtiotl.sto clevelop
/e-re
artd
created
\
dralts
Trn,cnt)'-[our
executive comnritte.eappointcclenits
At
farshion'
zr
reiteral-ive
in
reviette.d
tirelv tj'onr the NHBPEP Coordinating
used
comntirtee
cxecurive
the
meetings,
NHBPEP
The
Couimittec menrbershii:.
group processlo
Coordinating Conmrinecsen'edasnlcm- a modified ncxrinal
Tire Ni{Bissucs.
bers o[ 5 rmiting teams.eacho[ u'hich iclentih'and rcsolvc
revieu'cd
ttce
Commi
were co-chairedby 2 excculivecontmit- PEPCt-rorciinating
and
draft
irroviclcd
the pcnultimatc
tee membcrs.
tirc cxcclttive'col11Thc conccprcidcntifiedb1'the NI{- u,ritten comlllcnts to
nationillhl'pcrBPEP Coordinating Committee nlenl- nritrcc.In arddition.33
revi
cu'
cd and com l
caci
crs
tcnsi
on
bcrsl-rip\\'ere uscd to cievclopthc reNIIBPEP
Thc
document.
thc
on
mcntcd
llort oLltlinc.A timcline was clevclopcd
thc
approved
Committee
Coorclinating
in
5
work
to conrplcteand publish the
nronths.Bascd on Lheiclcntilied criti- JNC 7 rePort.
carlissuesanc{concePts,the executivc
RESI'I.T5
comnrittceidcntilicci relevantN'Ieclical
EP
(lr'leSi{) tc'rms and Classification of
Subjcct Hear<lings
o[ Bi)
clarssific:ltion
a
Iteylvorclsto furlher tcview Lhescien- tnnlr I proviclcs
The'
older'
or
l8
aged
)rerrs
tific literature.Tht'seMerSHternls\ve,It' lbr adulti
oI
nre'an
the
ott
is
basecl
MEDLINE se-archfs classi[it-.atirln
tusr:tlto gcntrralt.c
BP
scatt:d
tncasurccl
I
tnore.
or
ltropcrll'
f".ttlrat lbcuscdclnEngIish-larnguzlge.
n]()rctlffict-r'istr(lscic n ti [i c [i tcraturt' fro nrJanu- rcaclingson eacho[ 2 or
,."i 6'-11,
u'itli tl-reclatssi[icalion
ary 1.997througli April 2003-\rarious its. lrr L-ontrelst
fn rell()rt,il lle\\r
in
thcJNC
\\/cr(-'
rrrorricled
the
eviclence
o[ gracling
s)/sLenrs
prelrype'rtetlsiotr
c o n s i c l e r c da n d t l r e c l a s s i f i c a t i o r l .ot.gon' designatcd
and stilgcs2 zrnd3
s c h e n r eu s e d i n J N C V l a n d o t h e r has Leen ardded,
been cornb it r ed'
NIIBPEP clinical guiclelines\^'asse- hvpertensi on have
Management"
Initial Drug TheraPY
BP
Classification
Systolic
BP, mm Hg'
Diastolic
BP, mm Hg"
':120
Lifestyle
Modification
Encourage
Yes
Prehyperlension
120-139
StaEe t hyPerlenston
140-159
90-99
Stage 2 hyPertenston
>160
>100
Yes
drug
No antilryPerterrsive
indicated
Thiazide{yPe diuretics lor mosl;
rnav consider ACE irrtribitor,
ARB, P'blocker,CCB. or
comtrination
Drug(s)lor tlrecomPelling
irrdicatic;ns
:
1
TI-IEJNC7 REPORT
in AdultsWith
Treatment,and Controlof High BloodPressure
Table 2. Trendsin Awareness,
Yearso
74
1B
to
Aged
Hypertension
pitionat Health and Nutrition Examination Surveys,Weiglrted %
il (1976-1s80)
Awareiless
Treatment
0orrtrolf
lll (Plrase 1,
1988-1991)
lll (Phase 2,
1991-1 994)
1999-2000
R1
J I
'10
Accurate BP Measurernent
in the Office
The auscultatorl' nletilod of BP nlellsurementu'ith a ilrCIperiycalibratcdand
varlidatcdinsrrumcntsirould be used'r"
should be scatcdquictlv for at
Parrients
in a chair rather than on
ninutes
5
least
"
Li
fcstt'
l
c
i
czr(s
e
e
l
r4odi
f
th i s g o a l
uble. u'ith lect on dle
exztnilnertion
an
ti o n s "s c c ti o n)
floor anclarm supportedat hearrtlcvcl'
lv{casuremcnto[BP in tl-restanclingpoBenefits of Lowering BF
is indicatcciperiodicalh',espcer
I n c l i n i r : a l t - r i z r l sa,1 1 [ i h Y p e - r t c n s i vsition
u'ith 3596 ciallv in thoseat risk for postural}t11rothcrapr'hasbeenassctt'iatecl
[f
on. An elpllropriatc-sizcdcuf[ (cr"r
to 40% mrriulrcductionsin strolteinj t cr-rsi
r-irc
o[
B0')''-'
lexsL
at
encircling
itr-'
blaclclcr
c-idence;20?i:to 2596in m)'ocarclial
Llccllfarction; arndnrore than 509{'in lil=.10 ;rrm) shcrlrldbe ttscd Lr:t'nsurc
I
bc
shcluicl
mcelsuremcnt-s
least
,\l
trit-h
rac1,.
st-irgt:
in
ir is est.irlatedthat ixrie.rtts
BP is [he pcrintat r'r'l-rich
1 .h l ,p c rtc n si on(s)' stol i cB P . 1+ 0-159 maclc.5),stc,lic
nlore scrunclsis heard
2
or
o[
first
B
P
,
90-99)
the
di
astol
i
c
a
n
d
/
or
l
-i
g
mm
mm llg) and additional cardiovascu- (ptrasel ) anclcliastolicBP is the iroint
oI sounds
lar risk factors,achieving a sustaincd before t.lrediserppcarance
provideto
should
(ph:rsc
5)- Ph1'5icians
I2-mm l-ig dccrcasein systolicBP for
tlrt'ir
ivritittg,
in
:.lnd
I'crballr'
u'ill prcvcnt I clcathfor cvcrv llzrdents,
l0 y'sn1s
goals'
BP
and
nunrbt-rs
BP
of
spc.ci[ic.
ll lratientstrcated.In tl"rcllrcscncc
C\,D or targct-organdamage,onll: p 1rutsP Monitoring
tientsn'ould rec;uirethis BP redtictton Arnbulato!'Y
Anrbulatoq' BP lnonitoringiT provide's
to l)revcnt a deitrh.Ir
infomration about BP during dailv activi.tiesand sleep.AmbulatoryBP nroniBP Control Rates
of
I{lpertension is the most common pri- toring is u'arrantcd for evaluation
abin
the
(r,i,hiie-coat)
hypertension
nur)r diagnosisin the United Statest'ith
It is also
35 niiilion olficevisits asthe primarl' d1- senceo[ target-organinjuryt.
apparent
u'ith
patients
assess
(svs[o
helpfui
agnosis.l: Current coutrol rates
zrnddiastolicBP drug resistance,hlpotensive qmlptonrs
tolic BP <l+0 nlm I-1g,
(90 mm i{g), although imprQved,are r.r'ith anrihypertensivemedi cations, epid;-sstill lar belou' the Heaithv People2010 sod.ich1'pertension,and arutonclmic
are
vzrlues
BP
goal o[ 50Yo;307oare still unau'arethe]' funcrion. The anrbulatory
Au'ake
readings'
haveh)pertension(Taur-r'2)- in drema- usuallylou'er than ciinic
BP
joriw o[ patiens,controllingqistolich)'- hlpertersive individuals havea mean
durand
i-Ig
mm
135/85
perten-sion,u,hich is a more import-ant oi nl.or. than
The
C\,D rislt factor than diastol.icBP ex= ingsieep.nrore thanl2}tT5 mmllg'
moniBP
ambulatory
BP
using
of
leriel
ceptin patientsvoungerthan 50.yearstr
ollice n'leaand occurs nruch n*ta conrnronl,viri toring correlatesbetter than
inj ury' rB
t-organ
targe
rt'i
th
u
,r,rr.ri',..r,
considerabl*
older persons. has been
also promore difficult than controlling diasl AmbulatoD' BP monitorin'g
of BP
rolic hlpertension. Recentclinical trial$ vides a nleasureo[the percenuge
overallBP
the
havedemonsuatedthat effectiveBPcon' readingsthat are elevated'
reduction durtrol can be achieved in mosl patients load. and the extent of BP
+f,ata li)r lggg-2000 were computect (tv1.Wolz, unirubhsfretj rlatia, 2003) irJrn tfle Natlonal Hean, Lurtg' a15l tsloo':'l
"l'he srxtrl
LirimrnatronSurueysil ancilll (Ehases1 and 2) are'irom
lnstituie and clataloi-l.taronalHeatthand hlLrtflilon
Ot^^'l
D.
..
and Treatment ct Hign Bloorl Pres'
ReLrqttot tne Jotnl ttalronai Cornmifleeon Preventron,Delectron,Evaluatron,
1'10mm Hg or cJlaslohcclood presstti'eoi at leasi
sure.'1 Hrglr blt:oclpressureriiystot,c blooclpressrtrec,i at ieast
90 mnr Hg or tak:ng aniinype:'lenslve.rrleolcallon.
^r ,^^- +h^- oi.\ mm L.]n
cress';re ':t less than 90 mm Hg
rS,,.=l;i'.'b,,;;.r pt"r"irr" ot iess ihan 140 mm Hg and clastol;c ttlocd
TI.IEJNC7 REPORT
ing sieep. ln most indivicluals.BP clecreasesb)' 107oLo20% during tlie night;
drosein rn'homsuch decreasesare nol
.-,,\^^hr,rF^,ar
lJl CJLIIL
ar L
:-,--,...^^l
d,L lllLl
i:4L\LLI
-;-lt lJl\
l-^-,-,.-.li^
tLtl
L(ll LllU-
r,:rscuiareven[s.
Self-rneasurernentof BP
Bl ooclprcssuresclf-nreasuremcn
ts m a\/
bc.nefitpatierltsby providing inl'ornration on re.sponseto aurtihypcrtcnsive.
meclicatiori.inrl-rrovingpaticnt zrdherand in cvaluatinq
cnccu'idr Lheral)v,1'r
u'hite-coathl,irertension.Individuals
'wiLha nlcan BP of nlore than 1.35185
mm l{g measureda[ home are genere rl i yc ons ider edr o b e h f i re rtc n s i v e .
i{onrc nleasurcmcntdn:iccs should bc
chcclicclrcgularlr' [or arccurzrcl'.
Box 1. CardiovascularRisl<Factors
MajorRiskFactors
iivpcncnsiont
Cigarcttc smoliing
Obcsitl'(BMI >10)T
Ithvsical inactir.itv
Dvsliiricleuriat
D i a b c t e . sm c l l i t u s l
Darnage
Fleart
r'c;.trs
.'
i
L - c [ l v c n t r i c u l ; . r ri r v p c r t r o p l r y
Anqiua or prior tnvocardial in{irrcticrrr
Prior c oronr rv rcvascnl;.rrizltitrn
i-lcart failurc
Tira in
Fatient Evaluation
Strolic or transicnt ischcnric attitcii
E v a l u a t i o n o I p a t i c n [ s r , r ' i t i rd o c u Clrronic liidns' discasc
mcntcclllpcrtcnsicln hzrs3 objc:ctivcs:
lcripht.ral artcnal djscasc
(l ) Lozlssc-ss
lil'cstf'lcancliclcntil'otl',er
iictinopa tlir,
risli factorsor conconrit'rriior,'ascular
" l l i v l l i n c l i c a t c ls; o < l rr. r r a s si n i l c x c a l c t t i a r c ral s r r . c i g i rit1 1l i i i l r g r r r r r rt sl i v r c i c rbl ' , 't l r c s t l t t a t ' cr r i
tant disordersthartmav a['[ectprognoheight in meters; GFR. glc.mentlariiitraticln rflte.
ule lllctalx)u(:
rrrctairolir:
svrrcirrrnrc
5\'t-t(irolllc
srsarndguicietrcatmenl (Box 1); (2) to I lCtlnrponcuts rrl the
I
I
rt-r,czlliclcnt.ifiablec:ruse-s
oI high BP i i
(Box 2);and (3) to assess
thc pre-scnce
oI urge t-or-qandanrlgc lrrcl s i s , b l o o c l g l r t c o s ea n c i h e n r r t t o c r i L , I
or al-rscnce
C VD . T he dat a nc c c l c da rc a c c l u i re c l scRrnrpotassiunr,
crellininc (or Llrr'corBox 2. ldentifiable Causesof
ng esLinlatcdglclnrcrul;rr[iItirrotrghnrtrclicalhistorv, phvsic'rlc-"- re'-sponcli
Hyper-tension
anda lipid
Irnrinatio
n, rouLine.Iaborirtory[est5,ilncl traLionrate),irnd calciunrrtt;
Slecp apttt:a
(a[tera 9- to l2-hour [ast) t"hat
otlrcr diagnosricprocedures.
D r u q - i n c l u c e d o r c lr u q - r c i a i c d
irrr-rfile
(sccBox 3)
The physicalexanrinirlion
li poprotern choshouldin- includcshi gh-de.nsitv
Chronic iiidncv diselsc
al)prollriaLe
cludez1n
nrsrsurcnlenIo[BP, lcsterol,lor"'-densiD'lipoprotein choP r i m a r v a ld c l s t c r o n i s m
u'ir.hveri[iurtion in the contralaleralzrnn; Iesterol,and triglvcerides.O prionarltcst-s
discase
Renovascnlar
exirnrinationoI rhe opric fundi, bod1, include measlrrenentoI urinan' albuChronic stcroid therapv aud
index calculatcdas r.r'cighiin lii- nrin excretion or albumin/creatirline
n1i1ss
Cr-rshing svndrome
logranudivicledb)'the sqltarco[ hcight raLio.Iv{oreextcnsivetesting for idcnPheoclrromocvtoma
in metcrs (measuremcnto[ lvaist cir- dfiable causcsis not indicrrtedgencrCoarct.ationo[ thc aorta
BP control is nor zrclrieved.
cumferencezrlsomzrvbe r-rseful);arus- allv unle*ss
Thvroid or parathvroid discast
cultation for carotid, abdonrinirl.and
Treatment
:
fc-moralbruits; paipationoI tire tll'roid
gland;thoroughexaminationo[the heart GoalsoI Therap)'.Therultinlatepubiic
and lungs; exanrinationo[' Lhcabclo- healLhgoal o{'anti hlperrtensivetherapl' ate(l R,itha (iecreasein C\D complimen lor enlarsedliiclnel,s,nrasses,
and is ihe reduction o[ cardiovascul:rrand calions.In paticntsu'ith h1'pertension
abnormalaortic pulsat-ion;
paiirationo[- rc n a l n ro rb i di [), ancl mortal i i )' . B e- u'itli cliabetesor renal cliscase,the BP
the lou,er extrermitieslor edema and czlusemost patient,s11'1ifiliyperten- goerlis lessthan l30i80 nrni l-lg.rr'I
Lifestyle Iv{odifications.Adoption of
pulses;and ne.urologicalassessmerlt. sion, especially[hose aged at least 50
lifesn'lesb)'uil individuals is
u'ill
reach
BP
goal
healthy
the.
dizrstolic
)/e-ar:s,
Laboratory Tests and
onces);'stoiicBP is at goal. [|e irrimarl' critj.calfor the pre.ventionof high BP and
Other Diagnostic Procedures
focus sl'rouldbe on achier.rng[he sir5- an indispensablelrart o[ the nranage.R o u t i n e l i r b o r a L o r ) ,t e s t s r e c o n l - tolic BP goal (FtcLn{E).Treating sys- mcnt of those 1ari1[fiypertension.Mamended beiore initiating [herapf inrolicBP and diasroiicBP to targetstha[ jor lifestyle modifications shou'n to
clude an electrocardiogram;urinaiy'- are less than 140/90 mm Hg is associ- lor.l'erBP include u'eight reduction in
C200.3 American l.lciic;il Associatian. :\li riglits reserved.
TI-riiJNC7 REPORT
(Tanm 3).ioLifesq'lenodilications de- o[ 2 or more lifcstf ie moclilicationscan
creascBP, enhance antihl'pertetnsit'e arcilieveerrenbetler rcsuls.
Pirarmacr'rlogicTreatment. Exceiclrug efficacl',and dccr*rse cardiovasso- lent clinisrl trial outconle ciatairrove
cular risli. iror example.a 1C-r00-mg
cltrsses
ciium Dietary Approachesto SLopI-i1'- thatt-krwering BP r.l'ithse,r,erarl
z
r
n
g
r
o
tensitti
n
c
l
u
d
i
n
g
d
r
u
g
s
,
o
f
has
plarn
eife.crs
sinrilar
eatilrg
1:ertensiotr
enzvnte (ACE) inhibit.ors,
Combinat.iorils t-.onvertin-q
to singledrug dreraP)'.15
;rngi otensin-receprorbiociiers (ARBs),
r
B-blockers,citlcium chanrreiblocliers
Figure. Algorithm for Treatment of Hypeftension
(CCBs),arndthiazide-qpedir-rre
tics,u'ili
all re.ducethe conrplicationso['h1per4 and Taslr 5 proTABI-E
[ension.rorr"]i
r.ide a list of commoull uscd anLih\rpcrtcnsivczlgents.
the
beer-r
Thiazidc-npe diureticshzlr.'e
bzrsisof antihlpcrtensivethcrap)'in most
ou[conletriais.iTln t]rescLriais,inciuding the reccnth,publishcd Antihr,pcrrensiveand Lipid-Lou,crins Trcatnrcnt
to PrcvcntlJcart Attacli Trial.rl dir"rrctin
ics [ravebccn virtuztllyunsupptt-sscd
conlplipreventingthe carciiovascr-riar
Drug(stlor the
Stage 2 Hyperlension
Stage 1 Hyperlension
(SvstolicBP >160 mm llg or
( S y s t o l r cB P 1 4 0 - 1 5 9 t n m H g
CompellingIndicalions
o{'hlpertcnsicrn.The cxccption
catiLlns
(SeeTal:le6)
Drastolic
BP >100rnrnllg)
or Diastolc BP 90-99 mm llg]
AustraiianNationalBlood
is
the
Second
Drugls
Ollrer/rrrtih11;erten:;rve
Tl lazrde-Tlpe Diurotics for Most
2-DruqCornbinationfor Most
(Druretrcs.
ACE Lrlrrirrlor;
ARB,
bcLliriazrde-Ty1re
Diuretic
Lhatreporlcclsii-qirLi)'
triaP6
Prcssurc
{Usuatty
Mav Corrsrdcr ACE Ltltii:itcr, ARB,
p-Blocker,
CCB)as Needed
arrdACE hrllillitoror AflB or
rcgilfBlocl(er, CCB, or Cotnbirra|ror
rt'ith
a
r,l'hite
men
in
outcon'res
Lcr
llBlcrker or CCB)
mcn that-beganu'ith an ACE inbibit.or
comparcdu'ith otre startingu'ith a diti hlpcru rctjc. Di ureticsctrltanc:et.lrc:,rn
ir:nsivccllicacyoI ntttlticll'ugrcginre.ns,
Olrtirrrize Dosages or Add AcJditior-ralDnrgs Utttil Goal BP ls Acltieved
I i n achievil-tgBP ct>nl-rol. ;rnc1
ctn bc r-r-sefu
Corrsider Consultatron W(lr Hyllerterrsiotr Sg:ecialtsl
are nlorc aflordablethan ollit-.ranLihl'ilgcnts.Despite these findirerten.siveccptcrrblocker,arrd CC5,
ACE,angioLcnsin-convt-.rting
enzynre;ARB, angicrtcnsin-re
BP indicatesblc.,crd
1)rcssurc;
ings,diurclicsr cnurinutrderuscd.le
calciurnclrannel blocker.
Thiazide-qpediureticsshouldbc uscd
as initiarlther"airl'for ttrosti)arieltis$ith
Table 3. LifestyleN'\odificationsto ivlanage Hypertension"
or in combilrtpertension,eitheralor.re
Approximate Systolic BF
nirtion u'ith l of the other classes(ACE
R e d u c t i o n .R a n o e
Reconrmendation
Modificati<ln
inhibitors, ARBs, B-blockers,CCBs)
normalbody werght (Bl'/1,18.5-24.9) {-r-20mm Hg/10-l'rgweig$t
lr4arntairr
Weiqlrl reduction
dcmons[ratedto bc bencficial in ranl6cg2:.zr
2c
conuolledoutconletnzris.The
domized
6- 14 mm Hg'.5
Adopt DASH eating
Consume a diet rich irr tntits, vegetables.and
plan
low-fat dairy products witlr a reduced
list of compellingindicationsr:ecluiring
conterl ol saturaled and lotal{at
the use o[ cltheranlih\;pertensivcdrugs
Reduce dietary sodium intake to no more tlran 2-B nrm Hg::-z;
Dietarysodium
as
initiai therapy are listed in Tnuu 6.
reductiort
100 mEqiL (2.4 g sodiutn or 6 g sodium
clrloride)
I[ a cirug is not toleratedor is contrain4-9 tnm Hq2a2e
Physir.;al
Engage in regularaerobir: physir:alactivity
activiiy
dic:rted.then I of the othercla-sse-s
ll ro\/en
such as brisk walking (at leasi 30 mintrtes
shotrlcl
eve'nLs
carcliovasculzrr
to
reduce
per day, most da-vsof the u;eek)
be uscrclin-steatd.
2-4 mm Hgsr
liloderation of alcohoi Limil consumption to no more than 2 drinks
per day (1 oz or 30 mL ethanol[eg,24 oz
Achieving BP Control in Indiconsumpllon
beer, 10 oz vrrine,or 3 oz BO-proof
vidual Patients. Most patielltsu'ith lrywlriskey'l)in most men and no more than
pertension udll require 2 or nlore anti1 drink per day in vuomen and
liglrter-vreightpersons
hlpenensive medicatioLq[o achiev'ethei.r
Accreviatrons:Btvll, body mass index cal';uiatedas \rergni rn kilogams divided cy the sguare oi herght tn melers;
Addition o[ a seconddrug
goals.ta'15
BP
BP, orootJpressu;'e;DA.SH,Dieta;"/Approacnes to Stop Hypertensrot't.
';For overallcardrovascularnsk reduciron,stop srnokrng.The eitects oi inrplernentirrg
these nrodfrcalionsare dr:se arrd
from a different classshould be inititrme dependent and cc'uld be higherior some rndivrduals.
ated u'hen use of a single drug in adthose ir-rdivicluaisu'ho are ovN'eight
adoption o[ DieLaryApor obe-se2-1'r+:
proache-sto Stop l-I1'pcrtensioneating
p l a n ,r5u, hic h is r : ic h i n p o ta s s i u m
and calciumr"; clicur)' sodiunt reciucand
ti o l tr5 -r 7iph1t 5i. olac ti v i1 1 rr3 ' r!;
rn o d e lat ionof alc olr o ic o n s u rtrp ri o n
?564
TI.IEJNC7 REPORT
equurtec{oseslails to arcirieve
the.BPgoal.
When BP is more than 20/ILl mm l{g
above:goal,con-sidt-.ration
shouldbegiven
tLLr
n itliiLldlLItrS
nitinti^-
r l - , - . . . ' , r , -\4rILll
.,'itl- -'l J-..^
LrrCIZtiJ\;
/ QfU.q,S, ei-
ther asseparaLe
prescriptionsor in fixecldoseconrbinations(Figure).The iniriation of drug therap)'\ /ifi more rhan i
;1*Q:er1t.
rrlaryl6qt'easethe likelilrood of
achicvingth.eBP goal in a more rinrellr
lhshion. but pltrricularcauiion is advise.din thoseat r:iskflorordrostatichvpotcnsioll, such aspatienErn'ithdiabeTable 4. Oral Antihypertensive
Drugs"
Lcs,autotlomic d)rsfunction,and some
older persons.Use of gcnericdrugs or
Class
Drug ffrade Name)
combination drugs should be consid- Tlriaziciediuretics
Cttlorothiazide (Diuril)
crcd Lcrreduce prc-scriptioncosr.s.
