TĂNG HUYẾT áp ở BỆNH NHÂN đái THÁO ĐƯỜNG

T ÁP  BNG

Nguyễn Hải Thuỷ


SUMMARY
Hypertension is a common co-morbidity in diabetic patients. It substantially increases the risk of
cardiovascular disease in this patient. The goal of treatment of hypertension in diabetic patients is to
prevent the hypertension associated increase risk of cardiovascular disease death and disability.
Hypertension in diabetic patients has unique features such as increased salt sensibility,
volume expansion, loss of nocturnal dipping of blood pressure and pulse, increased propensity to
proteinuria, orthostatic hypotension and, isolated systolic hypertension.
Thus, the level of blood pressure and the diagnosis of hypertension should be based on multiple
blood pressure measurements obtained in a standardized fashion on at least three occasion. Because
of the tendency to orthostatic hypotension, standing blood pressure should be measured at each office
visit. Furthermore, because of the increased blood pressure variability in these patients, ambulatory
blood pressure measurements or home blood pressure monitoring may be very useful. The consensus
blood pressure goal in diabetic patients with hypertension is less than 130/80 mmHg


               

  THA tro   



Theo              




T ÁP  BNG
Hin vng nht v tiêu chí ch b
Tiêu chí THA ca WHO/ISH (2004) cn
cáo duy trì huyt áp bi 130/90 mmHg.
Theo Hip hng Hoa K nh THA b
là  130/80 mmHg.
Do tm quan trng ca tr s i vi b  bnh
n tuân th theo mt s nh:
- S dng máy huyt áp thu ngân.
- Thc hit 2 ln.
- Bc ngh t áp.
-   phát hin h huy.
- Cn loi tr THA phn ng,do tác dng ca thuu tr
n tim m
- Nu kin có th theo dõi HA trong 24 gi (Holter HA 24 gi).
- ng mng mch thng mch cnh.
- i tht trái, ch 
- Microalbumine niu.
- t.
- Khám bàn chân.
-  s huyt áp tâm thu còn gi ch s huyt áp c chân/cánh tay (ABI: Ankle Brachial Index)
NG HC VÀ CHUYT ÁP  BNH
NG
So vi b bm bao g
nhy cm mui, mt áp và nhp tim sinh lý v i protein
niu, h huy c. Ví d liu thp li tic xem xét
 u tr    tích máu trong khi c ch enzyme chuyn hoc c ch th th
angiotensin s dng cho bnh nhân có protein niu.
3.1. Mt khot áp v 

t áp và phn ln bt áp có mt s i huyt
áp và tn s tim trong 24 gi qua khn hình tr s huyt khi
thc dy và thp nht khi ng.
Khot áp khi tr s huyt áp gim 10-15%. Bc gi là mt khong
t áp khi tr s huy gii 10% so vi tr s huyt áp ban ngày.

Hình 1. Bi ng huyt áp sinh lý trong ngày qua kho sát Holter 24 gi


g

H.A tâm thu


mmHg


mmHg


H.A tâm thu



mmHg


mmHg



Bnh nhân có hi chng chuyn hoá tim (cardiometabolic syndrome) có
s mt khot áp khi theo dõi monitoring trong 24 gi.
u này ht sc quan trng bt qu và nhi 
ng ghi nhi thi protein niu là bin
chi v
Khong 30% bnh nhân nht qu xy ra trong khong
thi gian 6 gi n 12 gi u quan trong trong chic chn thuc.
c bit càng quan trng cho bt áp bui ti.
 tích máu và nhy vi cht mui
Ri lon cân bng mui và th tích dch ngoi bào là nhng hu qu ng nht ca
 t áp  tt c
bnh nhân THA và s nhy ci vi mut  ng, béo phì,
suy thn, gim n renin và chng ti M gy cm
mui  ng phi hp vn tui l
u quan trng khi theo dõi bc bii ln tui, bi vì tn
sut v y cm mui. Vì th gim lung mu
kèm vi gim ch  tit thm chng kali rt quan tri
ng này.
3.3. Microalbumin niu
Có minh chn THA  bu qu
ca bnh lý thn và bnh thng xng xuyên  bnh
    ng là biu hin ca bnh th    nh b  ng
microalbumine niu. C THA và bnh thn tác ng lng xut
hin micrialbumin ning phi hp vi kháng insulin, nhy cm mui, mt kho
huyt áp v i các cu thành ca hi chng chuyn hoá.
t áp tâm thu là yu t quan trng trong tin trin microalbumin ni
có s ng microalbumin niu là thành phn ca HCCH phi hp vu
này quan tru tr THA  bn các
thuc làm gim c protein niu ln h huyc ch enzyme chuyn, c ch th

