'

2008-2009

 :
JNC -
) +
13(20-


:
Primary care medicine

/l

i u.
{
t

ffi

!!F

SPI'CIALCofi{j\,lUJ\iiCA'fIOJ\

frLIFdICIAT'S{SRruFR

fiH'TE
bEVE[TE[T&epffirt
of
E

Fe

sF

tfueJmrm'fr

Natfrcma$
[ttee #$?FnerremtFffim,
CmH"TlHrT

ffietect$*m,Hwe$uetfiom,
and Ts'eetrmemt
m$HEghffi$mmd
Fnessu$$'e
TheJNC7 Rencrt
:\:'lnr \r. f,holranilrr. i\lf)

CeorgeL. Llakris.MD
I' t;nr-vR. Blacli [{D
\rillianr C. CLrslrruan"
h'[[)
L. Iz.zu^.1r.
h{D
Jor-trrrlr
Dani*l V. .ir.rnt:s.
NlD
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:

"The SeventhReportof the Joint NationalCommitteeon Prevention,

Detection,Evaluation,
andTreatnrent
of lligh BloodFressure"providesa new
guidelinefor hypertension
prevention
Thefollowingare
and management.
(1) In personsolderthan50 years,systolicbloodpresthe key messages:
sure(BP)of morethan140 mm Hg is a muchnloreimportantcardiovascular
(CVD)riskfactorthandiastolicBP;(2) Therisl<of CVD,beginning
disease
at115/75mm Hg,doubleswith eachincrement
of 20/10mm Hg; individuafs who are norrnotensive
at 55 yearsof age havea 90"/"lifetimerisk for
(3) Individuals
developinghypertension;
with a systolicBP of 120 to 139
mm Hg or a diastolicBPof 80 to 89 mm Hg shouldbe considered
as prehypedensiveand requirehealth-promoting
lifestylemodificationsto prevent CVD;(4) Thiazide-type
diureticsshouldbe usedin drug treatrnentfor
nrostpatientswith uncomplicated
hypertension,
eitheraloneor combined
with drugsfrom otherclasses.Certainhigh-riskconditionsare compef
iing
(angioindicationsfor the initialuseof otherantihypertensive
drugclasses
tensin-converting
p-blockenzyrne
inhibitors,
angiotensin-receptor
blockers,
(5] Most patientswith hypertension
ers,calciumchannelblockers);
will require2 or moreantihypertensive
ftredications
to achievegoal BP(<140/9A
mm Hg, or <130/80 mm Hg for'patientswith diabetesor chronickidney
(5) tf BPis rnorethan20/10 mm Hg abovegoalBP,consideration
disease);
shouldbegivento initiatingtherapywith 2 agents,1 of whichusuallyshould
be a thiazide-type
diuretiqand(7) Themosteffectivetherapyprescribed
by
the mostcarefulclinicianwill controlhypertension
only if patientsaremotivated.Motivationimproveswhen patientshavepositiveexperiences
with
and trust in the clinician.Empathybuildstrust and is a potentmotivator.
Finally,in presentingtheseguidelines,the committeerecognizes
that the
judgmentremainsparamount.
responsible
physician's

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

JAMA, idry 21, 1003-Vol 2ti9, l'lo. 19 (Reprinted)

www.jama.com

AuthorAffiliations and Financial Disclosuresare listed

ai the end of this article.
Conesponding Auihor and Reprints: Edward:J.P.occella, PhD, irvlPH,National Heart, Lung, and Blood Institute, National InstiLutesof Hedth, 31 Center Dr, MSC
2480. Bethesda, MD 2A892 (e-mail: roccella@nih
.gov).

G2003 American ivle<iicai Associaticrn. Ali righrs rescrv'cri.

:l

TIIEJNC 7 REPORT

Narional Committeeott Prevention,Detr:ction, Evaluation, and Treatment o[

tligh Blood Pressure" (.JNC 7) r'r'irs
baied on 4 factors:publication o[ manl'
new hl,pe.rtensionobsen'ational str'rdies and clinical trials; rreedlor a rleu/
arndcotrciseguide-linethat would
clt'.arr
be use.tulfor cli.nicians;need to siurclassificationo[BP; artrdztclear
plifi' 1i1s.
re.cognitiont.hattheJNC I'eports\vere
not being used t.o[heir maximutn benefit. This JNC report is prescntedin 2
scparatepublications:this current'succinct pracdcal guide and a nrore comrcport to be publishedsella1:rci-rensive
iatel1,, u'lrich u'ill provide a broarder
and justificertionlor thc curcliscr.rssion
rcnt rccommendations.In prc-senting
thcseguidciines.the committeerecosnizes that tlte resl:onsible phvsician's
his
.ludgment is paramount in managing
pzrtients.
or her
NNETFIGDS
Sinceirulrlicadon o[ ihe-JNCVl rcport.
LireNi{BPIIP CoorclinatingCommi[tee'
bv the directorof the Ni{LBI, hm
chaire'.cl
the''h1'regularlyrevicwedirnd discussccl
Lriatlirt
t.ht-ir
pcrtensiotrc-.linicaltrials
the
instance-s.
Inan)'
In
nuirl mt-.ctings.
studlarge-r
the
of
ir
rvtxtigator
6rrincipal
ies iras prescnt.edthe in[ornration ciirectly [o tlrc. Coordinating Comnritrce'
and rcTl're Comtnitte.e'spresent.ations
aud postedon the
vieu,sare-.sumnlarized