(generic)
Clrlortlraliclorre
Foilorv-up and IVlonitoring.Cncc ernHydrochlorothiazide
HydroDlURlL)1
1ifu1:pcrtcnsive
{l"4icrozide.
drug thcrapv is ir-ritiPolytlriazife lFenese)
atcd. nlost ir:rtientsshould return lor
lndapamide(Lczol)t
{ollou,-up ancl adjusrnlcnt o[ nreclicaMelolazone(lvlykrox)
tions at apllroximatc\' monthl) inrcrMelolazo[re (Zaroxolyn)
vals until LheBP.qoalis reached.Morc
rjirrretics
(Burnex)f
Bumetanifle
lrcclucntvisits il,ill be necessary[or p;r- Loc-:6t
FuroserrriQe
Licntsr.l,iLh
{Lasix)1
stzrgc2 hipcrtcnsionor r.l'iLh
Torsemide(Demadex)t
comp iicating comorbiclc.ondiricrn_s.
SePotassium-sp.raring
diuretics
Amiloride(Midamor)t
ruul i)otassiumanclcreatinineshoulcl
(Dyrenium)
Triarnterene
l:rcnronitorerclar leastI to 2 tinresper
Aldosterone-recef:tor bloct<ers
(lnspra)
Eplerenone
)/ulr.r':AfterBP is ar goaland suble, folSpironolactone (Alcjactonei-l
l cl r,r'- ull
v is it s c ln us u a l l )'b c a t _ j - to
Alerrr:ktl1Tt:normin)f
(:r-nro n Lhi rrtcnrzrls.Conroririd i ties.strch f3 BlocP.ers
Betarr:lo| (l(erlone)1'
irsI-lF, zlssoci:ttccl
clisearses.
such asdiaBisoprolol(Zebeta)f
bctcs,and the nceclfttrlaboratonrtt.sts
Metoprolol
{Lopressor)t
influencetlrc lrequencvo[visits.Orhcr
Meloprolol exlended release
cardiovascular risk factr-rr.s
should be
floprolXU
lrcaredto Lhcirrespectivegoals,and tol.,ladolcl(Corgardll
bacco avoidanceshoulclbe pronroted
Propranolol(lnderat)f
vi.gorousl)'.Lou'-doseaspirin therapy
Proprancilcllong-actirrg
should be consideredonly:u'hen BP is
{hrderalLA)t
Timolol(Blocadren)t
controlled,becausethe risk of hemorAceLrulolol(Sectral)t
rhagic stroke is increasedin parients [3-Blocl.rersrvith irrtrinsrc
s'y'mpatlromimeticactivity
q'i th uncon trolled hrpertension.6l
Penbutolol{Levatol)
Pindolol(generic)
Special Considerations
Tire patient u'ith hlpe rtensic'rn
and certain comorbic{itie-s
requiresspecialartcntion and follou,-upb;' rhe clinician.
Compelling IndicationS.Table6 clescribes compe.llingindication_sLha[require certain o,,t11fi1;pertensive
dr-ug
classes[or:lrigh-riskconditiorr. Thedrug
selections lbr rbe-secornpellingindications are based on favorableoutconre
data fiom.clinicairials. Combinirriono[
ag. 'r ts ma)' bs required. Other managem.ent consideradonsinclude medica-
Usual Dose,
Range, mg/cl
Daily
Frequency
125-500
12.5-25
l'4
u.c- t.u
0.5-Z
20-80
2.5-'10
5-10
t-z
CU- IUU
t-z
50-100
{o
Z
2
t-t
25-100
5-20
2.5-10
50-100
50-100
1.r
t-<
40-120
40-160
60-1B0
20-.10
200-800
10-40
lLr-40
Caryedilol(C,rreg)
12.5-50
200-600
ACE inlribitors
Labelalol(Normodyne,
Trandate)t
Benazepril(Lotensin)f
Captopril (Capolen)t
Enalapril
{Vasolec)t
FoSirroprilfMorrof:ril)
Lisinopril(ftinivil, Teslril)t
Moexipril(Univasc)
Perindopril{Aceon)
(Accr-rpril)
Ouinapril
Ramipril (Al{acei
Trandolapril(Mavik)
r i
10-40
25-100
2.5-40
10-40
10-40
7.5-30
4-B
10-40
2.5-20
t-t
1 a
{.1
t-a
1 A
(cctltinied)
(Reprinted)
JAi\AA,\,lay 21, 2Ct03-\t:l 289. No. 19 2565
)':'..'#
',,'
Tr-iEJNC7 REPORT
ci4l.si]';l''tl'61
lntcnsive lipicl managemc.r1and
L
as pir in t h e ra p y e rrea tl s o
incliciitcd.
I-IeartFailure. Ilearr failure, in the
foriii of'svslolic or ciiztstoiicvenlricuiar c11'5functit-rn,
resuirsprinrarilv fj'om
s),sto l ich1' penens io na n d i s c h e n ri c
irt-.iutclisease.
Fi-rsridious
BP itnd clrol e stcro lc ont r ol ar e t h e .p ri m a n ' p re \rendvc nlcasuresfor thoscat high risli
lbr I{F.r0In asj'nrplomaricindividuals
u'i tir demonsuablertentricular dvs[unction, ACE inhiL-'iLors
and f3-blociicrs
zrre
r e c o l l l n r e n c { c d . 5 lF
' 6o1r i h o s c u ' i t h
qrntptonratic r:cntriculard1,5ft1nction
or lavorabli' affcct t|e 1:rovression oIdizrenci-staqeheart disc.ase,
ACE inhibi- betic nephrol:ath1' xtt,1 recluce albutor-s.B-biocltcrs.ARBs, an.clariclosLe-minuda,55'5t'andARBs havc becn shou'n
rone blockersare reconlnlenclccl
alons to reduce progression [o ntalcroaibur-*$
u.itir i clolt rliurr:tics.at''a
ntrnunil."''"
Diabetic l-lvpcrtension.CombinaChronic Kidne)' Disease. ln pations of 2 or more cirugsare usualJv ticnLs uith chronic kidnev clisease,dcneedt-.d
to aclrier.e.
t}e rargctBP_gozrl
o{' fined bv citirer (1) reducecl excrerorl'
-l30/80
le-ssthan
nrm l-]s.rr.rrTl'riazicle I'unction u'i[h an estimated glourerular
diurerics,B-blocliers,ACE inhibitors, [i]u'ation rat.col'less than 6C ml/nrin pcr
ARBs,and CCBs arc beneliciaiin re- I .73 nrr (corr:esponding zrpproxinrirtel1,
ducurgC\,T)and srrokc inciclcnccin 1t;r- ro a crc:.lrinirreo[ > 1.5 mgidl [> ] 32"6
ricntsrn,irhciiallc1...')J'i-.rrl
Tlrc ACE lil- pmoVl-l rn men or ) I .3 m$di- [> 1]4.9
h i b i t o r - o r A R B - b a s c dr r c a l m c n [ s LrnroVi-l in n'omen)r0 or (2) Lhe pres-
T a b l e 4 . O r a l A n t i h y p ef t e n s i v eD r u g s ( c o n L ) '
Angiotensinll antaeonists
UsualDose,
R a n g e ,m g / d
400-800
1{i0iloo
Daily "
Frequency
1t -aL
Losartan (Cczaari
Olrnesartan{Benicar)
Telnrisartan{Micardis)
Valsartan(Diorran)
Calciumcirarrrrei
Diltiazenrextended release
/n--ii-^nn
blockers-non-Cihydropyridirres
ll Uu,
:0-40
:0-30
[i0-320
180-.120
t\JcrlUladl
DilacorXR, Tiazac)t
Diltiazemextenoed release
(CardizernLA)
120-540
Vera;lamiiimrnediaterelease
(Calan,lsoptrrr)f
C;rlciumchannel
- 4r'rydropvricli
b irlc11spr
nes
Verapamillong-actinq
(CalanSR, lsoptinSR)l
120-360
Verapamil-coer(CoveraHS,
VerelanPM)
120-360
Amlodipine iNor"'asc)
a a
l n
!--t'l',)
(Plendil)
Felodiprr-re
a ; a a ,
Z.J-.!\)
l - l
lsradipine(Dyracirc CR)
rr,-[3locl<ers
Central({?-agonislsand other
ceritrall'/acting drugs
60-120
l.lifediprne
lcrrg-actirrg{A.JalatCC.
ProcrardiaXL)
30-60
l'.lisoldipine(Sular)
10-40
Doxazosin{Cardura)
r-tt)
Prazosin(l\4irripress)f
Terazosin(H,/tnn)
t-z.J
Clonidine(Calapres)t
0.1-0.8
Clonidinepatc;h(CatafrresTTS)
0.'i -0.3
Metlryldopa (Aldonret)l
Eeserpirre(generic)
Guanfacine(generic)
Direcl vasodilators
2-3
Hydralazine(Apresoline)-l
l'/iinoxidiliLoniten)t
1 ,o;eekli.
250-1000
0.0s-0.?5
4.5-2
25-100
2.5-40
't+
,+
1 a
t-z
Abbreuatton:ACE. angtotenstn-converttitg
enzyme.
':Dosages mav van/ t:-ornthose lisled +-he
in
Ph),srcians'Desk Refercnce,33
whrclr may ce consulted ior addrlionaltrrtor-matron.
lAre rrow or wrll soon be(jome availaolein genenc preparatto;rs.
iA 0.1-mg dose inay be grvenevery oiher da-vto achrevelhrs dosage.
2566
JA.MA,I,,l;r1'21,
201)3--VollB9, l.io. 19 (Reprinted)
TI.IEJNC7 REPORT
nomic lactors iud li[e-st)'ic'ma1'be im- manzrgeditggressively 3trd aspirin
Trcatmen[recestratesof BP controi.$8
ommcnda[ions lor oider inclivicluals
llorLzlntbarriers to BP control in some shoulclbc uscd.
minoriq' padents.The prevalence,sertcrrsion i n OlderIn dit idrrals.,I-l)'- u'itir hflrertcnsio n, inclut{ing those'u'ho
H-11rc
vcrit)', and iniprtct o[ hlpertension alre pcrtension occurs in more ti'ran !wo have isolated q'stolic h;*pertension,
increasec{in blaclis, '',r'hoalso demon- t-hirdso[individuals after irgef:5 ],e+rs.r shoulc{follou'the sermeprinciplcs outsrale sonieu'JratreducedBP responses This i-sdso the populzrtionu'ittr the lbulined lbr llre ge.neralcare o[ hi'pertento monotherap)' u'ith p-blockers, ACE
inhibitors, or ARBs contpare.dr,r'ithdi- Table 5. CombinationDrugsfor Hypert$nsion
uretics or CCBs.Thesedifferendal reTrade Name
Combination Type
Fiked-Dose Combination, mgo
sponseszrrelargelir climinateclby d*g
Lotrel
ACEirrhibitors
arrdCCBs
Amlodipine/benazeprillrydrochloride
0,s/1o,5/20.1o/20)
i2.5i1
cornbinations tlrartinclude adequate
Enalapritmaleale./felodipine(5i5)
doscsof a diuretic. AngiotensinTarka
Trandolapril/r,e
rapamil (.2h8A, 1i24O,
converting enzvnle inhibi tor-induced
2/240.4/240\
angiocdenraoccurs 2 to 4 timesmore freACE inhibrtorsarrd diriretics
Benazepril/h-"-drochloroihiazide(5/6.2f.r, LoiensinHCT
clucntly in black patients ,n4,1tfilrper10/ 12.5, 20/ 12.5, 20/25)
Lcnsionthan in odrer groups.rr
Capozide
Capto prilihydrcclrloroihiazicje
{2fj,'15.
25/25,50/15, 50i25)
Obcsitv and tlrc N{etabolicS)ntdrontc.
Vaseretic
Erralaprilmaleate/lrydrcclrlorotlriazicJe
Obesitr'(bodi' mztssindex >30) is ernin6/12.5.10/25)
crcasingll' prer.'aientr:isk factor for the
Lisinopril/hvdrochlorolhiazide(10i12.5, Prinzide
dcvelopnrcnto[ h1'pcrtcnsionand C\,'D.
20/1?.5.20/25\
Thc Ach-rlL
Trealncnt Parnclill guideUnrretrc,
HClihydrochlorotlriazicJe
l'./loexrpril
\i .Ji | 1.c, ti)/tcl
line for cholesterolmanagemenLdeAccLrrelrc
OtrirraprilHClr'hydrochlortrtlriazide
fines tlie nrctabolics);nclromeas thc
(10,,12.5, zoi 12.5, 20/25)
prLscncco[ 3 or morc of' the [el]1ry,'ing
ARBs anc diurelic:;
Candesarlan cilexetil/h,ldroclrlorotliia:ide AtaoancjHCT
concli tions: abclonrinal obc'sit1,(u'arist ci ri16/12.5, 32i12.5\
} 102 cm [>.+0 in] in men
ctrm{crence
Eprosafianmesylateihydroclrlorothiazrde TevetenHCT
or )89 crn [)'35 in] in rn'onren),
glui600/12.5, 600/25)
> l.I 0
Avalide
(fasdnggluco.se
lrtresartan/liydrochlorollrituidet-i5/12.5,
coseintolt'.rancc
1 5 0 i 12 . 5 , 3 O O / 1 2 . 5 )
nrE/cll-[=tr.l rnnrol/Ll),BP o[at lcusr
Lo:;artan potassiunr/lrydroclrlcrothiazide Hyzaar
(> I.50
I 30/E5nrm l-lg,higlr tngll,ccricles
i5o,/12.5,100/25)
mg /d l [ > I . 70 r nnr ol /L ]),o r l o ra ' h i g h Tehlisartanihydrochlorolhiazrde
Micardis HC-I
(40/12.5,BOi12.5)
clcnsiL1'li.poprgtt'.incholesterol((40
Valsarlan/lrvdrochlorothiazide(80/12.5, DiovanHCT
rlg/dl [< I .0'1nrnrol,/Llin men or (50
160i12.5',)
n:g/dl- [<t.:O nrrnol/LJin u'onren)."6
l-enoretic
B-Bltrckersand druretics
Aterrolol/clrlofilralidone15Oi25,100i2:j)
I ntcnsivclifesntler:rodi[i car.ionshou]d
Ziac
Bisoprolol f unrarate/hydroclrlo rothiazide
be pursued in all indir.'idualswith dre
(2.5/6.25,5 i6.25, 10i6.25)
nrctaboJicsyndronre,and appropriate
Inderide
Propranol.cl LA/hydrochlorothiazide
drug therapv should be insriruted lor
(4Ot!25.80/25)
Meloprolol tartrate/hydrochlorotluezide
eaclro[ its components as indicated.
kf t Vcntfi cttlarllt p a'trophy. Left ventricular htlrci'"" -,lrf it an independcnr
risli lactor tir;.. . ;casesthe risk o[subTimolide
sequenLC\rD. iiegressiono[ left ven(1Ot25)
tricular |n,pcrt"roph)'occurs with ag- Cenlrally acting drug and diurelic
Methyldopa/trydrochlorothiazide
Aldorii
(250/15, 250/25, 500i30, 500,/50)
gressiveBP managemenl,includins
Reserpine/chlorothiazide(O.125/250,
Diupres
u'eight loss, sodium reslriction, and
0.25i500)
LrcaLnlentn'ith ali classesoI antihl,i:erHydropres
Reserpine/hydrochlorcthiazide
p.125/25, O.125/5Oj
[r'rLsirre'.
zlgentsexcept dre clirectvasodilalors, h)'dralazineand minoxidil. rr'7
Diuretic and diuretic
Amiloridel-lCl/ttydrochlorcthiazide(5,50) Moduretic
Pariphcral Arteriql Discasc.Per:iirirSpironolactone/hydroclrlorothiazide Aldactone
(25/2s,50/50)
erarlarterial diseaseis equivalenrin risli
Triamt
Dvazide. Max/de
erc ne/hyd rochlorothiazide
to ischenric hean disease.Anv classo[
(37.5/2?:,5O/2{:, 75/50)
andh)'pertensive drugs can be used in Abbrevrations:ACE, arrgioterrsrn-conveningenzirme:ARB, angiotensin-r'eceptorblocker: CCB, calcrum channel blocKer;
HCl, h;drochlonde; HCT, hydrocnbrothrazide:LA, tong-acting.
nrost patients r,l'ith peripl.-r'al arterial *-Qome
d.,Jg comb:natrons are ararlable in multiple fixed doses. Each drug dase is repot'ied rn milligi'arrs.
disease.Other risk tacrors should be
I
ovval
(Reprinted)
JAI\AA,
May 2I, 2003-Vol 289, No. 19 2s67
Tr{EJNC7 REPORT
I
shor-rlcliriive their BP checked regtr- definerdasBP that is, on repearedmeaizrrll'.Deveiopmento[ hyperrensionis a srl rement,at rhe 95ti r percen[ileor
reasonto con-siderother forms o[,con- grezlteradjustedfor ase.height, zrnclse.r.i]
trelception.In conrasl hormonereplteThe filtir Korotkoff'sound is useclro
nlent therapvclorsnot raiseBP.il i
defineciiastoiicBP.Cliniciansshoulcibc
\\;ornen u'ith h,vPe.rtension
u'ho Lre- alert lo the possibilirv o[ identillable
conlellregnantslrouldbe follorn'edcare- causesoIh11:ert.ension.
in vounger cirill'ul[r'bt'cause
of increasedrislis [o nrrrrher dren (ie, kidnel' disezrse,
coarctittiono[
and fetus.Merlri'ld6pa,B-blocl<ers,
and the aorur). Life-sn'Je
inte.n'enriollsare
\rasodilalorsareprc{bred nredicarjon-s
ibr strongil' recontnlepded.,
u'itfi pharnrirthe safcq' of tfie fr::tus.i2
Algiotensin- coiogic r.lreral:\' insti tu ted frrr hi gher i er,convertingeniyms inhibirors and AItBs cl s of B P . or i [ there i s i nsuffi cienr
shouldnor beusedduring pregnarno'be- rcsponscto lil'csqrlemodifications.i+
c:lLLsc
o[dre potentiai for feml dcl'cctsand Choices of antihyi:rertensiriedrugs arc
should be arvclided
in'*.r,omenu'iro are similarin childrenand adults,but efleclilieli' to becomepregnelnt.Prceclzrnrp- tive dosesfor children are olten smallcr
sia. 'n'hichoccursalter the 20th gcsrzr- zindshould be adjustcdcarefull)'.Angiotion u'cck of prcgnatlqy,is charactcr- tcnsin-con\.'ertinq cnR'meinhibitorsaurd
i z c d b y n e \ v - o n s ct o r u ' o r s e n i n g ARBssirotild nor Lreused in preqnzlntor
hypertension.albuminuria.and hlper- scxual l vzl cti vcgi rl s. U ncompl i cat cd
uriccmia. somctines u'ith corrgularion hrpcrtensionshor-rldnot be a rerlsonto
abnormalities.ln sonle patit:nrc,pre- rcstrict cirilclrcn lrom parricipatingin
eclamprsiar
nta1,dqy.loir i11to4 hrpertcn- phy'51.,.o1
LlcLivi ti cs. l-rzlrtic Llizrrl )' b cm use
sivc urgenc):or c:mergencv
and [1i]1,'ps- Ittng-tcrm excrcisettta1rls*,"r BP. Usc
c ; u ir e h o s l r i t a l i z a t i o n .i n L e n s i r . ' c ol' anabolicsteroidsshotrid!615t1-sngiv
sive tirerap1r.{ttl'7t'r
monitoring, earlvfetaldelivcrn/,and par- discor.rrageci.
Vigorousintervendonsalso
H-lycltensiorrin lVrrnrr:n.Orai cclntra- en[rrralantihlrpr:rtensive
and anticon- shoulclbe conductedlor orher cxisting
r'cptive-smay incrcue BP and the risk oI
vulsantthr:rapy.;r
(eg, snrolting).
modiliable risk flactt-rrs
h1:perLel'rS
ion i rrcrcasesiarith durzrdon o[
Chiirjrcn cmtl,4dolcscort.s.
In chiJH-r2crtcnsivcLir;qorcics
rrndEnrcrgcnuse. Wolnr'n tilliing oratlcontr;1(:cl)tjves clrcnand adolesccnts,
hypcrtensionis ri crs.P at-i t:nts
\\' i th rtrarl tedB P cl eva-
T a b l e 6 . C l i n i c a lT r i a la n d C u i d e l i n eB a s i sf o r Compelling
Indications
for tndividual
DrugCla
High-Risk Conditions
With Compelling
lndication*
Recommended Drugs
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Aldosterone
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ClinicalTrial Basist
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NI(F-ADA Guideline,rt'??
UKPDS,s'ALLHAT33
NKF Guideline,22
Caplopril Triai,55RENAAL,56
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PPOGRESS3s
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2568
JAMA, I-,ta,v
2t, 2003-Vol 289, No. t9 (Reprinted)
TI_IE-INC7 REPORT
(Reprinted)
JAMA, \4a1'21,2003-Vol 289, No. I9
f
2s69
TI{EJNC7 REPORT
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Preventive
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rtl"aiMedicine.UniverityofTnnesiee
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ii6,'rLi'ilfiA,ir"""t,
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257O JAMA,lvlrr,v
21, 1003_Vol 2B9,l.ro.l9 (Reprinted)
tQ2t-)03,A-rne
rica n l,l ediuil Associa lir.rn. ;lil rigiits reserv.ei.
Tr-lEJNC7 REPORT
Orleans, La); Haralambos 6avras, A4D (6r:ston University School of Medicine, Boston,Mass); Martin Crais,
/v1D(Feinberg School of Medicine, Northrvestem University, Chicago, lll);Willa A. Hsr.reh,MD (David Ceflen Scltool of fuledicine,Universitvof Californiaat Los
Angeles); Keiineth A. Jainerson. tuiD (Universiiy of
/vlichigan Mcdical Center, Ann Arbor); Norman M.
l(aplan, MD (lJniversil.yof Texas SouthwesternMedical Center, Dallas);Theodore A. l0tchen, MD (Medical College of Wisconsin, A4ilwaukee);Darriel Lcvv,
t u l D ( l . , l a t i o n a lH e a r t , L u n g , a n d B l o o d I n s t i t u t e ,
Framingham, Mass); Michael lr. /Vtoore, f,4D (Wake
Forest University School of rVledicineand Dan River
Region Cardiovascular Health Initiative Program, Danville, Va); Thornas J. fuloore, MD (Boston University
Medical Center, Boston, Mass); Vasilios Papademelriou, MD (Veterans Administration Medical Centr-,r,
W a s h i n g t o n , D O ; C a r l J . P e p i n e ,M D ( U n i v e r s i t yo f
Florida, College of Medicine. Gaines'rille,Fla); Robert A. Phillips,MD, PhD (New York University,Lenox
Hill Hospital, New York);Tlromas 6. Pickering,/v1D,
DPhii (A4ount Sinai A4cdicalCenter, New York. NY);
L. lvllchael Prisant. MD (Medical College of Georgra,
Augusta); C. \tenkata S. Ram, MD (Universitv of Ttlxas
Soutlrwestern Medical Centerand Texas Elood Pressure lnstitute, Dallas); Elijah 5aunders, r\,lD (UniversiLyof tu\arylandSchool of Medicine, Baltimore),Siephcn C. Textor, MD (A4ayoClinic, Rochester,Minn);
Donaltl C. Vidt, tu1D(Cleveland Clinic Foundation,
Cleveland, Ohio); Myron H. Weinberger, MD (lndiana UniversitySchool of Medicine, Indianapoiis);Paul
l(. Whelton, A4D, A45c(Tulane UniversityHeaith Scicnces Center, New Orleans, La).