th n gim s tin trin bnh thnh nhân này. Các
thui thi h huyt áp nhm kim soát
bnh thn phi hp nhiu thuc. Ngoài ra các yu t n ki
ng máu và thuc lá.
c
Vi s tin trin c bng mch ln mt di
và tr nên cng và huyt áng do h thng mch
không còn kh  tht áp tâm thu
c, hin tung gp  by ra ngay c b.
Thêm  liên quan gia THA tâm thu vi bnh lý vi mch và mch máu ln  bnh

3.5. H huy
ng máu d tr ph thuc vào h thng dy sau thi gian nm
ngh ng làm gim th tích tng máu và huyt i phn x giao cm
 kháng h thng mch máu, huyn s tim.  b
có bnh lý thn kinh t ng máu d tr ch và ri lon s nhy cm phn
x áp lc có th gây h huyt á mt cách tc thi hoc trì hoãn vì th gây ging
máu não gây choáng váng thoáng qua, mt, long chong và ngt.
u này rt quan trong nhm nhn bit bn nhiu
chu tr. Ví d ng thuc li tiu và thuc giãn mch ngoi biên và bi
ph th tích trong h huy mn tính.
  bnh nhân h huy ng giao cm biu hin vi toát m hôi, hi hp
khi s dng liu thp clonidine có th cn thi làm giáp ng giao cm quá mc. Ngoài ra
ng h huy  bc ch th th alpha adrenegic
ngoi biên gi và các tác nhân th hai cho các bu thuc
h huyt áp phi cân nhc liu lung thn trng  b huy trong khi
lm.

IV. SINH LÝ BT ÁP  NG







                   
Insulin.




    




 














ng kích thích NO.


 

                
     

 -  





    
  là TNF anpha và IL-           








qua trung gian 

.
-1 (ILGF-1) trong sinh lý và kháng insulin:
Insulin và insulin like growth factor-1 (IGF-
- 

              
-

IGF-                 
      
máu. Insulin và IGF-
qua kích thích p
-K-ATPase.
   
-
-

Insulin và IGF-

-K-ATPase.
-1 không n

-1 (insulin receptor substrate-

-
IRS-
-1 là serine-threonine kinase, Akt (protein kinase
B).

     
-1/insulin và các 
khác.

IGF--1 thông qua con
-K-ATPase 

-


-

và IGF-              



-1
, Amal F. Farag, James R.Sowers (2005). Diabetes and
Hypertension. Diabetes and cardiovascular disease. Second edition. Humana Press. 2005: 307-329)


 -1 t           
                
Insulin/IGF-
   

hoá do insulin và IGF-1.
Insulin và IGF- -
K-

Ngoài ra Insulin/IGF--K-ATPase và MBP, trong


             -     
 


V. KT LUN
THA  bng gp vi bng, nhiu yu t i
hp. T l bin chng và t vong ch yu liên quan tim mch. Song song vi kim soát tt
ng huyt và hn ch các yu t c tiu tr cn tuân th nguyên tc khi
s du tr không dùng thuc, chn la thuc hay phi hp nhiu loi thuc
nhm kim soát huyi 130/80 mmHg.

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
Na-K ATPase

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Phân bào

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