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

for Adultsnsgd l! lgrs or older

of BloodPressure
and lr^anagemerrt
Table 1. classification

Management"
Initial Drug TheraPY

BP
Classification

Systolic
BP, mm Hg'

Diastolic
BP, mm Hg"

':120

Lifestyle
Modification

Without ComPelling lndication

With ComPelling lrrdicationsf

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

DruE(s)Jor the crrtrPelling

indicationsf

2-Drug cornbinationfor mosl

diuretic
(usuallythiaaide-1YJ:e
and ACE inhibitoror ARB or
B-blocker or CCB)$

Drug(s)lor tlrecomPelling
irrdicatic;ns

DruE(s)ior tlre conrPelling

indications
Other antihvPerlenstveclrugs
fdiuretics,ACE irrlribitor'ARB,
fJ-blccker,CCE) as needed

Other antihYPertensveorugs -(diuretiiri,ACE inhibitor,ARB,

B-trtocXer,CCB) as needed

Ablrrevrations;ACE, angrotenstn-conveilingenzyne: ARB' angloiensin-rcep

'rTreatment cletermtrred by hrgho-siBP category.
-i-able
0.
tSee
iess'lhan 13O!8Omrn Hg'
iireat patrenrs wilh chronrc kidney disease or diabgies to BP goal oJ
glnitial cnnrbrned trlerapy inorro o" usecJc;au'inuslyirr those al rrsk ior orlt$siallc nygrolensiott

G'2003 Arnericzn l'lcdical Associalic'n- r\ll riglits resen'ed'

(Reprinted)JA/v1A,\'1e1'2l' 2003-\zol 289, I'lo 19 2561

:
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

but the majoriqrr'fili

1a;if1ftlrpertension.
antihypertcrnsive
more
or
2
requirc
faii-to predrugs.rt'r5when !rh1;5iqit1ts
scribe lifcstvIe modifisrtions, ard.eqttate
antihytertensive cirug doses,or appropriate drug conrbinarions.inzrdequateBP
control tna)' result'

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

areat inParieutsu'ith pr:eh1?crtcnsion

risk for progression[o |11rpcrcrezrsed
tcnsir;n;tl'roscin t-hc130/80to 139/8!)
mm l-lg BP rangc arc at lu'icc the rislt
ro cicvelc-ph1'pcrtcnsionas Liroscu'ith
lou'cr vztlue-s.o
CardiovascularDiseaseRisk
l'l rpertcnsion a[[ecs approxinratclv50
nrill.ionindivitltralsin theUnitt'clStilLes
i rn cia p pr ox inr alc h'I bi l l i o n i n d i v i d u As tlre pcrpulationages.
als r,r,grlcir,r'ide.
u'ill
rhe prevalenceof h,virertension
evt-n.furt.herunlessllroadnncl
increiisrr.
arc irrtplt-e[[ec.tive
ilt'eventivcnleaslll'(':s
Fralningthe
ltronl
rlrrntcd. I{eccntdata
inclithat
suggcsl.
h;rui I-leerrtStuclyi
at
55
nornlotcnsive
ztrc
r,r'lto
viduzrls
lor
rislt
life.tirne
a
have
90Yo
o[agc
)/currs
.
clcvclopin g hypt:rtcnsion
risk
betu'eenBP arncl
The relattionshilr
(C\D) cvellts
oI cardiovascu]ard.isez'se
and indepenis conrinuous,consistenL,
dent o[ other risk factors.The higirer
the BP, the grcaterthe chanceo[ myocardial inf:rrction, hearrtlailure (l-IF),
stroke, and kiclncy disease.For inclividuais aged 40 to 70 years,cach inBP or
in sir51o|1c
cremenLoi 20 mnr 1-1g
10 mm I-I.qin dizrstolicBPdouble-sthe
risk o[ C\rD acrosstire entire BP ran-qe
lronr I L5/75 ro t85i 115 mm l{g.$
The classificarionprehlpertension,
inrroducedin t.lrisreport(Table1), recsignalsthe
ognizesthis relarionsiripzrn.d
educationo[ health
need for increzrsed
careprotessionalsand drepublic lo decreaseBP levelsand preventtbe development of hypertel$ion in the.{eneral
population.!' Hyi:ertension prevention strategiesare availabieto achievc
2562