Funding/Supporh Tlris work was supporlcd cntirelv
by ttre l.lational Heart, Lung, and Blood Instiiui.e.The
cxecuiive cornmittee, writing teams, and reviewers
served as volunteers without remuneration.
The NHBPEPCoordinating Committee IncludesRepresentatives From the Following Mernber Organizations: American Academy of FamilyPhysicians;
Amerrc.rn Academy of Neurology; Americarr Acadcnry of
Ophthalrnology; Amencan Academy of PhysicianAssistartts; Anrerican Association of Occupational Heaith
l.lurses;ArnericanCollege of Cardiology;American College of Chest Physicians;American College of Occupational and EnvironmentalMedicrne; American Colle.qeof Physicians-AmericanSocietyof InternalMedrcine;
Arrrerican College crf Prevcniive Mcdicine, Arnericarr
Dental Associa{,ion;Arnerican Diabetes Agsociation'
American Dietetic Association; /rmerican Heart hssociation; American Flospil.alAssociation; American Medi cal Association, American Nurses Association; American Optorrtetlic Association; Amcrican Osteopathic
Association;,\merican Pharmaceutical Association,
American Podiatric Meci ical Association;American Public Health Associalion; Arnerican Red Cross, American
Society of Health-System PharmacisLs;American Society of Hypertension;American Society of I'lephrology;
Associalion of Black Cardiologists;Citizensfor Public
Action on Higlr Elood Prc:ssureand Cholc:sterol.Inc;
Hypertension Education Foundation, Inc; lnternational Society on Hypertension in Blacks;tiational Black
l',1
urset Association. Inc; N a tional Hypertension,Association, lnc; National Kidney Foundation,Inc; National
lvledicai Association; National OptomeLric AssociaLion;l.lational Stroke Association; NHLBI Ad Hoc Comnriiiee on Minority Populaticrns;Society for Nutrition
EducaLion; The Society of Geriatric Cardiology. Federal Agencies:lrgency forHcaithcare Researchand Qr.r.tlity; tleniers for Medicare and Medicaid Services;Department of Veterans Affairs; Health Resourcesand Servrces
Admirristration; National Center for Health Sl.atistics;
l.lationalHeart, Lung, and Blood lnstitute; Nalional lnstitute of Diabetes and Digestive and Kidney Diseases.
Acl<nowledgmenL We appreciate the assistanceof
Carol Creech, tu11l5,and Gabrielle Gessner, 85, from
American Institutes for ResearchHealth Program, Silver Spring, Md.
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Treatmeni of High Blood Pressure.Arch lntern Nled.
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Hypertension 2000;35:858-863. Pr
(Reprinted)
JAtvlA,h4ry?I. 1003-_Vol289, No. 19 2571
Self-nleasurernent of BP
Lstna1;
Blooclprcssuresc"l[-nre:Lsurcnlcn
bc.nefitpaticnt-sby providing in['ornrato zrndhypertcnsive
[ion otr response.
nreclicatiotr.itnproving patic.nrardller:zrttclin cvrtluating
enceu'ith [hera1]v,I'r
u'h i te-coat hl,itcrtcusiou.hidit'iduals
u'ith a nlcan BP of more than 1.35185
mm Hg measurcdatthoure zlrcgenera l i l ' g. nr idc r c d t o b c h 1 ' p c ri c n s i v c .
ilonre nleasurcnrcntdc\,icessirould bc
rcgularlr' lor zrccltrrrct'.
chccl<.cd
t-lr\\'omcn Li5r'cars)
Target-Organ Damage
i.-leart
L.c[tvent riculnr irvpt:rtropirr'
;\nginr or prior mvocardial inla.rciiotr
P r i c r r c c r ro n a r y I c v n s c t t l a r :i r t t i t r n
Fatient Evaiuation
E v a l u a r i o r -or I p a t i c n t s u ' i t h d o c u nrcntcclhlpcrtcnsicln has 3 r-rb.jsc11t'.t.
( I ) Loilssc-ss
olhc'lli{csn'lc zurcliclcnt-i[1,
t::rrcliclvascu lar ri sk Iactors i:r t:oncotl i that mav ai'fcctprognotarntdisc-rrdcrs
sis and guicietreatncnl (Box 1); (2) tcr
cause-s
of high BP
rcvcarlicle.ntiliable
(Rox 2); and (3) Lozlssess
the prcxcncc
or abscnceo[ urset*organdantagcrrncl
cl
C VD . T hc c lat anc c cl e da.rc a t:c l tti re
pirt,sic'rle.tthrotrgh nrcclicalhistr:rr\,,
att(l
anrinalio n. rouLine lallori1to ll' l-ests,
othcr d iagnosticproccdure-s.
should inThe physicalex;rnrinir[ion
oIBP,
ureasurcnlent
appropriat.e
clude21n
tetalarm,
u'i th vcrifi(ation in thc con[ralz't
o[ the optic fundi; bodv
cxarnrination
indcx calculatcclas u'cight in kirl1z1ss
logranu divicledb)' tlie squarco[ ireight
in metcrs (mcasuremcnto['uvaistcircumlerenccalso nlar1'bcuse[ul);ausarnd
cultation for carotid, al-rdontinal.
femoralbruits, palpationoI the tll'roid
gland;t-horoughcraminationo[ theheart
a n d l u ngs , ex am ina ti o no f' L l rea b c i o and
mztsses,
men lor enlargedl':idne1,s,
oI
abnormalaorticpulsation;Jraipation
the lower extre'mitieslor edemaand
assessment.
pulscs;and ne.uroiogical
Hcart lailure
Tirain
Strolic or transictrt iscltcniic :ttlxcii
Chro n ic liidnel' cliscasc
Pcriphcral ancrial disr,'asc
Retinopathv
''lllvtl
i n t l i c n t c sb o d v n r a s si n d c ; l c l l c t t l a t c r lr t sl - c i g l t t
rular filtratic)rtr:'tlc.
heigirt in ureters;GFR, glc.nre
t (-ltrnrt-ro ncn ts o[ t lrc nretai]oii r: st'ttd rcrtnc.
s i s ; l l l o o c l g l u c o s ea n r l h c r n a r , : , , : i i t :
(or tlrecp.rr(rr(':rtiltitte
scnlnrpotassittnt.
ng cstinlatcdglonrcntlrrrii lrr'-sponcli
a lipid
rate),irndcalciumltt;atrd
tralLron
prolilc (a[tc.r'ir
9- to I2-hour [ast) that
n choincludcshi gh-densirv lip<lprot.ei
lcsterol,lou'-clensi0'lipoprotein cholesterol,and triglvcerides.Oprionaltcst:
inciude mcelsltrenentoI urinant albumin excrction or albunrin/creatinine
ratio. lvlore exLcnsivetestingfor ider-rgencrtifiable causcsis not indica-rted
allt' unlcssBP control is not aciiieved.
Treatment
public
Goalsof Therap)'.Therilt-imate
healthgoal oI andhlpertensive[herap;'
is tl-rereduction o[ cardiovascuiarand
rc n a l mo rbi di t)' and mortal i [)' . B ecause most palients u'ith hyirertension, especiallythose agedat least 50
)/ears,u'ili re:rchthe.dizrstolicBP goal
Laboratory Tests and
orlcesystol.icBP is at goal. the prinrarl'
Other Diagnostic Procedures
locus should be on achievingthe sysR o u t i n e l z r b o r a t o r y1 9 5 t sr e c o n r * tolic BP goal (FtcuRr). Treating systolicBP and diasiolicBP to targetsthat
mended before iniriating tlr.erapyinclude an electrocardiograrn;urinaiv- are less than 140/90mrn Hg is associC2003 ,A-rnerirznllciicai
t l r c s r l r r e r co l
2563
JNC VII
..
..
>120
>80
Pre HTN
120-139
80-89
Stage I HTN
140-159
90-99
Stage II HTN
<160
<100
Thiazides .I ACE
CCB ,ARB ,I blockers
,
thiazides
+
..
* . 2 .
. . ) (CVD ,
. . ,MI , .
,40-70 20mmHg. 10mmHg. .
.CVD
. . , CVD
) .(50
,. . 10-20% .
.
" 3:
.1 .
:
"
60ml/min >GFR
< 55 < 65
30 < BMI
Dyslipidemia
"
.2 " ) . .( :
Pheochromocytoma
Primary aldosteronism
/
Renovascular disease
/
Sleep apnea
Cushing
.3 CVD
:
,
BMI ,
:
, :
ECG -
JNC VII
" .
,140/90 - ,
.130/80
:
, , .
18.5<BMI<24.9
DASH diet
,
2.4gr 6gr NaCl
30' ,
..
5-20mmHg
10kg
8-14mmHg
2-8mmHg
4-9mmHg
2-4mmHg
:
thiazides
.
".
:
CHF
Post MI
DM
blockers
ACE I
ARB
9
9
9
9
9
9
9
9
9
9
9
9
9
9
9
CCB
Aldosterone
antagonist
9
9
9
9
" . . . .
20/10mmHg , .
, .
.
. .
. . .
:
". " ,stable angina blockers CCB
.
unstable angina ,MI . ." blockers .ACE I
" . ACE I
.blockers " .
, ACE I ARB .
) GFR ( , .CVD "
3 .
ACE I .ARB 35%
JNC VII
, .
) (GFR<30ml/min .
cerebrovascular . . . . . 160/100 .
ACE I .thiazides
Metabolic syndrome : o < 102cm < 89cm
Glucose intolerance o
o. . 130/85
TG o
HDL o )> 40 50> -(
LVH .CVD ,
) hydralalzine .(minoxidil
Postural hypotension 10mmHg. , " ,
) (... blockers ,
. . ..
" . . . . ,methyldopa blockers . ACE I .ARB
" . . 95 . , ...
." .
,MI , , ,
.... .IV ,
:
- , .
, ,cox 2 inhibitors ,NSAIDs ,, , ,...EPO ,cyclosporine ,
. . :
Thiazides o - .
o gout
.
blockers o - ,essential ,thyrotoxicosis ,
tremor " .
o .2nd/ 3rd AV block ,
CCB Raynaud syndrome blockers ACE I ARB ACE I . .angioedema
Aldosteone antagonists - K sparing diuretics .
Clinical Guidelines
\GKRKNY \GKIRF
2008 \ZGEFP
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ZCE I\V .
8{6
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BGCP .
13{9
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
16{14
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
19{17
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12{7 NKD .
22{20
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19{13 NKD .
28{23
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39{20 NKD .
35{29
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
64{40 NKD .
42{36
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49{43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \KRG[BZF
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50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . \KRG[BZF FBVZPC
52{51
53
55{54
56
. . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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65{57
. . . . . . . . .
70{66
. . . . . . . . . . . . . . . . . . . . . .
77{71
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81{78
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3
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . .
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BGCP
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FNGMK BKF .("\GBKZC OKR[") \GKGNCDGPG \GNIPP \GK[VGI OKR[ Z\GK \ZKXKG OKKI \GMKB
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.6
.7
.8
.9
.10
.11
.12
.13
.14
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.(reassurance)
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KGYKN OT OKENKG \M[GPP FKPRB ,\GKRGZM FKNM \GNIP ,\GKZNGYSGGKEZY \GNIP ,FP\SB
24{6 OKNKDF QKC OKBKZCF OKJGTVFG \GYGRK\F NM \B OD QSIN OGKM WNPGP .QGSKIF \MZTPC
9 NKD ETG QGSKIF Q\P N[ FRG[BZF FR[C .ZKZ[N FYKZHCG ,\PGP UKDR N[ BGF QGSKIF .OK[EGI
.UZGIF B` C KRVN FR[ KEP QSIN QMP ZIBNG [EGI N[ [ZVFC \GRP K\[ \\N [K ,OKR[
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
10
LB ,OKENKF KBVGZ EGDKBG \GBKZCF EZ[P K"T OKXNPGPG FRGZIBN GZ[GB[ OKVSGR OKRGSKI
:OF \GBKZCF NSC ORKB QKKET
.UZGIC ZYKTC ,\GYGRK\C NG[NK[N KZYKTF NNGIPF (Rotavirus) FJGZF UKDR EDRM QGSKI .B
WNPGP QGSKIF .\GBKZCF NSC GZ[GB OZJ LB FH QGSKI N[ OKCKMZ\ KR[ GP[ZR NBZ[KC
:\GVKJC Q\KRG \GYGRK\F NMN EGBP
.FRPC \GVKJ 2 ,\GRP 3=C Q\KR :YJFJGZ CKMZ\F .1
:KNPKRKP NKD .\GTGC[ 4 :KNPKRKP QPH IGGZ .OK[EGI 6 ,4 ,2 :WNPGPF OKRPHF IGN
.\GTGC[ 6
.\GTGC[ 12 :FRG[BZ FRPN KCZP NKD
.\GTGC[ 32 NKD ET \GRPF 3 NM \NCY OKN[FN [K
.FRPC \GVKJ 2 ,\GRP 2=C Q\KR :SYKZFJGZ CKMZ\F .2
:KNPKRKP NKD \GTGC[ 4 :KNPKRKP QPH IGGZ .OK[EGI 4 ,2 :WNPGPF OKRPHF IGN
.\GTGC[ 6
.\GTGC[ 24 NKD ET \GRPF K\[ \NCY OKN[FN [K .\GTGC[ 20 :FRG[BZ FRPN KCZP NKD
OD LB OKENKC OKKRHGBG FBKZ \GYNEN ZYKTC OZGDF YEKKI ,YGYGPKGRV EDRM EPGXP QGSKI .C
EIGKP QGMKSC OKBXPRF OKENKN Q\KR (Prevenar) QGSKIF .IGPF OGZY \YNENG OE INBN
ENK NMN QGSKIF WNPGP M"M .(FNB OKENKN \GVGZ\F NSC BXPR) OKKRZEGI OKPGFKHC \GYNN
FYKZHC Q\KR QGSKIF .\GBKZCF NSC BXPR GRKB QKKET QGSKIF OZGCT LB OKK\R[ NKD ET
:OKBCF OKETGPN OB\FC
.FR[ NKDC UIE \YKZHG 6 ,4 ,2 OK[EGIC \GRP 3 :OK[EGI 6{2 NKD
.FR[ NKDC UIE \YKZHG OK[EGI N[ IGGZC \GRP 2 :OK[EGI 11{7 NKD
.OKK[EGI N[ IGGZC \GRP 2 :OKR[ 2{1 NKD
OKK[EGI N[ IGGZC \GRP 2 QGMKSC OKENKN ,\IB FRP OKBKZC OKENKC :OKR[ 5{2 NKD
.QFKRKC
.OK[EI OKRGSKI { 7 'SP IVSRC OKRGSKIF JGZKV
FRGH\ KVSG\
D3 QKPJKG
FEKNFP (OGKN \GVKJ 2) \GKPGBNRKC 'IK 400 { D3 QKPJKG Q\P \GBKZCF EZ[P KEK=NT WNPGP
\GEKIK 200 { D3 QKPJKG \VSG\ \XNPGP FNGPZGVP BNP QVGBC OKRGHKRF OKENKN .FR[ NKD ETG
.A QKPJKG \VSG\C LZGX QKB .(OGKN FVKJ 1) OGKN
11
NHZC
FCZ \GCK[I [K QMNG \GYRKF NKDC Z\GKC IKM[F K\RGH\F ZSIF BKF NHZC ZSGIP FKPRB
.GN[ OEYGP ZG\KBCG NHZC ZSI \TKRPC
NHZCF QGRKP .OKENKF NMN [EGI 12 ET OK[EGI 4 NKDP NHZC Q\P NT \GBKZCF EZ[P WKNPP QMN
OE \YKEC TXCN [K FR[ NKDC .FR[ NKD ET OGKN D"P 15=G FR[ KXI NKD ET OGKN D"P 7 GRKF
.QKCGNDGPFN
QGHPF KCKMZP ZB[CG NHZCC \GYGRK\F \RGH\ \Z[TFG ZGVK[ NT WKNPP KPNGTF \GBKZCF QGDZB
NBZ[KC .('EMG FNKED \GTZVF OT OKENK ,OKDV JTPN) NHZC KZK[M\ Q\P BYGGE GBNG OKKRGKIF
.NHZC KZK[M\ \VSG\N \GCK[I [K M"TG FGCD \GYGRK\C FKPRBF ZGTK[
\GYGRK\N CNI \YCB N[ \XNPGP \GPMP OKRGHKRF \GYGRK\ ,OKENKF KBVGZ EGDKB \XNPF KV NT
.NHZC KZK[M\ \VSG\N OKYGYH ORKB NHZCC OKZ[TGPFG YG[C OGKF OKKGXPF OKDGSFP
Z[YC YVS N[ FZYPC .\VSG\N GYYEHK BN ,OGKN NHZC D"P 10 O\RHFC OKNCYPF \GYGRK\
.TRGP NGVKJM NHZCF ZK[M\ Q\P \B UKETFN [K ,N"RM FNMNM Q\P \GRPKFPG \GPMN
.8 'SP IVSRC FRGMR FRGH\ JGZKV
12
\GVSG\G OKRGSKI
WGTK
2
3
WGTK
\GTRPKFG \GKZGNY QHBP ,QKHP NMGB Q\P ,FRGMR FRGH\ B[GRC OKZGFF OT QGEN [K :FRGMR FRGH\
.OKY\PPG OKVKJI N[ Z\K \NKMBP
\KRVGDF \GNKTVF .KIZMFG KTCJ ,KSKSC BGF FH NKDC OKENK NXB FTGR\C LZGXF :\KRVGD \GNKTV
\GI\V\FN ,\KJDZRBF FBXGFF \ZCDFN ,OKZKZ[ YGHKIN ,\GPXTF N[ \RHGBP FNKEDN \PZG\
\GENKC \KRCGP \KRVGD \GNKTV .FRP[FN QGMKSF \\IVFNG FRKY\ \KCKJRKEZGBGYG \KZGJGP
TGXKC NGNM\ \KRVGDF \GNKTVF .OKKIF NDTP NMC K\GBKZC SKSC OKGGFPF \GNKTV KNDZF \CXTP
('YE 60 \GIVN) \GK[VGIG ('YE 60{30 \GIVN) \GRCGPG \GIRGP \GKRGD CZ \GPK[P N[ KPGKPGK
.F\KIRG ZG\KR ,FKKI[ ,OKKRVGB NT FCKMZ ,FXKZ ,FMKNF QGDM \GKSKSCF \GTGR\F GNDZG\K QFC
FTKNY ,FJKTC ,FSKV\G FYKZH ,OKRG[ OKZCKB NT UGDF NY[P \BK[R ,UGDF NGDND ,UGDF QGHKB
UGXZ QPH YZVC \KRVGD NKTV FKFK BN ENKF OFC OKCXP TGRPN [K .ZGZEMG ZGEMC FJCI ,FZJPN
.(9 'SP IVSRC \KRVGD \GNKTV JGZKV FBZ) ,(FRK[F N[ QPHF YZVN JZV) FT[P Z\GK N[
,OKPI OKPP \GZKFH ,FTKSRC \GIKJC BSKMG \GIKJC \GZGDIC [GPK[ EEGTN [K :\GIKJC
OKKRVGB NT FCKMZ \TC QDP \ESYC [GPK[G OKKRVGB \GRGB\ \TKRP ,\GRGB\G \GNKVR \TKRP
D[KFC GKFK BN[ LM NTZG QGKYKR KZPGIG \GVGZ\ QGSMKB B[GR QGEK .(YGIC CKGIPM) \GKNKDNDG
OKENKG \GYGRK\ \ZB[F KB NT [DEG FTKCJ \TKRPG FKI[ B[GRC WGTK Q\RKK .OKENKF N[ OEK
.(5 'SP IVSR GBZ) CMZC
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
14
FZJNGB FRKZY KRVP ZGTF \RDFG KCKSVF QG[KTF KYHR KB[GR GRGEK :[P[N FVK[IG QG[KT
OT FRDF KMGSKPC [GPK[G 16{10 \GT[F QKC [P[N \M[GPP FVK[IP \GTRPKF KEK=NT \KNGDS
child abuse B[GRN CN OK[N [K .(FXNGI ,TCGM) OKVSGR FRDF KTXPBG 15 'SP FRDF KPEYP
.OKENK \IRHFG
.(4 IVSR FBZ) FVF \RKKDF \ZKP[G KPGK OGK OKKRK[ IGXIX WNPGP OKKRK[F \ZKP[N :OKKRK[
\BXPR FFGCD QEKS \NGM\ .8{4 NKDC OGKN D"P 800=G 3 NKD ET OGKN D"P 500=C LZGX [K :QEKS
.KNGYGZC ,OKEY[ ,OKRKEZS ,CNI KZXGPC ZYKTC
OKRGSKI
QGSKI N[ FKKR[ FRPG ETGPC GR\KR BN[ FZD[F KRGSKI \PN[F GNNMK OKRGSKIF
.(OKRGSKI \NCJ 6 'SP IVSR GBZ) 'B F\KM KEKPN\N IGZ \GTGCTCB=\PEB=\ZHI=\CXI
\\KZM ZIBN ZYKTC ,GRSGI OZJ[ QGMKSC OKENKN WNPGP OKYGYGPKGRV EDRM EPGXPF QGSKIF
QM GPM .HIV=C OGFKHG \GRKSI BMEP NGVKJ ,\GZKBPP \GNIP ,NGIJF \GNKTVC \GTZVF ,NGIJ
.OKK\R[ NKD ET OKENKF NNMN WNPGP
QGSKIF .FNTPG OKK\R[ NKDP YZ WNPGP (SGYGGPKGRV) OKYGYGPKGRV EDRM KEKZMSKNGVF CKMZ\F
N[ FRGZIB FRP ZIBN \GTGC[ 6 \IB FRPC Q\KR QGSKIF .N"RF QGMKSF \GXGCYC OKENKN Q\RKK
5{3=G \IB FRP 5{2 NKD QKC NCYKK ,OKK\R[ NKD ET FRP UB NCKY BN[ KP .EPGXPF QGSKIF
.(7 IVSR FBZ) .QMP ZIBN OKR[
15
WGTK
FNKMB KNDZF
FKR[ FRP { MMRV
FCGDG NY[P
QGKYR KNDZF
'B F\KMC FNKEDG \GI\V\F \GYKEC
\GTRPKFG \KC \GRGB\
OKYGYGPKGRV EDRM QGSKI ,OKM[B ,OKKRK[ ,FKBZ)
OKNKTZ OKZPGIP
\GXGCYC OKENKN 5 NKD ET
,FTKP[
\GVGZ\G
QGSKIF \GTXPBC QGMKS \KZNGYSGGKEZY \MZTP
KEKZMSKNGVF
(\ZG[YK\G \GESYG \GIKJC \GBSM
(SGYGGPKGRV)
FSKRM \BZYN FMZTF KRZYN FVK[IP \GTRPKF
KCKSV QG[KTNG [P[F
S"FKCN
16
12{7 NKD
(1, 2, 5, 8=16, 132, 166=169, 213, 214, 220, 221, 572=575)
WGTK
School=G OKEGPKN ,\TP[PC \GZG[YF \GKTC NNGM S"KC NKDC OKENK OT FIV[PF CN[ GFH
FRK[ \GT[ 9 \GIVN) FRK[ KNDZF B[GRC WTKKNG ZZCN [K OKENKNG OKZGFN WGTK \RKICP .phobia
\GKGGZ QPG[ \GXPGI OKNKMPF OKNMBPC \KIVFN [K .FNKMB \GTZVFG ,FRGMR FRGH\ ,(FPPKC
\YVSP \GPM NNGM FRGMR FRGH\ \GCK[I ZKCSFNG QKY\ \GKZGNY QGHKB NT ZGP[N ,OKY\PPCG
IVSRC JGZKV GBZ) OGKN D"P 1300 BKF F[GZEF \KPGKF \GPMF .FNKEDF CYT QGHPC QEKS N[
QG[KTF KYHR B[GRC WTKKNG ,(10 NKDP) NGFGMNBC [GPK[FG QG[KTF B[GR ZZCN [K .(8 'SP
.(12 'SP IVSRC JGZKV GBZ) FTKRPN OKMZEG KGVMFG KCKJYBF
\PYTN FZKYS \GYKECN OGYP QKB ,\TRGP FBGVZN KBYKZPBF FPK[PF IGMG KPNGTF \GBKZCF
QMG .\KNKN FCJZFG SKHZVGYRB B[GR ZZCN [K .(\ZCGIF UGSC \YGNIPC OKKGR[ OKB[GR FBZ)
.OKENK/ENK=FIV[P/FZGF EGYVK\ LKZTFN [K .FNKMB \GTZVF Z\BNG FEKPNG \GDFR\F \GTZVF
.\GKRECGB \GKJRG QGBMKE ,L[GPP NCB ,FIV[PC \GPKNB ,\GNNT\F KRPKS ,FIRHFN CN OK[N [K
.QGMKS \GXGCYC OKENKN 'H F\KMC QKNGYZCGJ QKIC\ TGXKC WNPGP
OKRGSKI
(Tdap-IPV) 'C F\KMC GKNGVG \NT[ ,FKZ\VKE ,SGRJJ EDRM QGSKI OKNNGM GH FVGY\C OKRGSKIF
.ZCTC GR\KR BN[ OKRGSKI \PN[FG
18
19
WGTK
19{13 NKD
(1, 2, 5, 8=16, 132, 166=169, 213, 220=223, 610=619)
WGTK
\RHGBP FNMNMG FRGMR FRGH\ B[GRC WTKKN [K ,OFK\GIV[P GB/G OKZDC\PN WGTK \RKICP
\ZK[T FNMNM NT WKNPFN [K EK\TC SKHGZGVGZJSGB \TKRPN .QEKSG NHZC ,\GKZGNY \RKICP
\GCK[I ,FRKZYF KYHR B[GRC QGEN [K .OGKN D"P 1300 BKF \[ZERF \KPGKF QEKSF \GPM .QEKS
\GT[F QKC OKK\T[P Z\GK) [P[N FZ\K FVK[IP \GTRPKFG FRKZY KMGSKPC [GPK[F
.(16.00{10.00
.OKKRK[ BVGZ KEK=NT FZDK[ \GYKECG OKKRK[ IGXIX B[GRC WTKKN [K Q[F \GBKZC \RKICP
\KKRCC FXBF FR[K GH FCG[I NKD \VGY\C :(\KRVGD \GNKTV { 9 SP IVSR FBZ) :\KRVGD \GNKTV
WKNPFN [K .\KRVGD \GNKTVN \EIGKP \GCK[I [KG OXTF \SP BK[P 90% OKD[GP[ LM ,OXTF
NT FCKMZ ,FMKNF) Z\GKG 'YE 60{30 L[PN \XZPRG \KRGRKC \GPKXTC \KPGKPGK \GNKTV NT
,S"FKCN FMKNF) OKKIF \ZD[P YNIM \KRVGD \GNKTV NTG .(EGTG ZD\B KNGKJ ,FKKI[ ,OKKRVGB
.(EGTG \KNTPC BNG \GDZEPC [GPK[
EXP LB \GNKTV L[PFN \GK\GZI\ JZGVS \GZDSPC OKBXPRF \GZTRG OKZTR YHING EEGTN [K
\KIVFN QGXZP TCGRG QM\KK[ \KRVGD \GNKTVC K\KKVM GB/G OHDGP YGSKTN OKZT \GKFN [K ,KR[
\GPKXTG IVRC \KCKJZGVS \GNKTV TGXKCN ZT \GKFN [K QM GPM .FNKMB \GTZVF CYT NY[P
,OKZGF) OKKRGXKI OKPZGD N[ OKXINCG \GKVKXC EGPTN LZGXC \GKFN NGNT GZGYP[ ,OKNGED
\K[KBF FPDGEF \GCK[I \B OKZGFN ZKCSFN CG[I .YHR OGZDN OKNGNT Z[BG (QPBP ,OKZCI
.OKZDC\PF N[ \GRGMRF \ZCDF LZGXN \KRVGD \GNKTVC YGSKTC
KYHR B[GRC WTKKN [K ,FH NKDC OKZDC\P OT [DVP NMC .OKR[TP OKZDC\PFP 15%{10%=M
,NGFGMNB \KK\[ KYHR B[GRC WTKKNG NGFGMNB \MKZX B[GR ZZCN [K .G\YSVFG G\TKRP ,QG[KTF
,FRBGIKZP ,[K[I) OKRG[F GKDGSN OKPSC [GPK[F KYHRC QMG FKK\[ ZIBN FDKFR[ FRMSF
.(OK[Y OKPSG KHJSYB
\GIVN FRK[ \GT[ 9 NT WKNPFN [K { FRK[ \GT[ ZVSPG OKRGMR FRK[ KNDZF ZZCN WNPGP
.FPPKC
\/ZDC\P NM OT ZCEN [K .FTKRP KTXPBC [GPK[G QKP \GNIP ,\KRKP \GDFR\F B[GRC QGEN WNPGP
\TKRPN WGTKKC FBVZPF EKYV\ \B QKKXNG FBGNI\ \TKRPN OGERGYC [GPK[ NT WKNPFN .EZVRC
OGYP \GGFN FNGMK FBVZPF .\GKDGHF B[GRC IIG[N OGYP [K .KGXZ BN QGKZFC NGVKJNG QGKZF
QGMKS KPZGDG OKZKTXC \GRGBMKE B[GRN EIGKPC CN OK[N [K .FYGXPC \GZTRG OKZTRN FMKP\
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
20
FIV[PC \GPKNB KCDN ZZCNG ,FZCIG \GDFR\F ,FEKPN \GKTCC QKKRT\FN [K .\GKGECB\FN
.(\KRKPG \KRVGD ,\K[VR) FKDGSN \GNNT\FG
\GDFR\F ,OKTGRVGBCG QFKRKPN \GKNKDNDC ,OKKRVGBC FDKFR \TC \GESYC [GPK[ B[GRC QGEN [K
.K\KC Y[R \GRGB\G OKMZE \GRGB\ \TKRP ,OK[KCMF NT
LNFPCG QGKZFN FSKRM KRVN OGKN \KNGV FXPGI D"P 0.4 \GIVN N[ ZGEM \NKJRN FCZ \GCK[I [K
.OKENGP OKPGP \TKRP O[N \BHG .OKRG[BZ QGKZF K[EGI 3
OKRGSKI
.QSGI OZJ[ KPN B=G
(2008) J"S[\ OKEGPKNF \R[P NIF Q\RK .(Tdap) \NT[=FKZ\VKE=SGRJJ EDRM QGSKI .2
.'I F\KMC
.QSGI BN[ KPN \GENKF NKD N[ FZDK[F KRGSKI \PN[F .3
(95%) NKTK QGSKI FRYPF NBZ[KC [EI QGSKI { (HPV) K[GRBF FPGNKVVF UKDR EDRM QGSKI .4
WGVRF OGFKHF BGF HPV=F UKDR .(KRDGRKXZY OYNI { 18 ,16 ,11 ,6) UKDRF N[ OKRH 4 EDRM
QGSKIF .OIZF ZBGGX QJZSNG OKRJZS OGZJ OKTDRN OZGDFG KRKP TDPC ZCTGPF Z\GKC
\GTZBKF \KIVK LMC[ BKF FIRFFG OKPEY\PF OKKRJZS OGZJF OKTDRF ZGTK[ \B \KIVP
OGFKH \TKRPC Z\GKC NKTK QKP KSIK OGKY \NKI\ KRVN[ NKDC QGSKI .OIZF ZBGGX QJZS
Z[BM KM IKRFN [K .26{9 OKNKDF QKC OK[RNG \GRCN Q\RKFN F[ZGP QGSKIF .GNB OKRHC
Q\KR QGSKIF .'I=N 'G F\KM QKC Q\RK (2011 \R[C FBZRM) \KPGBNF OKRGSKIF \KRMG\N SRMK
.(7 IVSRC B[GRF JGZKV GBZ) OK[EGI 6 ,OKK[EGI ,0 QPHC ZKZ[N FYKZHC
21
\NT[=FKZ\VKE=SGRJJ
NIF 'I F\KMC (Tdap)
.J"S[\ \R[P
.OKZSI OKRGSKI \PN[F
BMI
WGTK
,FNKMB \GTZVF
,FKPKNGC ,FKSYZGRB)
\GCK[I { (FRP[F
FRGMRF FRGH\F
KRKP WGTKG FTKRP KTXPB
9) OKRGMR FRK[ KNDZF
(FPPKC \GT[
KDGS NMC FZKFH FDKFR
\GZGDI \ZKDI ,CMZF KNM
\GRGB\ \TKRPG \GIKJC
OKMZE
ZIBN FDKFRP \GTRPF
NGFGMNB \KK\[
,QG[KT \YSVFG \GTRPF
OKPSP \GTRPF
.NGFGMNBG
,[P[N FVK[IF KYHR
FZ\K FVK[IP \GTRPFG
.[P[N
60{30 \KRVGD \GNKTV
,FMKNF) OGKN \GYE
,FKI[ ,OKKRVGB NT FCKMZ
\KCKJZGVS \GNKTV
ZD\B KNGKJ \K\GZI\
\GT[ \\IVFG (EGTG
FKHKGGNJF NGP FCK[K
.C[IPFG
22
39{20 NKD
(7=1, 26=17, 31=28, 47=43, 65=59, 75, 131=109, 137=133,
144=147, 206, 211=212, 215=225, 235=247, 500=541,
610=629, 638=646)
N[ FVGY\ GH .FEGCTG FZKKZY \KKRC ,OKENK \EKNG \GIV[P \PYF N[ FVGY\F GH FNB OKNKDC
OKR[TP FKKSGNMGBFP 30%=M GH NKD \XGCYC .EIB DGH \C/QCP Z\GK OK\KTN ,\KRKP \GNKTV
Z\K GPM \GKRGZM \GNIPC QKKET OKYGN ORKB GH NKD \XGCYC OK[RBF \KCZP .(OKZCDFP 45%)
FPGRNP JTPN) QJZS N[ FMGPR \GIKM[ \PKKYG CN \GNIPG Z\K \RP[F ,\ZMGS ,OE WIN
QGBMKEG FEGCT \GRGB\ ,OKMZE \GRGB\ CYT \GTKDV N[ Z\GK FFGCD \GIKM[ \PKKY .(\GKPYKGNG
.QDGH=QC EXP \GPKNBNG \GTKDVN \GVG[I OK[RF NNMP 10% \GIVN ,QM GPM .(20%=M)
TGRPN \RP NT ZYKTC FTKRP \GNGTVC JGYRN FKKSGNMGBF FMKZX FC FVGY\F KFGH ,LMN KB
FDKFR NT FEVYF KEK=NT \BHG FTKRPN \GR\KRF \GNIPG \GRGB\ \GZ[VBF \EKPC \GIENG
FRGH\ ,FZKES \KRVGD \GNKTV TGXKC ,QG[KTP \GTRPKFG \YSVF ,FEGCT \GRGB\ \TKRP ,FZKFH
KCDN .QGBMKEG IGZ KCXPN Z\GK FCZ \GTEGPG [P[N FZ\K FVK[I \TKRP ,FRP[F \TKRP ,FRGMR
.QGKZF CYTP NT FEVYFG \GRGKZFF LNFPC QG[KTP \GTRPKF ,\RHGBP FRGH\ NT FZKP[ OK[R
FTKRPG WGTK
KMZE ,IGJC QKP KCDN QMG OKENKG FIV[P \PYF ,\GKDGH ,\KRKP \GNKTV B[GRC WTKKN [K .1
FIV[P QGRM\ KB[GRC QGEN [K .OGERGYC [GPK[G HEPATITIS B ,HIV SGZKGGC \GYCEF
\GTVG\N \GTEGPG 'EMG KPIZ LG\ QY\F ,QGKZF \TKRPN \GNGND) FTKRP KTXPBC [GPK[G
.(KBGGNF
NIF NGJKN [K .QGKZF QGRM\ \TC OGKN D"P 0.8{0.4 QGRKPC \KNGV 'I NGJKN Z\GKC CG[I .2
OKPGP \TKRPN OKRG[BZ QGKZF K[EGI 3 LNFPCG QGKZFN FSKRMF KRVN OK[EGI 3=P
KZK[M\ \ZDSPC OD \BH NGJKN Z[VB .neural tube defect (NTD) QGDM OKKZCGT
QGKZFC NTD N[ ZGVKS OT OK[RN .\KNGV 'I D"P 0.4 \GIVN OKNKMPF QKPJKG=KJNGP
\NKI\ KRVN OK[EGI 3=P NIF D"P 5 N[ \KNGV 'I ZGEM WNPGP FIV[PC GB QNXB OEGY
.OKRG[BZ QGKZF K[EGI 3 LNFPCG QGKZF
CYTP 11 IVSRC JGZKV GBZ) K\EKN OGZJ CYTP TGXKC NT EKVYFN [K \GRGKZFF LNFPC .3
.(K\EKN OGZJ
KGVMFG KCKJYBF QG[KTF KYHR KCDN WTKKN FKKSGNMGBF NNMN QG[KT ET\NG ZZCN [K .4
QG[KT \YSVF NT GKNVGJPN WTKKPF BVGZ QG[KT \YSVF NT \/OKR[TPN WKNPFNG (KCKSV)
23
FMZEFG QG[KTF KYHR 12 IVSRC JGZKV FBZ) YKSVFN ,OKR[TPFP 10%{5%=N OGZDK
.(QG[KT \YSVFN
OGEB Z[CG \GKGGZ QPG[ \GXPGI OKNKMPF OKNMBP \\IVF ,FRGMR FRGH\ KB[GRC WTKKN [K .5
QEKSF \GPM .(FRGCR FRGH\ 8 IVSRC \GZKV GBZ) \GZKVG \GYZKC ,OKCKSC \GCZFNG ECGTP
,OKEY[ ,CNI KZXGP) QGHPF KCKMZPC FDK[FN Q\KR[ OGKN D"P 1000 BKF F[GZEF \KPGKF
'IK 800{400 BKF \XNPGPF D QKPJKG \GPM .QEKS KZK[M\CG (KNGYGZC ,OKRKEZS
NM ZIBNG \GRGKZFF LNFPC FYRFF \GCK[I \B [KDEFN [K .\GIVN OGKN \GKPGBNRKC
.FEKN
NGFGMNB \KK\[P \GTRPKF KCDN WTKKNG OKPSC [GPK[G NGFGMNB \KK\[ B[GR ZZCN [K .6
.OKPSG NGFGMNB \TV[F \I\ FDKFRCG NGFGMNB \KK\[C \GMGZMF \GRMSFG
.FEGCT \GRGB\G OKMZE \GRGB\ B[GRC QGEN [K .7
Z[GM IG\KV :\NNGMF \MZEGP GB/G \KRCGPG \RGGMP \KBPXT \KRVGD \GNKTVN EEGTN [K .8
,SKRJ) OKK[KBG ('EMG NSZGEM ,NDZGEM) OKK\XGCY JZGVS KYI[PC \GV\\[F KEK=NT KCGZKB
\GZKE\C (CN[N KGXZ) FKI[G OKKRVGB NT FCKMZ ,FXKZ ,FMKNF GB/G ('EMG [GGYS ,FJBZY
\GPKXTCG FNTPG 'YE 30 N[ QPH KYZVN (TGC[F KPK \KCZPC KGXZ) TGC[C OKPTV 5{3 N[
{220 KVN KCZPF YVGEFP 90%{55 C[GIPF Z[GMF \PZN OB\FC) \XZPR=\KRGRKC
/OKJS 3{1 /TGC[C 'TV 3{2 /OKNKDZ\ 10{8 /OKNGED OKZKZ[) IGM KRGPKB TGXKC .(NKDF
12{8 /OKNGED OKZKZ[ /\KCKSV FJK[) \G[KPD KRGPKBG (KRGRKC=KJKB CXY /\GZHI 12{8
30 \GIVN N[ \KRVGD \GNKTV NM .(TGC[C 'TV 4 /\GZHI 6{4 /FKVZF 'R[ 6{4 /FIK\P 'R[
F\GP\G FBGNI\ QKJYFN FKG[T YVGE ETKN Z[Y BNN TGC[F KPK \KCZPC OGKC \GYE
.(9 'SP IVSRC JGZKV FBZ) NY[PC \KIVFNG \GNIP ZVSPP
TKK\SFN WNPGP \GNKTVF TGXKC KRVNG \KRVGD \GNKTV TGXKCN \KBGVZF FXNPFF Q\P \TC
.2005 \R[P KDGNGKEZYF EGDKBF \GKIRFC
[P[N FZ\K FVK[IP \GTRPKF NT WKNPFN [K ,[P[N FVK[IF KYHRN \GTEGP ZKCDFN [K .9
KRRSPC [GPK[N FCZ \GCK[I [K .(TGCY QVGBC 16.00{10.00 \GT[F QKC OKK\T[P Z\GK)
.ZGTF N[ \KPXT FYKEC TXCN CG[I .FRKZY
.13 'SP IVSR GBZ OEYGP ZG\KBG QJZS \GNIP \TKRP .10
.10 'SP IVSR GBZ OE KNMG CN \GNIP \TKRP .11
.14 'SP IVSR GBZ CD KCBM \TKRP .12
.15 'SP IVSR GBZ \GSKJC FBGNI\ \TKRPG N"GIN OKNKKJP \BGVZ .13
.16 'SP IVSR GBZ ECM \GNIP N[ OEYGP ZG\KBG \TKRP .14
.19 'SP IVSR GBZ { FRK[ \GTZVFG FRK[ KNDZF .15
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
24
.(ZJPC) FCGD/(D"YC) NY[P=(BMI) Body Mass Index \GTXPBC FCGDG NY[P \MZTF .1
Z\K \RP[FG FRP[F BMI=2629 NY[P UEGT ,25{19 QKC BGF QKY\ BMI
\GIKM[ FNTPG OKKI \NIG\ F\KIVPF \KRGZM FNIPN OGKM \C[IR Z\K \RP[F .FNTPG
KPZGDG \KRVGD \GNKTV ,FRGCR FRGH\ 10{8 OKIVSRC JGZKV GBZ) QJZSG OE KNMG CN \GNIP
.(CN \GNIPN QGMKS
BMI=30
NKDP FKKSGNMGBN ,OKR[ 5=C OTV \GIVN 29{20 NKDP FKKSGNMGBF NNMN :OE WIN \YKEC .2
N[ K\IV[P ZGVKS OTG CN \GNIPN QGMKS KPZGD OT FNB .OKR[ 3=C OTV \GIVN 39{30
.FR[C OTV { OE WIN
TXCN FYEXF QKB :OIZF ZBGGX QJZS N[ OEYGP ZG\KBN OIZF ZBGGXP IJ[P \YKEC .3
OKR[ 3=N \IB FYKEC TXCN WNPGP .OK[RF \KKSGNMGB NNMN OEYGP KGNKDN FYKZS \GYKEC
N[ IGGZPC \GRKY\ \GCG[\ 2 ZIBN \BHG FGCD QGMKSC OK[RC QKP KSIK OGKY \NKI\ ZIBN
OKCZ OKV\G[ OT OKRDGP BN QKP KSIK OGKYM ZEDGP OIZF ZBGGX QJZSN FGCD QGMKS .FR[
JGZKV GBZ) \GCZ \GV\G[ GN GKF[ DGH QC OT GB ,(15 NKD KRVN) EGBP ZKTX NKDP (3 \GIVN)
.(13 'SP IVSRC
\GPG[ OT ,FPGRNP N[ K\IV[P ZGVKS OT \GXGCYN \K\VGY\ ZGT \YKEC TXCN WNPGP .4
OGKC OKK\T[P Z\GK [P[N TGCY QVGBC \V[IRF FKKSGNMGBC QMG \GKVKJBG \GKJKXGRNP
\TRGPM FIMGF BN OKBVGZ KEK NT FYKEC .\KPXT FYKEC FKKGXZ .16.00{10.00 \GT[F QKC
.FPGRNPP F\GP\G FBGNI\
OEYGP ZG\KB .FKKSGNMGBF CZYC QGBMKE ZG\KBN OGYP [K :QGBMKE N[ OEYGP ZG\KB .5
\[DZF OBF" :ZGYKS \GNB[ 2 \GTXPBC \BH \G[TN Z[VB .FBGNI\ G\KIVK NGVKJG
L[PC OBFG ?"FGGY\ ZSGI GB [GBKK ,QGBMKE \GCGZY OK\KTN QGZIBF [EGIF L[PC
QGXZ ZSGIG OKKIFP FBRF ZSGI ,QKKRT ZSGI \GCGZY OK\KTN \[DZF QGZIBF [EGIF
ZGZKC TXCN WNPGP \KCGKI BKF FNB \GNB[N \GIVN \IB FCG[\ OB ?"OKZCE \G[TN
.\GKRECGB \GC[IPG QGBMKEN BNP
OK[KDZG OKKRZT \GKFNG \GTEGP ZKCDFN OK[RF KBVGZG OKENKF KBVGZ ,FIV[PF KBVGZ NT .6
.\GRGKZFF LNFPC NNGM JZVC OK[R EDRMG NNMC FIV[PC \GPKNB ZG\KBN
EZ[P N"MRP KZHGIG DGH KRC QKC \GPKNB B[GRC \KBGVZF \GZE\SFF \GKIRF GBZ)
QGKZFF \TC ,\GRGKZF KRVN QGMKSC OK[RG QGMKSC OKENK KGFKHN \GCK[I [K M"M .(\GBKZCF
.FDGH QC EXP \GPKNBNG \GTKDVN FVG[I BKF OB F[KB NM NGB[N OGYP [K .FEKNF ZIBNG
GB \GPKNBN F/UG[I F/\B OBF { \GPKNB KCDN NGB[N NCGYP OGKM" :\XNPGP FNB[
."ZIB OGYP ,ZVS \KC ,FIV[PF ,\KCF \ZDSPC LC OKTDGV OBF
25
FECTP \GYKEC
.FKPRBG NHZC ZSGI N[ FFGCD \GIKM[ CYT QGKZF NM ZIBN OK[RN :QKCGNDGPF \PZ \YKEC .1
NGZJSNGM LS) \GFGCD NGZJSNGM \GPZ N[ OEYGP ZG\KB KM GBZF OKZYIP :NGZJSNGM .2
BXPR QM GPM .CN \GNIPP F\GP\G FBGNI\ \KIVP OFC NGVKJG OKBKZC OK[RBC (HDL=G
NNGM CN \GNIPN OKCZ QGMKS KPZGD OT OK[RBC NGZJSNGM LDL \EZGF KM OKZYIPC
BKF 2007 \R[P ICSI=F \XNPF .CN \GNIPP F\GP\G FBGNI\ F\KIVP BKF UB \ZMGS
35 NKDP OKZCDN OKEKZXKNDKZJG LDL ,HDL ,NGZJSNGM LS NNGMF KRPG[ NKVGZV TGXKC
.\GPGE \GXNPF FKRJKZCCG FKNZJSGBC .OKR[ 5=N \IB FNTPG 45 NKDP OK[RNG FNTPG
NGZJSNGM LS \YKEC BKF 2004 \R[P \TRGP FBGVZN KBYKZPBF FPK[PF IGM \GXNPF
QKB) OKR[ 5=N \IB 45 NKDP OK[RF NMNG 35 NKDP OKZCDF NMN FZKYS \YKECM HDL=G
.(FRMFM OGXC LZGX
\IB 45 NKDP OK[RNG 35 NKDP OKZCDN KRPG[ NKVGZV TGXKC :ICSI=F NT \SSGCP GR\XNPF
Z[B FNBNG .KBYKZPBF FPK[PF IGM \GXNPF KV NT OD NGTVN Z[VB \BH OT .OKR[ 5=N
LDL NNGMF KRPG[ NKVGZV TXGCK { OKMGPR HDL GB/G OKFGCD GBXPK NGZJSNGM LS KMZT
K\IV[P ZGVKS OT OK[RBN .(CN \GNIPN QGMKS KPZGD 10 'SP IVSRC JGZKV GBZ) .NGZJSNGM
,HDL, LDL ,NGZJSNGM LS) KRPG[ NKVGZV \YKEC \XNPGP \K\IV[P FKPEKVKNZVKF N[
.FR[N \IB (OKEKZXKNDKZJ
OKRGSKI
(Td) FKZ\VKE=SGRJJ ,B=G A SKJKJVF
.OKR[ 10=N \IB FKZ\VKE=SGRJJ \YKZH \XNPGP
KECGT QGDM FGCD QGMKSC \GXGCY NT [DE OT ZCTC GRSGI BN[ FNB NMN B SKJKJVF EDRM QGSKI
/KRC[ OK[RB ,QKP \NIPC GNI[ OK[RB ,OKCZ DGH \GRC/KRC OFN GKF GB [K[ OK[RB ,\GBKZC
.GKZXGPG OEN OKVG[IF FNBG B SKJKJVF UKDRF N[ OKB[R OFN[ DGHF \GRC
QMG OKZCD OT QKP KSIK OKPKKYPF OKZCDNG OKPS KYKZHPN OD WNPGP B=G A SKJKJVFN QGSKI
,FYKZPB OGZE ,FYKZVB ,FKSB) I\V\PF ONGTN N"GIN OKNGKJG \GTKSR KRVC OKEPGTF NMN
.ZCTC GNI BN KM OKTEGKG FNB OKRGSKI \NCYC OKRKKRGTPF NMNG ,(FVGZKB IZHP ,ZCT[N P"FZC
.(OEYGP ZG\KBG ECM \GNIP \TKRP B[GRC 16 IVSR GBZ)
26
ZBGGX QJZS \GTZBKF \KIVK LMC[ BKF FIRFFG OKPEY\PF OKKRJZS OGZJF OKTDRF ZGTK[
QGSKIF .GNB OKRHC OGFKH \TKRPC Z\GKC NKTK QKP KSIK OGKY \NKI\ KRVN[ NKDC QGSKI .OIZF
OKRGSKIF \KRMG\N SRMK Z[BM KM IKRFN [K .26{9 OKNKDF QKC OK[RNG \GRCN Q\RKFN F[ZGP
,0 QPHC ZKZ[N FYKZHC Q\KR QGSKIF .'I=N 'G F\KM QKC Q\RK (2011 \R[C FBZRM) \KPGBNF
.(7 IVSRC B[GRF JGZKV GBZ) OK[EGI 6 ,OKK[EGI
\TV[
BXPR QGSKIF ,\BH OT .\GBKZC KECGTNG OKKRGZM OKNGIN FR[N \IB WNPGP \TV[ EDRM QGSKI
OT OKZGFF NMN OD GKNT WKNPFN Z[VB QMNG \TV[ \GXZV\F \TC FBGNI\ \\IVFC NKTK
.QKKRGTPF NMNG OKRJY OKENKG \GYGRK\
SGYGYGPKGRV
OT FNBNG NGIJ \\KZM ZIBN GPM FFGCDF QGMKSF \GXGCYN Q\RK SGYGYGPKGRV EDRM QGSKI
FRPF KZIB OKR[ 5 Q\RK\ FKR[ FRP Z[BM \GRP 2=C \KRGSKIF \MZTPF \B \GBMEPF \GNIP
\RGPSK\ ,FBKZG CN \GNIP) \GKRGZM \GNIPC OKNGI { KRGRKCF QGMKSF \GXGCYN .FRG[BZF
.\IB QGSKI \RP Q\R\ ('GMG \KJGZVR
\PEB
\GRP NT WKNPFN [K .\GRSGIP NBZ[KC \GKZGVF NKDC OK[RF \KCZP ,OKRGSKIF \GKRKEP CYT
QGSKI"F \GTXPBC \PEB EDRM \RSGIP FRKB[ ,45{18 NKDC F[KB NMN \PEB EDRM QGSKI
.(MMR) \PEBG \ZHI ,\CXI EDR "[NG[PF
:QNFNM BKF "\PEB EDRM \RSGIP F[KB" \ZEDF
:GB .\PEB EDRM QGSKI \GRP K\[ ZCTC FNCY
FGCD) \PEB EDR QSIP NKKM N[ GPGKY NT FEKTPF FECTP \YKEC \GBXG\ FEKC [K
FRP \GTXPBC QSIN BNB OKREDGR NKKM YGECN QKB ,\GRKSI NT EGTK\ QKB[ F[KBN .(30IU=P
OKN[FN KEM ,ZCTC FNCY[ \GRPF ZVSPN OB\FC ,[EGIP Z\GK N[ IGGZC \GRP 2 GB \IB
QSIN QKB .MMR { \PEB \ZHI \CXI EDRM [NG[P QGSKIM Q\KR QGSKIF .QGSKI \GRP 2=N
.QGKZF \TC \PEB EDRM
27
FTKRPG WGTK
2
3
28
64{40 NKD
(7=1, 21=54, 69=72, 82=75, 144=150, 208=212, 215=247,
256=302, 375=394, 429=505, 610=629, 638=646)
OT .\GZKBPP \GNIP ,CN \GNIP ,\ZMGS ,E"NK GPM \GKRGZM \GNIP \GIKM[ FNGT GH FVGY\C
IZGB NGFKR BGF \GNIPF NMP F\GP\G FBGNI\ \TKRPNG \\IVFN Z\GKC NKTKF KTXPBF \BH
\KRVGD \GNKTVG Z\K \RP[FP \GTRPKF ,FRGMR FRGH\ ,QG[KT \YSVFG \GTRPKF NNGMF BKZC OKKI
.(12 ,10{8 OKIVSR FBZ) .FZKES
KBNKDCG OK[R \PGTN OKZCD NXB 5{4 KV FRKF CNF ZKZ[ OJGB \GIKM[ 50{40 OKBNKDC
\YSVF OT ZCTPF NKD \VGY\ GH .OK[R \PGTN OKZCD NXB 4{3 KV FFGCD \GIKM[F ,64{50
NKD 'CY NXRN [K .OKKIF NDTPC KTCJ KGRK[ NBM \SGF \YSVFN SIKK\FN [K .OK[R NXB \SGF
JGZKV GBZ) \GNIP N[ OEYGP ZG\KBNG \KRG[BZ FTKRPN \GXNPF Q\PG QGMKS KPZGD ZG\KBN GH
.(18 ,17 ,13 ,12 ,10{8 ,D"V OKIVSRC
.11 'SP IVSRC K\EKN OGZJ CYTP \GXNPF GBZ \SGGF \YSVF ETG 40 NKDP \GRGKZF KCDN
WGTK
NT GKNVGJPN WTKKPF FIV[P BVGZ ,QG[KT \YSVF B[GRC WTKKNG QG[KTF B[GR ET\NG ZZCN [K
.(12 IVSR FBZ) OKR[TPF GKNVGJPP 10%{5%=N QG[KT \YSVFN OGZDN NGMK ,QG[KT \YSVF
NT EKVYFN [K .(10 ,8 OKIVSRG 39{20 OKNKDC \GXNPF FBZ) \RHGBPG FRGMR FRGH\ B[GRC WGTK
.CN \GNIP \TKRPN FKPEKVKNZVKFG \ZMGS ,E"NK QGHKB
,FMKNF :\NNGMG KCGZKBF Z[GMF IG\KVN \ETGKP \KRVGDF \GNKTVF :\KRVGD \GNKTV B[GRC WGTK
10 \GIVN) \GYE 60{30 :L[P ,(\KPGKPGK KGXZ) 5{3 :\GZKE\ .FKI[ ,FZK\I ,FCKMZ ,FXKZ
ZGVK[NG TGC[/'TV 3{2 :IGMF ZGVK[G ZGPK[N .\XZPR=\KRGRKC :\GPKXT .(UXZC \GYE
OGK OGKF KKIC \KRJRGVSF \GNKTVF \ZCDF .\GIK\P KNKDZ\ \GTXPBC TGC[/'TV 4 :\G[KPDF
.(9 'SP IVSRC \KRVGD \GNKTV JGZKV FBZ) C[IPG FKHKGGNJ \GT[ \\IVFG
.(19 'SP IVSRC FRK[ \MZTF FBZ) FPPKC FRK[ \GT[ 8{6 NT WKNPFNG FRK[ KNDZF ZZCN [K
.16.00{10.00 \GT[C [P[N \M[GPPG FZ\K FVK[IP TRPKFN [K
.OKNGFGMNB \GBY[P \KK\[P \GTRPKFG NGFGMNB KYHR B[GRC WTKKN [K
FNKMPF FJBKE ,\KRVGD \GNKTV NT WKNPFN [K ,ZCTPF NKDC \GBKZC OK[RN \GNIP \TKRP KCDN
Z[BC .QG[KT \YSVFG OGKN D QKPJKG N[ B"RKC 'IK 800{400=G QEKS D"P 1500{1000 \GIVN
NGVKJ TKXFN BN OKXKNPP GRB ,OGKFN QGMR ,(HT) \SGGF \YSVF ZIBN KNRGPZGF NGVKJN
29
ZCTPF NKD KRKPS\N IGGJ ZXY NGVKJM YZ BNB ,CN \GNIP \TKRPN L[GPP NGVKJM KNRGPZGF
\GTXPBC FTKRP 17 'SP IVSR GBZ B[GRF JGZKV .Z\GKC ZXYF QPHF L[PNG LGPR QGRKPC HB ODG
.\GVGZ\
.18 IVSR GBZ :OK[RNG OKZCDN SKHGZGVGBKJSGBC NGVKJG OEYGP ZG\KB ,FTKRP
QVKSYGNZG QVKSYGPJ ,QKZKVSB GPM \GVGZ\G QEKSG D3 QKPJKG GPM OKRKPJKG \NKJR
FTKRP 17 'SP IVSR GBZ :QJZSG OE KNM ,CN \GNIP N[ \KRG[BZ FTKRPN (Chemoprevention)
.42{36 'PT 65 NKDP \TRGP FBGVZ YZVG \GVGZ\ \GTXPBC
BMI
NTP OEF WIN OB FR[N \IBG 120/80 ET OEF WIN OB OKK\R[N \IB OE WIN \YKEC .3
.120/80
[P[N OGKF L[PC FNTPG OKK\T[ N[ FVK[I ,ZKFC ZGT GPM QGMKSC \GXGCYN ZGT \YKEC .4
.FCGZYF FIV[PC FPGRNPG (16.00{10.00 \GT[)
:(13 IVSRC JGZKV) E[F QJZS N[ OEYGP KGNKD .5
FYKZS \KRMG\ \ZDSPC OK[RF NMN 74{50 OKNKDC OKK\R[N \IB FKVZDGPP \YKEC
.QGPKHC FYKZS \ZDSPC BN[ 74 NKDPG QGPKH \NNGMF \KEGTKK
\\IVFN \PZGD FRRKB 74{50 OKNKDC FKVZDGPPN \VSG\C BVGZ KEK=NT \KREK E[ \YKEC
.F\GP\
,OB) FRG[BZ FCZKYC K\IV[P ZGVKS OT OK[RN YZ 40 NKDP FR[N \IB FKVZDGPP \YKEC
F\NI FIV[PF \CGZY Z[BM .FKSVGKCC FKVKJB OT FZKV[ E[ \NIP GB (\C ,\GIB
NKD KRVN OKR[ 5 FZKYSF \YKEC TGXKC \NI\F NT WKNPFN [K 45 NKD KRVN E[F QJZSC
\YKECN FYEXF QKB \GKZYIP \GKGET KV NT .\GIBF GB OBF NXB E[F QJZS \TVGF
.49{40 OKNKDC OK[RF NNMN FYKZS \YKECM FKVZDGPP
.\GBKZC NSC \GNGNM N"RF \GYKECF NM
SDF KTPF QJZS N[ OEYGP KGNKD .6
\\IVFN \GNKTK GBXPR \GJK[ ZVSP KM KEPN \GSSGCP \GKGET \GPKKY OGKFN QGMR
ZG\KBG FTKRPN FYKZS \GYKECM \GXNPGP QM NTG SDF KTPF QJZSP F\GP\G FBGNI\
:KRGRKCG LGPR QGMKSC OK[RBC OEYGP
OK[RNG OKZCDN 74{50 NKDP (OKK\R[C OTV ET) FR[C OTV FBGXC KGPS OE \YKEC .B
\IB FBGXC KGPS OE \YKEC .FKVGYSGRGNGY TGXKCN OKRVGP \KCGKI FBXG\ OT FNBG
\BXPRG FCZ \GIGR KBC GB QGMKSC FMGZM FRRKB ,Z\GKC FJG[VF ,\KSIK BKF FR[N
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
30
2006 \R[PG Z\GKC \GFGCDF QF GH FYKEC \GNKTKN \GKTEPF \GKGETF .\GBKZCF NSC
\GTXPBC KTPF QJZS N[ OEYGP ZG\KBN \KPGBN \KRMG\ NT \GBKZCF EZ[P HKZMF
FYKEC \MZT \GTXPBC 74{50 OKNKDC FKKSGNMGBF NNMN FBGXC KGPS OE \YKEC
.Hemoccult Sensa
FBGXC KGPS OE \YKEC OT CGNK[ BNN GB CGNK[C OKR[ 5=C OTV FKVGYSGEKBGPDKS .C
FYKECFG F[Y FYKECN FRMFF ,KTPF NM \B FPKDEP FRKB FYKECF .FR[C OTV
.\KR[NGV
NKD CKCS OKKIC \IB OTV \GIVN GB 74{50 NKDP NIF OKR[ 10=C OTV FKVGYSGRGNGY
NKD ,BCF YZVC \GKGXP 74 NKDN ZCTP FYKECF TGXKCN OKBR\F KCDN \GZTF) .65{55
ZETKFC \GZK[K K\NC \GIMGFG ONGTC OKIPGP \TE NT \SSGCP GH FXNPF .(FNTPG 65
OGZDN FNGNTG \KR[NGV FYKECFG F[Y FYKECN FRMFF .\BH YEC[ ZYGCP KRKNY ZYIP
.ZKER LGCKSM KTPF \GCYR\FN
.D
,FBGNI\G F\GP\ \\IVFC FNKTK FYKECM FIMGF OZJ \KNBGJZKG FKVGYSGRGNGY KCDN .E
OKVKNGV \Z\BPM FKVGYSGRGNGY FYKECN FK\GRGM\C FFH FBXPR GH FYKEC LB
.GH FYKEC FGGNPF FRKZYF \VSG\ \B QGC[IC \IYN [K ,\BH OT .OKNGEKDG
\GKPGBN FYKZS \GKRMG\N KNMM FRKEP OG[C OGKF ET GNCY\R BN \GKVGYSGERBF \GYKECF
FKVGYSGRGNGY QMNG FYKZS \GYKECP OK[ZERF OKRGKZJKZYFP YNIC \GEPGT QRKB[ OG[P
.50 NKDP FKSGNMGBF NNMN \KPGBN FYKZS \YKECM FRG[BZF FZKICF \YKEC FRRKB
KGPS OE \YKEC TXCN OKXKNPP GRB \GBKZCF EZ[P \XNPF NT LP\SFCG ,\GYKECF NNMP
FYEXF [K .FSRS JNGYGPF \MZT \GTXPBC 74{50 NKDC OK[RNG OKZCDN FR[N \IB FBGXC
\GXGCYN \GVKET \\N [K .KPTV EI BNG OKK\R[N \IB ET FR[N \IB \K[TR BKF OB GH FYKECN
.ZIB KRG[BZ QJZSG ,KTPF QJZS N[ K\IV[P ZGVKS ,OKTGEK OKVKNGV :FGCD QGMKS \GNTC
50 NKDP OKR[ 10=N \IB FKVGYSGRGNGY NT WKNPFN Z[VB { (Case finding) EEGCF FNGIF \PZC
NM FBGXC KGPS OE \YKEC OKTXCP ORKB[ FNBN) 65{55 OKNKDF QKC OKKIC OTV \GIVN GB
LGPR QGMKSC FKKSGNMGBN FZKYS \YKECM \GBKZCF NSC \Z[GBP FRKB GH FYKEC .(OKK\R[=FR[
\KBGVZF \GZE\SFF { KTPF QJZS N[ OEYGP ZG\KBN FKVGYSGRGNGY B[GRC FEPT ZKKR GBZ)
.(2007 NBZ[KC
TXCN WNPGP FRG[BZ FDZEP FIV[P CGZYC SDF KTPF QJZS N[ K\IV[P ZGVKS OT OK[RBC
QCC NGEKDF QICGB GC NKDFP \GIV OKR[ 10 GB 40 NKDP OKR[ 5=N \IB FKVGYSGRGNGY \YKEC
\GKHGVKNGV BN \G[ZGP \GRGPSK\ N[ FZYPC 25 NKDP FKVGYSGRGNGY TXCN WNPGP .FIV[PF
ONGTC OKIPGP \TE NT \SSGCP GH FXNPF .\[ZGP \KHGVKNGV \RGPSK\ N[ FZYPC 15 NKDPG
.\BH QIC[ ZYGCP KRKNY ZYIP ZETKFC
.\K\YNE KTP \NIP OT OKNGIC \K\VGY\ FKVGSGRGNGY \YKEC TXCN WNPGP
OT QKP KSIK OGKY) ,QGMKSC \GXGCYN OKR[ 3=N \IB OIZF ZBGGX QJZS N[ OEYGP ZG\KB .7
GN GKF[ DGH QC OT QKP KSIK OGKY GB ,EGBP ZKTX NKDP ,3 \GIVNG OKRDGP BN OKV\G[
.13 'SP IVSR GBZ B[GRF JGZKV .(\GCZ \GV\G[
31
N[ K\IV[P ZGVKS OT FGCD QGMKSC OK[RN WKNPFN Z[VB FNI[F QJZS N[ OEYGP ZG\KB .8
QPSN OE \YKEC TXCN ,FKKR[G FRG[BZ FDZEP FIV[P \GCGZY K\[C \GIVN FNI[F QJZS
\GNKTK \GBEGGC FIMGF OZJ KM OB ,FR[N \IB KNRKDG=SRZJ ERGBS FZJNGBG CA 125
ZGVKS OT \GKHRM[B OK[RC .OK[R Q\GBN QJZSN KJRD WGTK NT OD WKNPFN Z[VB .\GYKECF
K\IV[P ZGVKS OT GB FRG[BZ FDZEP FIV[P \GCGZY K\[C FNI[F QJZS N[ K\IV[P
FKXJGPN E[IC KJRD WGTKKN \GRVFN WNPGP (Breast-Ovary Syn) E[+FNI[F QJZS N[
[KG QM\K GH FXGCYC .FNI[F QJZS I\VN 80% ET N[ QGMKS FNB OK[RN .BRCA OKRDC
FZKYS \YKEC TXCN HB ETG QGKZVF \VGY\ UGSC \GNI[F N[ \K\TKRP F\KZMN FYEXF
.N"RM
.14 'SP IVSR GBZ CD KCBM \TKRP .9
[K .\GRECGBN FKKJRG QGBMKE N[ \GTVG\N OKKRZKT \GKFN [K :QGBMKE N[ OEYGP ZG\KB .10
G\KIVK ,OKB\P NGVKJG OEYGP ZG\KB .\ZDGCF FKKSGNMGBF CZYC QGBMKE ZG\KBN OGYP
\/BMGEP [KDZP F/\B OBF" :FJG[V FNB[ \GTXPBC \BH \G[TN Z[VB .FBGNI\
GB QKKRT LN FKF BN QGZIBF [EGIC OBF GB ."QGZIBF [EGIC FGGY\ ZSI GB \/[BGKP
\GIVN \KCGKI FCG[\F OB .\GRKPH \GKNGVKJ \GK\[\C LZGX ,QCGPM ,[K .OKKIFP FBRF
.QGBMKEN ZGZKC \G[TN [K \IB FNB[N
.OK[R EDRM \GPKNBG FIV[PC \GPKNB B[GR ZZCN WNPGP .11
FECTP \GYKEC
NGZJSNGM LS) \GFGCD NGZJSNGM \GPZ N[ OEYGP ZG\KB KM GBZF OKZYIP :NGZJSNGM
BXPR QM GPM .CN \GNIPP F\GP\G FBGNI\ \KIVP OFC NGVKJG OKBKZC OK[RBC (HDL=G
NNGM CN \GNIPN OKCZ QGMKS KPZGD OT OK[RBC NGZJSNGM LDL \EZGF KM OKZYIPC
\R[P ICSI=F \GXNPF .OE KNMG CN \GNIPP F\GP\G FBGNI\ F\KIVP BKF UB \ZMGS
NKDP OKZCDN (OKRPG[ NKVGZV) OKEKZXKNDKZJG LDL ,HDL ,NGZJSNGM LS TGXKC BKF 2007
FBGVZN KBYKZPBF FPK[PF IGM \GXNPF .OKR[ 5=N \IB 45 NKDP OK[RNG FNTPG 35
35 NKDP OKZCDF NMN FZKYS \YKECM HDL=G NGZJSNGM LS \YKEC QF 2004 \R[P \TRGP
\IB KRPG[ NKVGZV TGXKC :ICSI NT \SSGCP GR\XNPF .OKR[ 5=N \IB 45 NKDP OK[RF NMNG
IGM \GXNPF KV NT OD NGTVN Z[VB \BH OT .45 NKDP OK[RNG 35 NKDP OKZCDN OKR[ 5=N
LS KMZT Z[B FNBN .HDL=G NGZJSNGM LS \YKEC OGX BNN TXCNG KBYKZPBF FPK[PF
(NGZJSNGM LDL) OKRPG[ NKVGZV TXGCK { OKMGPR HDL GB/G OKFGCD GBXPK NGZJSNGM
FZKYS \YKECM KRPG[ NKVGZV TXCN WNPGP \VSGR FYKECN GZHIK KM IGJC BN[ OKNVGJPCG
FKPEKVKNZVKF N[ ZGVKS OT OK[RBN .(CN \GNIPN QGMKS KPZGD 10 'SP IVSR GBZ)
\IB (OKEKZXKNDKZJ ,HDL, LDL ,NGZJSNGM LS) KRPG[ NKVGZV \YKEC \XNPGP \K\IV[P
.FR[N
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
32
OKRGSKI
:OKNNGM FH NKDC OKRGSKI
,OKKRGZM OKNGING ,\GBKZC KECGTN .50 NKDP FKKSGNMGBF NNMN FR[N \IB \TV[ EDRM QGSKI .1
.40 NKDP \GZKBPP \GNIPG \GKRGZM FBKZG CN \GNIP OT
ZIBN OKNGI QGDM FGCDF QGMKSF \GXGCYN \IB QGSKI \RP :SGYGYGPKGRV EDRM QGSKI .2
ZSIG HIV=C OGFKH ,OKZCB \N\[F ,OKDGNGRGPKB OKKGYKN ,NGIJ ZETF GB \\KZM
.FRG[BZF FRPF ZIBN OKR[ 5 \XNPGP FKR[ FRP .OKRKNGCGNDGRGPKBC
FBKZG CN \GNIPC OKNGI) "KRGRKCF QGMKSF" \XGCYC OKNGIN \KPTV EI FRP \XNPGP
.(\GKRGZM
.OKR[ 10=N \IB FKZ\VKE=SGRJJ EDRM QGSKI .3
.(16 IVSRC JGZKV FBZ) B=G
FSKJC FBGNI\ \TKRPG OKNKKJPN OKRGSKI KCDN { 65{40 OKNKDC OF OKCZ OKNKKJP .5
.15 'SP IVSR FBZ
33
NM SGRJJ=FKZ\VKE QGSKI
OKR[ 10
BMI
FKVKJB OT E[ \NIP GB (FRG[BZ FCZKY) K\IV[P ZGVKS :E[F QJZSN FGCD QGMKS
.(HT) KNRGPZGF NGVKJ N[ \M[GPP \NKJR ,ZCTC E[ QJZS GB ,FKSVGKCC
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
34
10=N \IB FKVGYSGRGNGY NT OD WKNPFN Z[VB FBGXC KGPS OE \GYKEC TXCP GRKB[ KPN
\GBKZCF NSC \BXPR FRRKB FYKECF .65{55 NKD CKCS \IB OTV \GIVN GB 50 NKDP OKR[
ONGTC OKIPGP \TE NT \SSGCPG ,LGPR QGMKSC OK[RBN OEYGP ZG\KBN FYKZS \YKECM
.\BH YEC[ ,ZYGCP KRKNY ZYIP ZETFC
40 NKDP \GKIB ,OKIB ,FZGFN KTP QJZS ,\K\YNE KTP \NIP :KTPF QJZSN QGMKS \GXGCY
.FIV[PF QC QJZSC FYN GC NKDFP OKR[ 10=C \GIVF NKDP GB
35
FNTPG 65 NKD
(7=1, 28=29, 55=58, 144=158, 206=212, 220=221,
226=230, 256=302, 395=400, 576=599, 610=629, 647)
FKZJBKZDN \KPGBNF FXTGPF OTJP KNGSZ SKZKB Z"EG DZCRHGZ KNB Z"E \GXNPF NT SSGCP
FPEYF
FNTPG 75 NKDF \XGCYC QMNG 81 OK[R N[G 77 BKF NBZ[KC OKZCD N[ \TXGPPF OKKIF \NIG\
.Z\GK FGCD FKFK NNMC OK[RF ZGTK[G OKRPNBP \GRPNB Z\GK GKFK
.\GRPNBG \GBNPKDN F[KZV N[ FVGY\F GH .\GKRGZM \GNIP N[ FFGCD \GIKM[ \PKKY FH NKDC
NMC GPM .\GKRGZM \GNIP ZGCT \KRPH GC \GVGZ\ ZVSP M"EC OKNJGR OKCZ OK[RB GH FVGY\C
OF \GNIPF NMP F\GP\G FBGNI\ \\IVFG \TKRPN OKK\GTP[PF OKTXPBF QKC ,NKDF \GXGCY
FBZ) .Z\K \RP[FG FRP[FP \GTRPKFG FRGMR FRGH\ ,\KRVGD \GNKTV ,QG[KT \YSVFG \GTRPKF
.(18 ,17 ,13 ,12 ,10{8 OKIVSR
B[GRN JZV) +75 KRC QKCN 74{65 KRC QKC \GNKECPF \GKBZ \GMP\R \GXNPF QKB ,NNMMG NKBGF
.GNB NKD KECGZ KR[N \GXNPFF QKC EKZVFN QGMRN GRKBZ BN (SDF KTPG E[F QJZSN QGRKS \GYKEC
\Z\GM \I\ \GPG[Z \GVETG\P \GNGTV .\[DEGP \Z\GM \I\ \GPG[Z \GKBZ \GMP\R \GXNPF
\Z\GM \I\ \GPG[Z ECNC OKIPGP \TE \GGI KV NT GNCY\F[ \GXNPF K\I\ GYC \[DEGP
.\ZIB ZPBR OB BNB \K\R[ BKF \GNGTVF \GZKE\ .KGJR C\MC
36
NT EGPTN QPG[F LS NT .KGGZ QPG[ 10%=P \GIVG SRZJ KRPG[ \B OGPKRKPN \KIVFN
.\GKZGNYF NNMP 35%{20%
http://www.healthierus.gov/dietaryguidelines
FB Z
10{8 ,TGC[C OKPTV 4{2 L[PC OKZKZ[ KZHIP/IGM KRGC OKNKDZ\ TXCN OD [K
\GZHI 10 \GIVN N[ OKJS 2{1 NKDZ\ NMC ,\GKZYKT OKZKZ[ \GXGCYN OKNKDZ\
.NKDZ\ NM NT
37
\GYE 10 L[PN FT[N P"Y 3.2 ET N[ ,\KSIK KJB CXYC FMKNF :\KCGZKB \GNKTV
[K[Y ZGCT N"YY 88 =) \GVGXZ \GYE 30=N FDZEFC FKKNT .OGK KEP UXZC
FBXGFN TKDFN Q\KR GHM FZGXC .TGC[C OKPK 5{6 L[PC (D"Y 70 NY[PC
LS \B \GNTN KGXZ ,\GPNYB\FF OT .TGC[N N"YY 500=M N[ \XNPGP \KJDZRB
.FMKNFF QPH \NVMF \ZHTC TGC[N N"YY 1000 N[ \KJDZRB FBXGFN ET \GNKTVF
:OKRGSKI .D
.GK\SF K[EGIC \TV[ EDRM (1
OK[RBN FH QGSKI N[ FKKR[ FRP Q\RK\ .KPTV=EI QVGBC SGYGYGPKGRV EDRM (2
\NCY HBP OKR[ 5 GVNI[ ZIBN ,65 NKD KRVN QGSKIF N[ \IB FRP GNCKY[
.QGSKIF
.OKR[ 10=N \IB (Td) \PZY=\XNV EDRM UIE (3
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NGVKJF \GRGZ\K \B NVGJPF KRVC SGZVN [K KHB (\KPMSKB CN \NIP CYT \GGP
GRKKFE ,LEKBP OKKZ[VBF OKRGMKSF \BG ,\KCCNF FBGNI\F OGXPX GRKKFE ,EIP
IGM N[ BCF Z\BC KGXP USGR TEKP .KPGPKE KIGP WC[G NGMKTF \MZTPC OKPGPKE
USPSTF): http://www.ahrq.gov/clinic/uspstf/) FTKRPN \KBYKZPBF FPK[PF
.(16 'SP IVSRC B[GRF JGZKV) uspsasmi.htm
38
D QKPJKGG
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.HGV[BP ZHGI NVGJPF[MG OK[EGI 6 KEP FZKYS :K\VGZ\ NGVKJ
39
.QGBMKE QGICBN USGR TEKP \GNEN [K ,\KCGKI BKF \IB FNB[N FCG[\F OB
\GKTCP \KRKNY \GP[Z\F GB NGB[\ QMG \VNGIF FR[C FNKVR KTGZKB \ZKYS :\GNKVR
NT FTKCXP \IB \KCGKI FCG[\ .GNVR BN[ FNBC OD (balance) \GCKXKC GB (gait) FMKNFC
.\GNKVRN QGMKS KPZGD ZGZKCC LK[PFN [KG \VSGR FNKVRN FGCD QGMKS
:FZTF .OKR[ 5=C OTV \GIVN N[ \GZKE\C B[GRF KCDN NGB[\ :OK[RC Q\[ \JKYR=KB
90%=M) NGVKJF \GNKTKG (OK[R [KN[ KR[N ET) FFGCDF \GIKM[F CYT FXPGB FYKECF
.(FINXF
65 NKDP FKKSGNMGBF NNMN FZKYS \GYKECM \GXNPGP QRKB[ \GNGTVN \GXNPF ZVSP QNFN
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BMI
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\ZMGSG OE WIN Z\K GPM FBGNI\N QGMKS OZGD FGGFP QM LB ,OKKIF \NIG\ ZXYP GRKB
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QKC BGF OB { FR[ KEPG ,120/80> OEF WIN OB OKK\R[ KEP \GIVN OE WIN \EKEP
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,6) \GK\GBG OKZVSP 6 N[ CGNK[ OK[IGN ,F[KINF KRVN \GNY OKV[GR .G\KKBZ IGGJN WGIP
BN OB .6 LG\P 3 NT ZHI OB FINXFC ZCT YECRF .ZGHIN YECRFP OK[YCPG (I ,E ,5 ,2 ,B
FRKB[ QHGBF \B OGSIN YECRF NT .EZVRC QHGB NM OKYEGC .ZIB CGNK[ OK[IGN IKNXF
.\YECR
40
KEK=NT BKF OKKRK[ \YKECN FXNPFF :[K[ FEKPC \GC\G\FG OKKRK[F ,FVF NNI \YKEC
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\GBXPRF FNBG 65 NKD ET CYTPC GKF BN[ OK[RC :OIZF ZBGGX QJZSN FYKZS \YKEC
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41
KEP
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FBGXC KGPS OE
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(OKK\R[ KEP) FKVZDGPP
QEKS Q\P
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42
13 'SP IVSR
OKZGTK[F OKNGT ,QM GPM .NBZ[KC ODG GNGM ONGTC OKNGT OKRG[F QJZSF KDGSC FBGNI\F KZGTK[
.FNTPG 70 OKNKDC 100,000=N 4,450=N ET 39{35 OKNKDC 100,000=N OKZYP 200=P) NKDF OT
.\GRG[F QJZSF \GNIP KZGTK[C \GKR\B 'CYG ZEDP KNECF OKPKKY USGRC
FBKZF QJZS ,SDF KTPF QJZS ,E[F QJZS :OF NBZ[KC OKIKM[F OKZKBPPF OKNGEKDF
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:\GKR\B 'CYG QKP KVN Z\GKC OKIKM[F OKNGEKDF N[ \GTZBKF KZGTK[ \NCJ QNFN
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40.2
55.8
21.4
95.8
30.3
41.5
30.3
5.3
11.7
22.7
24.5
56.9
25.4
2.6
4.5
10.9
21.2
1.3
7.9
19.6
9.24
1.6
5.1
10.3
14.7
4.9
5.7
13.6
17.3
8.9
13.4
6.8
8.1
4.3
\B[F DGS
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CZYC FKKNT \PDPG \KEGFKF FKSGNMGBF CZYC FEKZK \PDP \PKKY 2004 \R[P
.\KCZTF FKSGNMGBF
107
\KRG[BZ FTKRP
KV NT TXC\PF OEYGP KGNKD .OEYGP KGNKDN \GNGTV KRV NT \GNKTKG \GVKET QJZS \TKRPN \GNGTV
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OKKIF IZGB QKC Z[Y [K KM YVS QKB ,\GRG[F \GKR\BF \GXGCYFG ZEDPF KNECF KV NT .EGBP
Q\KR BNB OKP[P FZKHD GRRKB QJZSF \GNIPP ZMKR YNIG OKZKBPP OKNGEKD \GI\V\FG
OKRGPZGF ,USGR [KN[N \KBZIB FKGYN FRGH\ ,QJZSF KZYPP [KN[N KBZIB QG[KT .FTKRPN
NT OKPZDR QJZSF KZYP NNMP 80% GRKKFE .OKVSGR 10%=N OKRG[F OKRDC OKPDVG 15%{10%=N
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FZCSF \GNGTV TXCN [K .TGNFG J[GGF ,FVF ,KTPF QJZS ,Q\[F \KIGVN[ ,CNCNF ,FBKZFG
OGI\C NGTVNG ZGHTN [K .KEGSKF ZVSF \KCG LZF NKDFP NIF QG[KTF \TKRP B[GRC FMZEFG
ZKGGBN O\GMH NT EKVYFN OKR[TP BNF NT .OKZKTX OKZDGCPG OKZDC\PN QG[KTF \YSVF
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OKXNPGP OK[PR OTG EIGKPC ZKFC ZGT KNTCN YZ .15 'SP FRDF KPEYP OT [P[ KRRSPC
.FT[ NM IZPKFNG EKVYFN [K [P[C \M[GPP \GF[C .(25 'SP) Z\GK OKFGCD OKPEYP
KGRK[ :QGDM \GZKBPPN EK[IFN OKKG[TF ,OKPKKYF ZGTF KTDRC OKKGRK[ NT IKD[FN CG[I
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
108
OKR\[PF OKTDR ,(FKZJPKSB ,OKZKES BN \GNGCD) FZGX ,(P"P 6 NTP ZJGY) NEGD ,TCX
.OGPKE \TVGFG ,\GZKFPC
\GNGNDC [GPK[ GKVN TEKP TKVGF \GRGZIBF OKR[C) .QGKZF \TKRPN \GNGNDC L[GPP [GPK[
.(QGMKSC FKKNT NT FBZP GRKB OK\IVGP OKRGPZGFF KHGMKZ QFC[ \GKRZEGPF
FR[ ZIBN ZCM E[F QJZSN QGMKSF \B NKEDP (HRT) \SGF \YSVF ZIBN KNRGPZGF NGVKJ
\B OD ZKCDP KVKNIF KNRPZGFF NGVKJF .NGVKJ \GR[ 5 ZIBN \K\GTP[P NED QGMKSFG
.\GNI[F QJZSN QGMKSF
.Z\K \RP[F
OKNKDC FVK[I OD .14{10 OKNKDC EIGKPC OKCGZP QDJRZ KPGNKXN FVK[I ,\RRKKP FRKZY
.E[F QJZSN QGMKSC \IMGP \K\GTP[P FKNTC FGGNP OKZIB
.(DN J'D) \VTKN FVK[ICG \GZP[PC FEGCT CYT QKRGJNPF OHKNGCJPC [GCK[
GYN[ OK[R CZYC BXPR LB E[F QJZS \GTZBKFG QG[KT QKC [NI Z[Y BXPR { QG[KT
\GR[TP CZYC \GCKSF NMPG E[F QJZSP F\GP\ N[ Z\GK FGCD YFCGP ZGTK[ E[F QJZSC
.\GR[TP BN \PGTN
.BRCA2=G
BRCA1
.FYRF
.TGC[F KPK \KCZP OGKN \GYE 60{30 FZKES \KRVGD \GNKTV TGXKC
OK[RN ZKCTFN CG[I LB \GK\ZCI \GJNIF OF OKENK ZVSPG QG[BZ ENK \EKN NKD ORPB
.E[F QJZSN QGMKSFG OKENK ZVSPG FRG[BZ FEKN NKD QKC Z[YF ZCEC TEKPF \B
.\SGGF \YSVF ZIBN L[GPP KNRGPZGF NGVKJPG OKRGPZGFC KIZMF BN [GPK[P \GTRPKF
GB/G OKKE[ \\KZM NGY[N Q\KR { BRCA2=G BRCA1 OKRDC ODVF \GKB[R OK[R KCDN
OKKE[ \\KZM ZIBN 90%=C \EZGK E[F QJZS \GTZBKF .TRGP NGVKJM \GNI[ \\KZM
.40 NKD KRVN \TXGCP \GNI[F \\KZM OB ,\K\TKRP \GNI[ \\KZM KZIB 50%=CG ,\K\TKRP
QF[ ,OK[RN QVKSYGNZG QVKSYGPJ GPM \GVGZ\ Q\P NGY[N [K { FTKRPN K\VGZ\ NGVKJ
OK[RC FBGNI\C FEKZKN \GPZGD FNB \GVGZ\ KM FIMGF QKB .E[F QJZSN FGCD QGMKSC
N[ FFGCD \GIKM[ GPM KBGGN \GTVG\ FNB \GVGZ\N [K QM GPM .BRCA1 QDN \GKB[R
GBZ) QVKSYGPJ Q\PC OIZF \KZKZ QJZS N[ FFGCD \GIKM[G OKNGCPBGCPGZJ OKTGZKB
.(TRGP K\VGZ\ NGVKJ { 17 IVSRC JGZKV
QFC QKB[ \GKBGVZ FKKPEF \GYKEC \ZDSPC ZYKTC ,\RRKKP FRKZYN FVK[IP \GTRPKF
.IZMF
110
.(KTPF QJZS KRVP FRKDP FTV[F QEKSN) .\KNGV FXPGIG QEKS ,OKCKS \MKZX
\GTZBKF YFCGP QVGBC \KIVP (HT) \SGGF \YSVF ZIBN KNRGPZGF NGVKJ KM BXPR USGRC
N[ \GTZBKF FNTF NKCYPC LB GNJR BN[ FNB \PGTN OKRGPZGFF \GNJGRC KTPF QJZS
.KTPF QJZS \TKRPN KNRGPZGF NGVKJ \NKJR NT WKNPFN QKB .OE KNMG CN \GNIPG E[F QJZS
112
WNPGP .\KRMG\F \CIZFN FXNPF QKB FH CN[C .FFGCD E[ \GVKVX NNDC FCZFC FMGPR
,FKVZDGPP \GTXPBC ZYS \YKEC \GRGZSIG \GRGZ\K KCDN 49{40 NKDC F[KB NM OT QGEN
FKVZDGPPN \GRVFN WNPGP) K[KBF FRGXZC C[I\FNG QGMKSF KPZGD N[ FMZTF TXCN
.(FYKECF TXCN \[YCPF FH NKDC F[KB NM ZYS \YKECM
OT OK[RN YZ BVGZ \YKECG 40 NKDP FR[N \IB FKVZDGPP TXCN BKF FXNPFF OGKM .3
KRVN E[F QJZS ONXB FND\F[ \C GB \GIB ,OBC E[F QJZS N[ K\IV[P ZGVKS
NKDC E[F QJZSC GYN[ \GIB GB OB N[ K\IV[P ZGVKS QFN OK[R KCDN .\SGGF \YSVF
\GIV OKR[ 5=C \GKFN LKZX FYKZS \GYKEC TGXKCC NKI\FN [K GC NKDF KM WKNPFN [K ZKTX
.FIV[PF \CC QJZSF BXPR GC NKDFP
F\KIVP ,FYKZS \YKECM E[F N[ \KPXT FYKEC TGXKCN OK[R \Z[MF KM \GET FBXPR BN .4
QKSC NGED ZYIP .GH FYKECC \NTG\ NM GPKDEF BN OKZYGCP OKZYIP .F\GP\G FBGNI\
\BH \PGTNG \KREKF FYKECN QGZ\K NM OKDEF BN ,OK[R QGKNP TCZ N[ FKKSGNMGB NT TXGC[
\GKFN OK[RF KRVC WKNPFN [K \BH OB .\GZ\GKP \GKSVGKC TGXKCC \ZMKR FKNT BXP
.!QPXT OK[RF KEK=NT OKND\P OKNGEKDF \KCZP QKKET ,OKKE[C OK[GDN \GKRZT
50 NKDP \IB QJZS \NGI Z\BN \RP NT KM ZGMHN [K { NNS (Number Needed to Screen) .5
'VGZV KRG\R) 1000 YGZSN [K ,50 NKD \I\P \IB FNGI Z\BN \RP NTG OK[R 200 YGZSN [K
.(E[F QJZS N[ OEYGP ZG\KBN \KPGBNF \KRMG\F JZRZ ED
GHP FFGCD E[ QJZS KGNKD \NGMK \NTCM FRGZIBN FPDEGF FYKECF :E[F N[ MRI \YKEC .6
.\GBKZCF EZ[P KEK=NT FZ[GBG \GKJRD \GNY\ \GB[GRF OK[RF \XGCYC FKVZDGPP N[
OKRDC ODVF \GKB[RN FR[N \IB FZKYS \YKECM E[F N[ MRI TGXKC BKF FXNPFF
.BRCA2=G BRCA1
OKK\R[N \IB BVGZ \YKEC BNN \ZYGS FKVZDGPP TGXKCN BKF FXNPFF OGKFN QGMR :OGMKSN
QGPKH \NNGMF \KEGTKK FYKZS \KRMG\ \ZDSPC NBZ[KC OK[RF \KKSGNMGB NNMN 74{50 NKDP
{ FR[N \IB \ZYGS FKVZDGPP \YKEC .QGPKHC FYKZS \ZDSPC BN[ 74 NKD NTPG ,K[KB
GB .\C GB \GIB ,OB NXB E[F QJZS N[ K\IV[P ZGVKS QFN OK[RN 49{40 NKDP BVGZ \YKEC
\GKB[RN FR[N \IB E[F N[ MRI \YKEC .FKSVGKCC FKVKJB OT FZKV[ E[ \NIP OT
.BRCA1, 2 FKXJGPF
\GGXN FMZEF \GZDSPN DGBEN [KG \KNNMF \KRVGDF FYKECFP YNI FRKF \KRKNY E[ \YKEC
.\GBRF FTGXKCN KBGVZF
KNC GB OT 5=N \IB FKVGYSGEKBGPDKS TGXKC OKCGJ \ZGYKC FZYP KZYIP ZVSP KV NT .2
OF \GRGZSIF .40%=C KTPF QJZSP F\GP\F \B F\KIVP FR[N \IB KGPS OE \YKEC
.GND\K BN OKTDRFP 50%=G KTPF IJ[ NM \B FSMP FRRKB BKF ,\KR[NGV FYKECC ZCGEP[
.FZKYS \YKECM GH FYKEC NT OKXKNPP GRRKB GRB
55 OKNKDF QKC OKKIC OTV \GIVN GB 50 NKDP NIF OKR[ 10=N \IB FKVGYSGRGNGY TGXKC .3
QJZSP F\GP\ \RJYF NT FBZPF ECNC EIB \ZGYKC ZYIP NT \SSGCP GH FXNPF .65=N
\BH OT .OKVKNGV \\KZMG KGNKD NT OKSSGCPF OKNEGPP FKXNGVZJSYBPG 57%=C KTPF
Z[BM EIGKPC ,OKVSGR OKMGCKSNG KTPF \GCYR\FN \GZ[VB OT \KR[NGV FYKECC ZCGEP
LZGXN FKVGYSGRGNGY \GYKECN OKZG\F QM GPM .OK[RB KRGKNKPN FZKYS \YKECM TXGC\
NT F[YK QMNG (OK[EGI 3 ET) OKPKGSP OKZGHBC EGBP OKMGZB OF NBZ[KC QGICB
FRRKB FYKECF .FKKSGNMGBF NMN FZKYS \YKECM FKVGYSGRGNGY TGXKCN LZTKFN \MZTPF
OGKF ET GNCY\F BN \GKVGYSGERBF \GYKECF .FKKSGNMGBF NNMN FYKZS \YKECM \XNPGP
YNIC \GEPGT QRKB[ OG[P ONGTC FRKEP OG[C \GKPGBN FZKYS \GKRMG\N KNMM
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
114
F\ZDSPC[ SDF KTPF QJZSN \KPGBN \KRMG\ NT 2006 \R[C HKZMF \GBKZCF EZ[P
TGXKCN FRPHF G\KCN NCYP EIB NM .FYKECF \B TXCN 50 NKDP OKC[G\F NM OKRPHGP
OE \YKEC \MZT F\KCF NCYK (FKKGND \IKN[ KEK=NT) U\\[FN GRGXZ TKCK OBG FYKECF
.\KXZBF FECTPN FMZTF IN[\ FYKECF TGXKC ZIBN .OKPK 3 L[PN TGXKCN FBGXC KGPS
.ETKF \KKSGNMGB CZYP 30% KEMN FTKDP OGKM \GRTKFF
QJZSC FNIPF LNFP \B FR[P BGF[ \GM\GI \GIMGF QKBG \GZMKR F\GP\G FBGNI\C FGGNP
\KRGPZTF N[ FBNP F\KZM N[ NY QGZ\K FBZF FRGZIBN OSZV\F[ ZYIP .FJGNCN OYGPPF
USGRC .\KNNMF F\GP\C KRG[ NM FKF BN .\KRGPZTF QJZSP F\GP\ KCDN NGVKJ ZSGI KRV NT
N[ EGCKB GPKDEF OKKJZGBK\ OKIG\KR ZVSP .FYKZS \GYKEC KEK NT GND\F OKNGIFP 5% YZ
OMSN Q\KR ,\BH \GCYTC .FYKZS \YKEC ZCT[ FNGI NMN FCGJ \GMKBC OKKI K[EGI 8{3
USGRC \BH ,GN NKTGFNP Z\GK FNGIN YKHFN FNGNT PSA GB DRE \ZHTC FYKZS FH CN[C[
FYKZSF TGXKC ZKIP LZTGP C"FZBC)FKKSGNMGBF NMN FYKZS TGXKC N[ ZKEBF KNMNMF ZKIPN
35 N[ FHKNRB=FJPC .(FR[N ZNGE EZBKNKP KR[C 50 NKD NTP OKZCDF NMN \GGNRF \GYKECFG
FKKSGNMGBF NNM \ZKYS TGXKCN OGYP [K OBF YECR 2002{1994 OKR[F QKC GTXGC[ OKZYIP
\GTXPBC) FZKYSF \GYKECC[ TGCYN Q\KR BN KM BXPR .\KRGPZTF QJZS N[ OEYGP KGNKDN
IMGF BN ,USGRC .F\GP\NG FBGNI\N OKPZGDF OKDGSF BYGGE OKND\P ,(PSA=N OE \YKEC
FFGCD OKKI \GMKZBN OZGDG Z\GK FCZ \NTG\ YVSP OEYGP KGNKD \GCYTC OEYGP NGVKJ[
GBZF BN \KRGPZTF \ZSFN KNYKEZ IG\KRG PSA \GTXPBC \KCKSRJRKB FYKZS OD .Z\GK
.GZYSR BN[ FNB \PGTN \KRGPZTF QJZSP Z\GK FMGPR F\GP\
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY
116
\YKECM PSA \YKEC GZCT[ FNTPG 50 NKDP OKZCD QGKNP NM NT KM QTJR \NTG\=\GNT CK[I\C
GRICGBK ,20,000=G FKSVGKC GZCTK ,90,000 OMG\P ,OKFGCD PSA KMZT GKFK 110,000=N FYKZS
Q\[ \JKYR KB GI\VK 300 ,IG\KRF CYT G\GPK 10 IG\KR GZCTK OFP ,10,000 OB .QJZSC OKYGNM
NT TKV[P FKF BN QJZSF DGS OKZYPFP ZMKR YNIC Z[BM \BHG \GRGB QKBC GYNK ,4,000=G
.FND\F BN GN FNGIF KKI LNFP
.OKZCD 55,512 GNNM[ OKZYGCP OKZYIP KR[ YZ GBXPR ,2006=C FPSZGV[ QZMGYF N[ FZKYSC
BXPR BN \GBXG\F N[ [EIP IG\KRC .\GK\GTP[P \GKDGNGEG\P \GKTC GKF OKZYIPF KR[C
NT FTV[FF FYECR BN OKZYIPC .(RR=1.01) PSA \ZHTC FYKZS \GCYTC F\GP\C FEKZK
\GHGIP 2=C C"FZBC FCYGT ZYIP .FYKZS QPHC KGD[ QGICBP TDVKFN FNGMKF OKKI \GMKB
OKNKDC OKZCDC NKDZF NGVKJF \PGTN \KRGPZTF QJZSC NGVKJG FYKZS N[ \GBXG\ FGG[F OKRG[
BN .OKZCD 215,000=P FNTPNC CYTP TXGC M"FS .OKR[ 11 L[PC \GBKZC IGJKC KNTC 79{65
NGVKJG PSA KEK NT FYKZS GZCT[ FNB QKC \KRGPZTF QJZSP \GGPF KZYP ZGTK[C NECF BXPR
OKRGDZBF N[ FPMSF FR[K .FYKZS GZCT BN[ FNB QKCN FRKZYG \KRGPZT \\KZM KEK NT
FBGVZN KBYKZPBF FPK[PF IGMG \GBKZCF EZ[P \EPT ,\KBGVZF \GZE\SFF N[ OKKBGVZF
K\GZK[ ,K"CMP \XNPF) OKZCDF \KKSGNMGB NNMN ZYS \YKECM PSA TXCN BN[ (USPTF) \TRGP
.(\GBKZC
QVGBC \KRGPZTF QJZS N[ \PEYGP FYKZS NT OKXKNPP GRRKBG OGYP QKB OGKFN QGMR :OGMKSN
PSA \YKEC TGXKC \Z\GS GH FXNPF QKB ,\BH OT .50 NKDP OKZCDF \KKSGNMGB NNMNG K\JK[
BNN OEBC \BH OKTXCP OB .FGCD QGMKSC OEBC GB KJPGJVPKS OEBC KRJZV QVGBC
.ET\NG \GRGZSIG \GRGZ\K ZKCSFN [K ,G\[YC KVN OKPGJVPKS
QJZS N[ OEYGP KGNKDN FYKZS \YKEC TXCN FYEXF QKB FKDGNGYRGBN \KPGBNF FXTGPF KV=NT
ZYIP ZETFCG ,ECNC OKIPGP \TE NT SSC\FC .NKDZ QGMKSC OKZCDF \KKSGNMGBC \KRGPZTF
50 NKDP FR[N \IB (ERGBS FZJNGB) TRUS+PSA \YKEC TXCN WNPGP \BH QIC[ ZYGCP KRKNY
70=P ZKTX NKDC QICGB[ \KRGPZTF QJZS N[ K\IV[P ZGVKS N[C FGCD QGMKSC FKSGNMGBC
.FRG[BZ FDZEC FIV[P CGZYC
QJZS I\VN 80% ET N[ QGMKS GR[K BRCA1, 2=N OKRDC FKXJGPG K\IV[P ZGVKS OT \GKHRM[B
OEYGP ZG\KB BKF FKDGNGYRGBN \KPGBNF FXTGPF K"T \MP\RF OGKM FXNPFF .FNI[F
\GCGZY 2 .1 FGCD QGMKSC OK[RN FR[ NM OEC CA-125 QPSG KNRKDG ERGBS FZJNGB \GTXPBC
FNI[F QJZS N[ K\IV[P ZGVKS .2 ;FNI[F QJZSC GNI[ FRG[BZ FDZEP \GIVN FIV[P
N[ \K\TKRP F\KZM \NKY[NG KJRD WGTKKN \GRVFN WNPGP QM GPM .BRCA1, 2 OKRDC FKXJGPG
.QGKZVF \VGY\ UGSC \GNI[
118
N[ \GRM\KFFG LZGXF \TKCYNG ,QGMKSF \MZTFN KJRD WGTKK NT WNPGP (1 FNCJ) \K\[ZG\
QJZSF \GRGPSK\ \KCZP .\GZKBPPF \TVGFN OKBZIBF OKRDC \GKXJGP KGNKDN \KJRD FYKEC
BN[ 50% N[ KGMKS GR[K OKBKZC OKJZVN[ ZPGNM ,\KJRRKPGE \KNPGHGJGB FZGXC \G[ZGP
[ZK BN[ KP .\K\IV[PF FKXJGPF \B G[ZK[ 50% N[ QGMKSG ,\K\IV[PF FKXJGPF \B G[ZK
OKKGXP FKXJGPF \B G[ZK[ OKB[R[ EGTC ,Z\K QGMKSC KGXP GRKB \K\IV[PF FKXJGPF \B
\RGPSK\F KGFKHN CG[I WGTKKF ,\KZ[VB FRKB \KJRD FRICB OB OD .QJZSN ZCDGP QGMKSC
.OB\FC FTKRP/CYTP \KRMG\ \TKCYG \K\IV[PF
40%=MG E[F QJZS KZYPP 12%{10=M \GZKCSP QFG 2.5% BKF \GKXJGPF \GIKM[
NKD CKCS \K\TKRP \GNI[ \\KZM ,\GKB[RC .KHRM[B BXGPP OK[RC FNI[F QJZS KZYPP
.FNI[F QJZSP ODG E[F QJZSP OD F\GP\ QFG FBGNI\ QF FRKJYPM FIMGF 40
.2 FNCJC OKJZGVP KJRD WGTKKN FKRVFN OKRGKZJKZY
BRCA1/2
.D
(FCZY \DZE NMC FNI[ QJZSC GNI[ \GCGZY 2 GB) FNI[ QJZS OT FRG[BZ FDZEP FCGZY
E[ QJZS OT \GCGZY 3
.(FRG[BZ FDZEP FCGZY QFP \IB) 50 NKDN \I\P QICGB[ E[ QJZS OT \GCGZY 2
120
\GRGPSK\F K\[C .HNPCC=N KJRD ZGZKCG APC=C \GKXJGP \YKEC { SDF KTPF QJZS .2
,QJZSC FBGNI\ OKRKJYP OKPKB\P FTKRPG CYTP KTXPB[ IMGF QNFN \GJZGVPF
.SDF KTPF QJZSP F\GP\ OKRKJYPG
\RGPSK\F .(familial adenomatous polyposis) FAP { K\IV[P KJGJPJREB SKHGVKNGV .B
FHM BXPP[M .OKKIN KR[F ZG[TC ZCM SDF KTPC OKVKNGV 100< OGKYC \RKKVB\P
OKKGXP OKB[R .APC ,FNIPN OZGDF QDC \GKXJGP \YKEC \XNPGP ,SDF KTPC FND\P
.NGMKTF \MZTP NM LZGBN \GKGZKBPPC \GNIN QGMKSC
\RGPSK\ HNPCC (Hereditary Non-Polyposis Colon Cancer) { \RGPSK\N KJRD ZGZKC .C
OGKMG ,(Q\[F KMZE QJZSG OIZ QJZS ZYKTC) \GVSGR \GKGZKBPPN QGMKSC OD FGGNP GH
FKXJGP[ (MSH2, MLH1, MSH6, PMS1, PMS2, MLH3) OKRD F[K[ \GIVN OKTGEK
OKYHR QGYK\ \MZTPP YNI OF GNNF OKRDF NM .\RGPSK\N OGZDN FKG[T OFP EIBC
NGEKDF \PZC \BJC\PF \KPGRD \GCKXK KB \TVGFN FNKCGP OFC FTKDVG ,B"REN
,K\IV[PF ZGVKSF S"T \KRKNY \RICGBP \RGPSK\F .MSI (Microsatellite instability)=M
SIKK\FC TXGCP KJRDF ZGZKCF .(3 FNCJ) \RGPSK\N ZGZKC TGXKCN OKRGKZJKZY OR[KG
Q\KR ,\GIKM[ \GKXJGP \GPKKY OFC[ ,KRKHGZD GB KHRM[B BXGPP OK[RBC :BXGPN
\GKXJGPF GNN[R OB GB ,\GZIB \GET KBXGKC .FNB \GKXJGP \YKECC NKI\FN
MSI=N NGEKDF \PYZ \YECR QG[BZ CN[C :\KCN[=GE FYKEC \TXGCP ,\GIKM[F
KRGCNIN NGEKDF \PYZ N[ FTKCX \XNPGP ,NGEKDC MSI FFGHP OB ,KR[ CN[CG
.\RGPSK\N OKPZGDF OKRDF N[ UXZ \YKECG HNPCC=F
\GBVZP/OKKJRD OKRGMPN) K\IV[P QJZSN WGTKK \EKIKN \GRVFN WNPGP N"RF OKCXPF NMC
.\GCGZYF OKR[C \GCZ \GKGI\V\F FRKKF\ KBEGGCG Z\GKC KR[EI GRKF FH B[GR ,(\GKJRD=GYRGB
122
20 'SP IVSR
EGYKR
KNPKSYP
KBPXT
YGYH
FZHTN
5
5
3
3
LB FSRP
ZSGI QKDVP
QGIJKC
BN
NDGSP
TXCN
2
2
1
1
0
0
0
0
FNKMB
[GCN
\K[KB FRKKDKF
F XI Z
2
2
0
0
\KIGVN[C FJKN[ .5
FBGXC FJKN[ .6
FJKPP \GZCTF .7
BSKMN
\GZCTF .8
OK\GZK[P
FMKNF .9
\GDZEP .10
BSKMC [GPK[ .11
BN[ KPN) OKNDND
(LNGF
K[KB NGVKJ
10
10
5
5
8
8
4
4
10
10
8
8
15
12
10
15
10
5
12
8
4
8
5
3
3
2
1
0
0
0
OKZDGSC FJKN[
5
5
\GEKKR
.1
.2
.3
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159
QKJGNIN KBPXT
QKJGNIN KGN\
100 :QGKX
0
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,BMI . . " , , , , , :20-39
.:. o 5 ,20-29 3 .30-39
o
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Pap smear , 3 ) 20 , (
. :40-64
BMI . . 40-49 .50 5 .. 50 40 . ,50 5 , 50 75mg 40 75:
BMI .. ) (ADL :
, .
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US .B ,A ,15
.
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( , , .
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,
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. ,
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70 .
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. .
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.
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, - CT .
.
. .
.1 - salicylates ,acetaminophen-
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PO . 1.2 " ) . 4(
":" acetaminophen- ,salicylates- " .
) , ' (.Thyphiodfever -
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.
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.
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) ,(a .
) ,
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.strong cardiac contraction in reaction to decreased preload triggering a vagal response
. , ,
, , . , , .
.
-Situational Syncopes )
( , ) ( , , )
(.
, )<20"
10< ," ( . , , .
) , '( .
. , , ,
) . Postprandial hypotension .TCA , .
<20" . .
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, . - . . .
.
. .
. .
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.
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PE .
.
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,
. .
,
. , .
- .18-33% -
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, MI- .
vasovagal, situational, orthostatic, and medication-induced 45% ,
,10% ,4% .37%
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. 50%- - .
- .electrophysiology study- .tilt-table testing -
. 5 . .
30-60 , 5 .
, .
.
.
, . ,
aortic stenosis . .
Syncopal patients with frequent premature ventricular contractions (>10 an hour), repetitive
premature ventricular contractions (32 in a row), or sinus pauses (>2 seconds) on Holter
monitoring have an increased risk of sudden death.
Continuous-loop recording , .8-20%
EPS . .
EPS VT .
Upright Tilt Testing . 60-
. , 15 .
. 65-80% . 90%-
75%- , .FP .
, . . ..
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50% .
. .
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.
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.
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.
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,
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:
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.
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CRP CRP
,CRP
.CRP
CRP CRP - .
.
.
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ESRD .
,
, .
) (HRT
) (
.
.
- ) ,(26-39% ) (23-28%
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) , "(
ACE . ,
- . ACE
. ACE - .ARB
.
)
( . .
)
( . ,
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.
- ICD
. ICD ) (EF 30% - -
.31% -
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CLASS I - -
.
.
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, . C
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, , HDL -
.
- ) , , , ,
, ( .33% -
.
-
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. .
) (risk stratification -
. , , -
-
.
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3 .
ST .
)
(...TIMI
- 6
.
.
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) , , ,
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.CABG -
CABG PCI )
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.
- ,
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,ACE(
)( .
-
,
".
. .
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.- .
METS 3- .
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.
.
- " . .
ST
.
- 41 -
. :
.1
.2 -
postinfectious .
.3 - .
-
.
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.
, , ,
. " ,
.
:
.1
.2
.3
.4
.5
.6
:
sulfur dioxide, nitrous oxide.
-
:
cough variant 28% .eosinophilic bronchitis
COPD
- -
Chronic rhinitis
Chronic sinusitis
Pharyngitis
ACE inhibitors 10-15%
.
43% Reflux esophagitis gastroesophageal reflux
21%
postnasal drip ,) 19% 38% ( postinfectious status ,,9%
1.5 .
" postural drainage
- -"
,codeine dextromethorphan
.guaifenesin
. ,
postinfectious cough .
Bordatella pertusis .TMP-SMX
GERD ,H2-blockers , .PPI
CT ,
CT
Management of Asthma - 48
Asthma is a chronic inflammatory disease of airways, affects 5-7% of the population, with prevalence and
mortality greatest among city residents. Regardless of precipitant (allergens, cold, exercise, pharmacologic
agents) the pathophysiologic final common pathway is airway inflammation, with bronchial edema, smoothmuscle contraction, and excessive mucus production .Clinical manifestations include: wheezing, dyspnea ,
cough, sputum. Presentations range from pure bronchospasm, with little cough and mucus production, to a
predominance of bronchorrhea and coughing that mimics bronchitis or an URTI.
Extrinsic Asthma typically have a history of atopy, onset of symptoms during childhood or
adolescence, predictable seasonal occurrence, and response to environmental stimuli. Prognosis is
relatively good, with 70% found to be symptom-free 20 years after onset
Intrinsic Asthma usually begin having symptoms in the 3rd-4th decade. Sputum production is
considerable, so that differentiation from chronic bronchitis is sometimes difficult. Minor URTI often
precipitate attacks.
Some presents with exertional dyspnea and cough and no demonstrable wheezing. Sometimes more
refractory to treatment.
Postexertional Asthma is a form of airway hyperreactivity most common in children and adolescents,
the stimulus is believed to be a reduction in the temp. of inhaled air; vigorous exercise on a cold, dry day
is particularly apt to trigger attack. Bronchospasm does not occur during exercise, it becomes marked
shortly after exercise ends and can last for up to 1 hour.
Occupational Asthma the development of sensitization through inhalation exposure to an
occupationally related allergen. Can trigger bronchospasm, especially in a person with preexisting
airway hyperreactivity. There is a direct relation between exposure and onset of symptoms. Typically,
patients are symptom-free during day off from work, only to have a flare-up on returning.
Nasal polyps and Aspirin Sensitivity comprise a curios but important familial asthma syndrome.
Bronchospasm is associated with aspirin intake. The findings of nasal polyps in a person with a history
of asthma should lead to consideration of aspirin sensitivity. Aspirin sensitivity is elicited among 21%
of adults with asthma. Cross-reactivity with NSAIDS (almost all), 7% with acetaminophen.
Classification of Asthma:
Category
Day symptoms
Night symptoms
Lung function
Mild intermittent
2 days per week
2 nights per month
FEV1 80% of predicted
Mild persistent
> 2 days per week, not daily > 2 nights per month
FEV1 80% of predicted
Moderate persistent
Daily
60% < FEV1< 80%
> 1 night per week
Severe
Continuous
Frequent
FEV1 60%
Treatment modalities:
-2 agonist bronchodilators - Supporting role in the treatment of asthma. The short-acting preparations
(terbutaline, albuterol) have a rapid (2-5 min.) onset of action and lasts 4-6 hours. The inhaled long-acting 2
agonists (salmeterol, formaterol) provide up to 12 hours of bronchodilation with a minimum of systemic
effect. Onset of action is delayed, so they do not obviate the need for short-acting when acute bronchospasm
arises. They are used only in conjunction with a program of corticosteroid therapy.
Adverse Effects when used in high doses can trigger systemic adrenergic side effects: palpitations, tremor,
tachycardia. High doses may also cause hypokalemia. Regular use of both short- and long-acting
preparations may lead to tolerance to their bronchoprotective effect
Recommended use: Short-acting - prophylaxis for exercise- and cold-induced asthma; symptomatic relief of
acute symptoms. Frequent bronchodilator use is an important sign of disease exacerbation and the need for
additional anti-inflammatory therapy. Long-acting - in moderate-severe asthma, but only as an adjunct to
steroids.
Inhaled Glucocorticosteroids(beclomethazone) - Long-term anti-inflammatory therapy of asthma. Are
topically active. Systemic absorption is limited, but some of the inhaled dose invariably swallowed. The
onset of action is usually gradual, and it may take days for patient to notice improvement. Full benefit may
not be evident for several weeks.
Adverse Effects: When used at moderate doses, produce few adverse systemic effects. The principal
localized complaints: sore throat and hoarseness, oropharyngeal candidiasis, vocal cord muscle weakness
When used at high doses (750-850 g/d): Hypothalamic-pituitary-adrenal suppression, decreased bone
density, growth retardation in children, glaucoma, cataracts and dermal thinning in the elderly.
Oral Glucocorticosteroids - Remain the most effective treatment for asthma, especially in severe, acute
exacerbations
Onset of action occurs clinically within 8-12 hours of intake, t1/2 12-24 hours. A short-term course (5-10
days) of high-dose prednisone (40-60 mg/d) begun at the earliest sign of an acute exacerbation can control
an attack that does not respond promptly to maximal doses of inhaled steroids and bronchodilators. When
combined with rapid tapering to full cessation within 5-10 days, a short course can obviate the need for
emergency department treatment, reduce the risk for acute relapse, and avoid adrenal suppression.
The adverse consequences of prolonged daily use: osteoporotic fractures, adrenal suppression, skin changes,
aseptic necrosis of bone, aggravation of diabetes mellitus.
Leukotriene Modifiers (montelukast) interfere with leukotriene activity by inhibition of synthesis or
receptor antagonism. Have proved useful for prophylaxis of mild exercise-induces asthma and for control of
mild-moderate persistent disease. It is hoped they will have a steroid-sparing effect. Are especially effective
in the treatment of aspirin-induced asthma.
Anticholinergic Therapy - May add some marginal bronchodilation to that provided by 2 agonist therapy
in severe bronchospasm. It is the bronchodilator of choice for blocker-induced bronchospasm and appears
useful in the elderly.
Cromolyn Sodium and Nedocromil are useful as prophylactic agents for exercise or allergen-induced
asthma and as substitutes for inhaled corticosteroids in mild persistent disease.
Theophylline and aminophylline - The role in asthma care has narrowed. Current use is limited to patients
with moderate to severe asthma bothered by nocturnal exacerbations and to those with refractory, steroiddependent disease.
Monoclonal Anti-IgE Antibody (Omalizumab) - subcutaneous use in moderate to severe asthmatics 12
years old and older with evidence of allergen sensitivity and poor symptom control with inhaled
corticosteroids.
Treatment Guidelines: Anti-inflammatory therapy is the foundation of treatment for long-term
control and bronchodilators have a supporting role.
Mild Intermittent Asthma: Bronchodilator therapy as needed with a short-acting 2 agonist (MDI 2-3 puffs,
repeated in 20 min. if necessary)
2 agonists are also effective as prophylaxis for mild episodes of exercise- or cold-induced asthma when
taken a few minutes before the inciting activity.
Avoidance of environmental precipitants.
If 2 agonist therapy is needed more than twice weekly, therapy for mild persistent asthma should be
considered.
Mild Persistent Asthma: A low-dose inhaled glucocorticosteroid is the treatment of choice (MDI 2-4 puffs
x2/d)
If it is desired to avoid steroids, consider montelukast 10 mg every morning.
Treatment of acute symptoms with as needed use of a short-acting 2 agonist
If 2 agonist therapy is required daily or increasing dosing, therapy for moderate persistent asthma should
be considered.
Moderate Persistent: Intermediate-dose inhaled corticosteroids (Beclomethasone, MDI 4-8 puffs x2/d)
If nocturnal symptoms are a problem or it is desired to limit steroid exposure, continue low-dose inhaled
steroid therapy and add a long-acting 2 agonist (salmeterol, MDI 1-2 puffs every 12 hours)
Or montelukast (10 mg every morning) as alternative for limiting steroid dose
Treatment of acute symptoms with as needed use of a short-acting 2 agonist
If 2 agonist therapy is required daily or increasing dosing, therapy for severe asthma should be
considered.
Severe Persistent: High-dose inhaled corticosteroids (4-6 puffs x4/d)+long-acting 2 agonist (2 puffs every
12 hours).
For acute severe exacerbations start a short course of high-dose systemic glucocorticosteroids: prednisone,
started at 40-60 mg/d and tapered to full cessation within 5-10 days.
Treatment of acute symptoms with as needed use of a short-acting 2agonist + inhaled ipratropium (2 puffs
prn)
Consider any persistent requirements for daily or increased dosing of bronchodilator therapy as indications
to add daily systemic steroid therapy (Prednisone, 10-20 mg every morning).
Hospital care is indicated if:
Subjective report of difficulty breathing
Failure to respond to inhaled 2 agonist therapy followed promptly by full doses of prednisone
Use of accessory muscles of respiration
Pulsus paradoxus of more than 10 mmHg
FEV1 of less than 1.0 L/sec, Peak flow reduced by more than 50% and declining
Arterial PCO2 inappropriately high for RR
Underlying cardiac condition
Inadequate home situation or a history of poor compliance
.
, , .
. " .
. , , gag reflex , .
, ,
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) (.
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. , .
, , . ,
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" . ,
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, . .
, .self-limited , ,
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.
80% .
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, , , 10- ,CPK
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.\ . ,
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-.
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,
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- ,
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( , -
. )
( nonpropulsive (tertiary) simultaneous contractions
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) ( .
.
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)( , )( , ) ( , NO- ,
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:
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. mmhg12-30 : )
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. , - , , ,
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.
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). 10%- 20(.
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grade dysplasia 10.high grade-
:D.D- , , , , ,
.
: !
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.
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: :"stepwise approach" -
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) ( - ,
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, , , ,
, .
:
Step 2 H2 .PPI- H2
-PPI .H2
.
. PPI- ) atrophic gastritis
( H.PYLORI .
- 64
(1) : - , (2) .
- , (3) . -
.
-:
, , , . .
-staph. Aureus : , 2-8
, 12 ," .
-Clostridium perfingens 8-24 , .
-E.coli 0157:H7 , , 3.
* .476
:Drug induced diarrhea -
,pseudomembranous colitis l
.IBD
*) : .(478 -IBS .
. .
-IBD , . - , , ,.
-Diabetic enteropathy
. .
-dumping syn. gastroenterostomy .vagotomy ........
* DD .474
:acute+travellers diarrhea
: , , , , , , , .
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, . " ,
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rose spots , ,typhoid- , ,
.
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.
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giardiasis amebiasis .
, ) ( .
.
: , , , + , .
: - ,CBC , , ,
. - . - .
. .C.difficile toxine . .
ELISA .giardia
.
, .laxative abuse -
: > 200ml/d .IBS- < 1L/d .
: .collagenous/lymphocytic colitis
.
24-72
. .
:
: .self-limited (1) : -"
. .
(2) .IV (3) . "
diphenoxylate ) ,loperamide (Imodium
shigellosis .e.coli 0157:h7 (4) .IBS -
,
. - ampicillin oral chloramphenicol .TMS-
.quinolone, oral amoxicillin, TMSPseudomembranous .erythromycin -
.vamcomycin, metronidazole -colitis
,metronidazole - giardia .quinacrine
: -IBD . .
- . - -Lactase deficiency .
-Pseudomembranous colitis . -IBS .
.
.IBS
4 - . -
.
: . ,
. , .
. .
- 65
, .
3 ) . .( 5
<= 35 .
:
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,
2
Impaired evacuation.
:
:
- , ,..
? ) (
GI , , , , , ..
, ) .. (
.
, , , , ,
,
) , , (
) , , (
:
, ,
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- , , ..
- , ,..
- , ,..
:
,
.
:
-
- .
Ca, glucose, K, Cr-
:
) (
, ,
). CRC 25% CRC (.
+ ) (
:
" .
Anal manometry
Balloon insertion
Defecography
Colonic transit studies
:
, .
)( 1.5-2L
Uninterrupted time for defecation
4-8
:
1. Nonabsorbable saccharide/ bulk laxatives ( e.g. lactulose, sorbitol,
)polyethylene glycol solutions.
, .
"- , .
)2. Magnesium-containing laxatives (e.g. magnesium citrate, milk of magnesia
.
)3. Surfactant laxative (e.g. docusate
,
/ :
H2-blockers (1 .cimetedine, ranitidine, famotidine
.recurrence- > ,1% .
. .
:PPI (2
.H2-blockers , .
".
(3 : ) calcium carbonate (tums
.
:NSAIDS , ,
. : , ,
, , " .H.Pylori
. (1 : .COX-2 selective-
(2 misoprostol PPI , H2-blocker -
.NSAID
: 4
90%- . 12 .
H.Pylori .50%- ,
" .
:Follow-up :
4-6 , ,
" ., 8
< 40 . :
" "
, .
:
) H.Pylori ( ,
. :
.Zollinger Ellison < 500pg/mL Zollinger -
.Ellison
:
.
: ,
.
Combination programs are often necessary to attain the treatment goals of a fasting glucose level below
140 mg/dL and an HbA1c level below 7.0%, especially as the disease advances.
Diet and Exercise
Patients who start off with lower fasting blood glucose levels will tend to normalize their blood glucose
with less weight loss than those who start off with higher values.
Rigidly developed and prescribed diets should be avoided in favor of diets adapted to the patient's
lifestyle. The goal is gradual, sustained weight reduction of approximately 1 to 2 lb each week.
Diet Composition
The American Diabetes Association recommends diets low in calories, low in fat, and liberal in
complex carbohydrates, with as much as 60% of total calories allowed from carbohydrates. Eating of
potatoes causes greater increases in blood glucose than does eating beans or wheat. Type 2 patients
may benefit from a diet that is lower in total carbohydrates and higher in unsaturated fat and fiber.
Increasing fiber content, which occurs with a higher intake of complex carbohydrates and a decreased
intake of refined carbohydrates and animal fats, is associated with a low prevalence of diabetes
mellitus. Increased intake of unprocessed foods (e.g., cereals, grains, fruits, and vegetables) improves
glucose tolerance in type 2 diabetics and decreases insulin requirements in type 1 diabetics.
Special Dietary Considerations for Patients on Insulin
Three meals, supplemented by snacks midmorning, midafternoon, and before bed, are needed to
provide a source of glucose during the sustained presence of exogenously administered insulin. 2/9 of
calories at breakfast, 2/9 at lunch, 4/9 at dinner, and 1/9 as snacks. Simple sugars are generally
restricted because they worsen postprandial hyperglycemia; however, patients should carry a source of
simple sugar, such as fruit juice or sugar candy, to limit an insulin reaction.
Exercise
Significant improvement in glycemic control has been demonstrated from a program of moderate
aerobic exercise performed three times per week for 30 to 60 minutes.
Because of the possibility of underlying ischemic heart disease, an exercise electrocardiogram (ECG)
should be considered before a rigorous exercise program is undertaken by a sedentary person with
long-standing diabetes or other atherosclerotic risk factors.
Drug Therapy: Oral Agents
If diet, exercise, and weight reduction to an ideal body weight fail to control blood sugar reasonably
well (i.e., fasting glucose greater than 140 mg/dL, postprandial glucose greater than 160 mg/dL, or
HbA1c greater than 7.0%), relieve symptoms, or prevent ketosis, then drug therapy is indicated. Drug
therapy is also indicated if it is unlikely that the patient can lose weight or if the patient is pregnant.
Insulin remains the agent of first choice in persons with severe hyperglycemia (fasting glucose greater
than 240 mg/dL), whether from type 1 or type 2 disease. Oral agents (the sulfonylureas, biguanides
(e.g., metformin), thiazolidinediones (e.g., the glitazones), and glucosidase inhibitors (e.g., acarbose))
are effective in type 2 disease with moderate hyperglycemia (fasting glucose between 140 and 240
mg/dL). The recommended glycemic goals of drug treatment are a fasting glucose level below 140
mg/dL and an HbA1c level below 7.0%.
Sulfonylureas
An absolute average reduction in HbA1c of 1.5 to 2.0 percentage points, along with a reduction in
fasting glucose of 60 to 70 mg/dL, is achieved in most cases. However, with time, despite continued
therapy, glucose control worsens and a second oral agent or insulin is required. Failure to demonstrate
any reduction in glucose early on suggests that oral-agent therapy will probably fail
In about 25% of patients, treatment goals are achieved with sulfonylurea therapy alone.
In another 50% to 60% of patients, the initial response is good, but an additional agent is
required over time to achieve treatment goals.
The 15% who fail to exhibit a primary response probably have more advanced disease or
slowly progressive type 1 diabetes.
Adverse Effects
The principal risk of sulfonylurea use is hypoglycemia.
Weight gain.
no increase in the incidence of coronary events associated with the prolonged use of oral agents.
Patient Selection
The sulfonylurea drugs are a first choice for oral-agent therapy.
These agents are commonly prescribed as initial pharmacologic therapy for patients who remain
moderately hyperglycemic (fasting glucose between 140 and 240 mg/dL) despite dietary and exercise
measures.
Insulin Lispro
Insulin lispro, an insulin analogue, has a faster onset and shorter duration of action than regular insulin.
Because it is short acting and need not be administered until just before eating.
Candidates for insulin lispro include persons with type 1 disease requiring tight control with intensive
insulin therapy but at high risk for hypoglycemia. Other potential users include those with a recent
onset of type 1 disease who retain some basal insulin secretion.
Insulin Glargine
Insulin glargine is a long-acting insulin analogue with a steadier absorption pattern over 24 hours
compared to Ultralente and less risk of nocturnal hypoglycemia.
Cannot be mixed in the same syringe with other insulins.
Basal Insulin Program
Typically, twice-daily doses of an intermediate-acting insulin (NPH or Lente) or a single dose of a
long-acting insulin.
An important shortcoming of traditional basal regimens is the increased risk of hypoglycemia.
Solutions include changing the timing of the evening NPH administration to bedtime and switching to a
more constantly absorbed, long-acting insulin preparation.
If the basal insulin level is insufficient to suppress morning hepatic glucose production, then fasting
hyperglycemia occurs, the so-called dawn phenomenon. This is not to be confused with the rebound
fasting hyperglycemia that occurs as a response to nocturnal hypoglycemia (the Somogyi effect).
Prandial Insulin Programs
administer the mixed-insulin(regular+medium) regimen at least 30 to 45 minutes before breakfast and
dinner to ensure that the peak action of regular insulin is properly timed and not too late.
Intensive Insulin Therapy
An intensive regimen is based on frequent home glucose monitoring, multiple daily injections of shortacting insulin before meals to provide better prandial control, and use of a long-acting insulin
preparation for basal control.
approach to the problem of erratic glycemic control is to postpone the evening NPH dose until bedtime.
Indications for intensive therapy include:
type 1 diabetes and type 2 disease in younger, sophisticated, motivated patients without
established complications.
Pregnancy.
Combined Oral-Agent and Insulin Programs
In patients with type 2 disease who require very large insulin doses and experience unacceptable
weight gain, the addition of metformin can improve glycemic control.
a patient whose oral-agent program is ineffective may benefit substantially from supplementation with
a single modest dose of NPH insulin administered before bed.
Initiation of Therapy
Treatment should be initiated with 10 to 15 U of an intermediate-acting insulin and increased by
approximately 2 U each day, depending on the results of blood sugar monitoring performed by the
patient.
Important Causes of Worsening Hyperglycemia during Insulin Therapy
Inadequate dose
Increased caloric intake
Failure to take insulin properly
Occult infection (especially urinary tract)
Coronary ischemia
Severe emotional stress
Use of corticosteroids
Somogyi phenomenon
Insulin resistance
Growth hormone surge in early morning
The Somogyi Phenomenon
The Somogyi phenomenon, in which rebound hyperglycemia and possibly ketosis occur after insulininduced hypoglycemia.
switching from NPH or Ultralente to insulin glargine may reduce nocturnal hypoglycemia.
Insulin Resistance
Insulin resistance is occasionally the cause of poor control. It is arbitrarily defined as the requirement
for more than 200 U of insulin daily.
Control of Associated Cardiovascular Risk Factors
With 75% of deaths in diabetic patients caused by cardiovascular problems, the importance of reducing
atherosclerotic risk factors cannot be overemphasized. These efforts are even more productive than
attempts at tight control of blood sugar and must not be overlooked.
Hypertension
The drugs of choice inhibit the angiotensin system and include the angiotensin-converting-enzyme
(ACE) inhibitors and angiotensin-receptor blockers (ARBs). They appear to limit hyperfiltration and
preserve renal function. Patients must be monitored for hyperkalemia. The thiazide diuretics may
modestly compromise glucose intolerance, which makes them less desirable as first-line agents. Betablockers are effective but can mask the sympathomimetic warning symptoms of hypoglycemia.
Lipid Disorders
Effective control of hyperglycemia often improves the lipid profile by reducing triglycerides and
raising HDL cholesterol, but intensive insulin therapy that causes weight gain may actually increase
LDL cholesterol and lower HDL cholesterol. Metformin use is associated with reductions in
triglycerides and LDL cholesterol and slight increases in HDL cholesterol. The thiazolidindiones
decrease triglycerides and raise HDL cholesterol, but they also increase LDL cholesterol. The
sulfonylureas and acarbose have no effects on lipids.
Management of Complications
Renal Failure
Studies suggest that treating all diabetic patients prophylactically with an ACE inhibitor may be costeffective, irrespective of renal sediment findings.
Metformin use needs to be restricted in the setting of renal insufficiency (creatinine greater than 1.5
mg/dL in men, greater than 1.4 mg/dL in women) because it is excreted by the kidneys and high doses
increase the risk for lactic acidosis.
If contrast studies are necessary, Nephrotoxic antibiotics and nonsteroidal antiinflammatory drugs
(which can inhibit renal prostaglandin activity) should be avoided prior to the dye study.
Neuropathy
The tricyclic amitriptyline is the standard treatment. Initial data from placebo-controlled studies of
gabapentin are very encouraging. Phenytoin seems to cause the least toxicity and should be tried first.
The postural hypotension, impotence, and urinary retention associated with autonomic neuropathy are
usually permanent.
Enteropathy
Cholestyramine has been found to be of benefit in controlling the diarrhea of diabetic autonomic
neuropathy.
Ophthalmopathy
Proliferative retinopathy accounts for the majority of cases of blindness among type 1 diabetics,
whereas macular edema resulting from nonproliferative retinopathy accounts for most cases of
blindness in type 2 diabetes. Prevention is the best treatment, achieved by a reduction in
hyperglycemia.
Glucose Intolerance and Pregnancy
Maintenance of blood sugars in the physiologic range (60 to 120 mg/dL) should be achieved. Women
with postprandial readings in excess of 165 mg/dL have an increased incidence of diabetes in later life.
all pregnant women be screened for glucose intolerance by weeks 24 to 28 of gestation. Screening is
conducted with a 50-g oral glucose load. Patients with a 1-hour serum glucose level in excess of 140
mg/dL should be given a 100-g glucose tolerance test and treated if the level is above 165 mg/dL at 2
hours.
All patients with glucose intolerance should be treated with diets that limit simple sugars and total
calories (35 to 38 calories per kilogram of ideal weight before pregnancy) and tested for elevation of
blood sugar every 1 to 2 weeks until delivery is indicated. Patients showing fasting sugars in excess of
95 mg/dL or 2-hour postprandial levels above 120 mg/dL should be considered for insulin therapy;
During the first trimester, the insulin dose of a patient with type 1 diabetes should be reduced because
insulin requirements decrease and the risk for hypoglycemia is increased. In the second trimester, the
type 1 diabetic requires more insulin as the diabetes becomes more labile and the chances for the
development of ketoacidosis (with its associated risk for fetal death) rise. Third-trimester dose
requirements usually do not change.
Monitoring
Hemoglobin A1c
Measurement of the HbA1c concentration allows an assessment of overall glycemic control for the
preceding 2 to 3 months. Levels of less than 8.0% indicate blood sugar levels of less than 200 mg/dL;
values of 11% to 12% correlate with glucose levels in excess of 300 mg/dL and indicate poor
carbohydrate control.
For Complications
Patients with diabetes should undergo at least an annual office evaluation.
More frequent office visits are usually necessary for patients on insulin therapy and with complications
of diabetes. Laboratory monitoring should include:
urinalysis to check for proteinuria and sediment and a determination of
blood urea nitrogen and creatinine to estimate renal function.
The urine should also be sent periodically for microalbuminura determination, which provides the
earliest available indication of nephropathy.
The detection of microalbuminuria is an indication for instituting renal protective measures, such as
therapy with an ACE inhibitor or ARB.
For Adverse Effects of Drug Therapy
The thiazolidinediones require regular monitoring of serum liver enzymes. Testing should be
conducted biweekly at the start of glitazone therapy and continued monthly for the first year. Any ALT
elevation in excess of three times the upper limit of normal is an indication for immediate cessation of
therapy. The renal and hepatic function of patients on metformin must be monitored.
PATIENT EDUCATION
Weight reduction to ideal body weight is the most important therapy that can be offered to patients with
type 2 diabetes. The emphasis on diet therapy for the type 2 diabetic should focus more on caloric
restriction than on actual percentages of carbohydrate or simple sugars.
INDICATIONS FOR ADMISSION AND REFERRAL
Acute hospitalization is indicated in:
diabetic patients with protracted nausea and vomiting who are becoming dehydrated and
hyperglycemic.
cellulitis of the foot.
acute pyelonephritis.
elderly diabetic patients with pneumonia or urinary tract infections
Referral to an endocrinologist is indicated for the diabetic patient who is subject to marked fluctuations
in blood sugar.
When proteinuria is in the nephrotic syndrome range and the creatinine level begins to rise above 2.5 to
3.0 mg/dL, referral to a nephrologist is necessary.
Recent experience favors watchful waiting for asymptomatic cholelithiasis. Ophthalmologic referral is
indicated when background diabetic retinopathy first becomes evident.
THERAPEUTIC RECOMMENDATIONS
Prevention
Prescribe a program of lifestyle modification for those with fasting glucose approaching 125
mg/dL and postprandial glucose approaching 200 mg/dL.
Implement lifestyle modification with a program of modest weight reduction (7% sustained
weight loss), moderate exercise (2.5 hr/wk of walking at moderate pace), and a low-fat, lowcholesterol diet.
Consider adding hypoglycemic therapy if glycemic control not sufficiently improved or
lifestyle modification not successfully implemented.
Attempt to normalize hyperglycemia; the goal is an HbA1c concentration below 7.0% and a
fasting glucose level below 126 mg/dL.
Emphasize the importance of maintaining ideal body weight. For those who are obese,
institute caloric restriction without compromising the regularity of meal timing.
Prescribe regular aerobic exercise and a low-saturated-fat, reduced-calorie, balanced diet.
Assess long-term glucose control with HbA1c measurements performed every 3 to 4 months.
Perform a comprehensive history, physical examination, and selected laboratory studies
(blood urea nitrogen, creatinine, cholesterol, urinalysis, urine for microalbuminuria) at least
annually for evidence of coronary artery disease, cerebrovascular disease, peripheral vascular
disease, neuropathy, nephropathy, and retinopathy.
Carefully monitor renal function for azotemia and check the urinary sediment for proteinuria
and microscopic hematuria. Promptly institute tighter control of hyperglycemia and prescribe
angiotensin block by means of an ACE inhibitor or ARB at the first sign of nephropathy. Even
for patients with no sign of nephropathy or hypertension, consider instituting prophylactic
ACE-inhibitor therapy if they are middle-aged to reduce the risk for development of
nephropathy. When the serum creatinine level reaches 3 mg/dL, obtain a nephrology
consultation regarding candidacy for dialysis or transplantation.
Refer all diabetic patients for annual ophthalmologic diabetic retinal examination.
Emphasize foot care to diabetic patients with neuropathy or vascular insufficiency.
Consider early institution of intensive insulin therapy as soon as the honeymoon period ends
(rising nocturnal insulin requirements) to achieve very tight control (HbA1c 6.0% to 7.0%),
especially for highly motivated patients. Consider less intensive insulin therapy or infusion
pump technology for those unable to carry out an intensive insulin regimen.
For those attempting intensive insulin therapy and starting treatment as an outpatient:
For basal control, start with a modest dose of long-acting insulin, such as NPH, Ultralente, or
insulin glargine, administered once daily in the evening (before dinner or at bedtime). Initiate
therapy at a dose of 15 U and increase in increments of 2 U, based on fasting and 3 a.m.
glucose determinations and HbA1c levels. If using NPH, consider giving the dose at bedtime,
especially if fasting hypoglycemia is a problem.
For prandial glycemic control, begin a program of short-acting insulin, such as regular (CZI),
Semilente, or insulin lispro, starting at 5 U administered 15 to 45 minutes before each meal for
regular or Semilente insulin, or 5 to 15 minutes for insulin lispro. Short-acting regular insulins
can be mixed with NPH and Ultralente, but not with insulin glargine.
Prescribe human recombinant insulin for newly treated diabetics to minimize risks for insulin
allergy, insulin resistance, and antibody development.
Consider prescribing insulin lispro (or another fast-onset, very short acting insulin),
administered 5 to 15 minutes before each meal, to patients achieving tight control but bothered
by frequent hypoglycemic episodes or the inconvenience of a standard regimen of regular
insulin.
For those unable to carry out an intensive insulin program or who may still be in the honeymoon
period, where nocturnal insulin requirements remain small:
Begin a twice-daily insulin regimen at a total daily dose of 0.5 to 1.0 U/kg body weight
consisting of an intermediate-acting insulin (e.g., NPH or Lente) mixed with a short-acting
preparation (e.g., CZI or Semilente), administered before breakfast and before the evening
meal; two-thirds of the daily dose should be given in the morning and one-third in the
evening. The dose ratio of NPH to regular insulin should be 2:1 in the morning and 1:1 in the
evening. If nocturnal hypoglycemia develops, split the evening dose, prescribing regular
insulin before dinner and NPH before bed.
Adjust doses according to fasting, 4 p.m., and 3 a.m. glucose determinations.
Teach the importance of regular caloric intake and regular spacing of meals to match peak
insulin effects and activity schedules.
Emphasize weight reduction to ideal body weight as the cornerstone of therapy for type 2
diabetes. The composition of the diet per se is less important, but the diet should have a high
ratio of polyunsaturated to saturated fat and contain cholesterol and complex carbohydrates.
Diets low in protein may be beneficial in averting diabetic nephropathy.
Prescribe a practical program of regular exercise that fits the patient's lifestyle. Consider a
program of regular moderate aerobic exercise performed three times per week for 30 to 60
minutes.
If after 4 to 8 weeks of diet and exercise the treatment goals have not been achieved and the patient
shows mild to moderate glucose intolerance (fasting glucose less than 240 mg/dL), then:
If after 4 to 8 weeks of diet and exercise treatment goals have not been achieved and the patient is very
symptomatic or manifests moderate to severe glucose intolerance (fasting glucose greater than 240
mg/dL), then:
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temperature greater than 38.0C (100.4F), absence of cough, swollen or
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disorders are 50% more likely to be alcoholic, and similarly, the prevalence of anxiety
disorders is 50% higher in persons who suffer from alcohol abuse or dependence.
Table 226.3. Medical Causes of Anxiety
TYPE OF
CAUSE
SPECIFIC CAUSE
Cardiovascular Angina pectoris, arrhythmias, congestive heart failure, hypertension,
hypovolemia, myocardial infarction, syncope (of multiple causes),
valvular disease, vascular collapse (shock)
Caffeinism, monosodium glutamate (Chinese-restaurant syndrome),
Dietary
vitamin-deficiency diseases
Drug Related Akathisia (secondary to antipsychotic drugs), anticholinergic
toxicity, digitalis toxicity, hallucinogens, hypotensive agents,
stimulants (amphetamines, cocaine, and related drugs), withdrawal
syndromes (alcohol or sedative-hypnotics)
Anemias
Hematologic
Immunologic Anaphylaxis, systemic lupus erythematosus
Hyperadrenalism (Cushing's disease), hyperkalemia, hyperthermia,
Metabolic
hyperthyroidism, hypocalcemia, hypoglycemia, hyponatremia,
hypothyroidism, menopause, porphyria (acute intermittent)
Encephalopathies (infectious, metabolic, and toxic), essential tremor,
Neurologic
intracranial mass lesions, postconcussion syndrome, seizure
disorders (especially of the temporal lobe), vertigo
Asthma, chronic obstructive pulmonary disease, pneumonia,
Respiratory
pneumothorax, pulmonary edema, pulmonary embolism
Carcinoid, insulinoma, pheochromocytoma
Secreting
Tumors
Among the psychiatric disorders to be considered in the differential diagnosis of
anxiety are the depressive disorders.
The presence of multiple physical symptoms (six or more), high patient rating of
symptom severity, low patient rating of health status, physician perception of the
patient encounter as difficult, and age less than 50 years are important clues for an
underlying anxiety or depressive disorder. Because there are effective treatments for
anxiety disorders, a diagnostic trial of an anxiolytic medication might help resolve a
difficult diagnostic situation.
Treatment
1. Psychotherapy (Supportive psychotherapy- empathic listening, education,
reassurance, encouragement, and guidance; Insight-Oriented Psychotherapy- guiding
the patient to an understanding of the association between circumstances, emotions,
and symptoms; Cognitive Behavioral Therapy (CBT)- reconditioning or modifying
patients' behaviors or the association between a stimulus and response. Techniques
include general relaxation-response training (for tolerating anxiety symptoms), in vivo
exposure and desensitization (for phobias and avoidant behaviors), cognitive therapy
(for panic and obsessions), and exposure-response prevention (for OCD)).
2. Medications
A. Benzodiazepines- the anxiolytic of choice. To justify continued treatment, the
patient should demonstrate a decrement in anxiety, with enhanced performance or
decreased avoidant behavior. Side effects include sedation (especially in combination
with alcohol or other sedative agents), impaired memory, and, rarely, disinhibition
characterized by increased hostility or aggression. Alcohol and cimetidine slow
hepatic BZD metabolism and increase risk of toxicity. Daily use of BZDs over time
- 227
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