JAMA, lday 21, 2003-Vol 289, t'{o.19 (Reprinted)

G2003 Arneriran l,lcdical Associaliutr. Al! riglits reserv'cd'

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

Microallruminnria or cstinute.d GFR {60 rul/miri

A.qc(>55 r'strs for mcn. -65 r'cars lor rvoureu)
F a m i l l ' h i s t o r v o f p r r n r a t u r r : c a r c J : i o v a s c r t l acri i s c n s ei . m t : t r ( 5 5
:
()r \\;onrcn 6i r-r:ars)
Target-Organ

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.

iAMA, \4ay 21. 1003-Vol 289, No. 19 2563

JReprinted)

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

JAMA,)day2I, 2003*-Vol 289. No. 19 (Reprinted)

O2003 ,irmeriran l'ledicai Associaticn. Ali rig.lirs reser-v'eC.

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-

tions alreadyin use,tolerabiliq,.and ciesireclBP targeLs.In many cei.se-s,

speciaiist
consultation ma)' be indicated.
Isciremic lieart Disease.ischemic
heart disea-se
is the most Lronlmonform
o[ target-organdanrageassociaredu'itlr
ir11:ertension.In pati.ents1a,i1l1
hyperte n s i o n a n d stabl e angi na pectori s,
th e fi rs t d r ug o[ choi ce i s usual l v a
ring
B-i:rIoclter; rit.rnuti vcly. Io,,rg-,r.

CCBs can be u-sscl.lIn 1:ratienLs

r.r'iLh
zicutecoronar)rfl/nclromes(unstableangina or myocarclialinfarction). h1'pertensionshould be treatedinitiallv u'ith
B-blocliersand ACE inhibirors,aeu'irlr
addition ol'other drugs arsnecded{'or
BP control. In pzrtienlsu'ith postntyoc a r d i a l i n . f e r r c t i o nA, C E i n h i b i r . o r s ,
B-blocliers,and aidostcroneirntalgonists harreilroven to lte rl1ostbencfi-

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

Cc,nrbinedcr- and B-blockers

Caryedilol(C,rreg)

12.5-50

200-600

ACE inlribitors

Labelalol(Normodyne,
Trandate)t
Benazepril(Lotensin)f

G,'2003 American ir,lcdical Associaricn. At! riglir.s rescrved.

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

Drug ffrade Name)

Candesartan (AlacanrJ)
E;;rosartanffevetan)
lrbesartan(,Avapro)

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

I'licardipine sustained release

(CardeneSR)

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)

cnce o[albundnuria (>:Otl mg/d or 200

ms albumin llcr gralnr of creatinine),
theraireutic goais ;lrc.to slou'clcteriorzrtion o[rcnal ltinction;rnd prcvcnt CVD.
|"ll,pcrLcnsion apircars in thc majoritrr o{'
tlrcsc paticnls and tl-rc1'slic,uld rcccir.'c
ngqrcssivc BP nranagcmcnt. ofltcn u'ith
3 clr morc drtigs to rcach tar-qc[BP r';tlues r-,i'lcsstirun 130i80 mm i-lg.'t!'''*
Thc r\CIl inhibitors anci AIiBs lrzrvc
rl e mo ns Lrat ccl I'ayc-rrirl-rlc
c IIccLs crn Lhe
p r o g r c s s i o n o I d i a r b e t i ca n d n o n d i a a linritc-d inbet.ic renal rJisearse.'i5-5c'r'4
cr&lsc in scrunr creatininc o[ as nruch
a s 3 5 9 ' o1 f 1 r v s b ; r s c l i n c u ' i t h A C E i n h i b i t o r s o r A R B s i s a c c c p t ; r b l cl n c l r r o t
i1 r(':1sonto rr,rthholci t.r'ca[nrcnttrnlc:ss
h y l t c r l < a l c r n i zdr c v e l o p s . o r \ \ ; i i h a c l v a n c e d r c n a l d i s c a s c ( c s t . i t n a t e dg l o rncrular [i]iration rirtc .{3ll ml_/rnin lter
I .73 rn2,corresponding t.oa .scrunrcrez r L i r r i n eo f 7 . 5 - 3 . 0 n r g / d L 7 2 1 . - 2 ( t 5
iinrol/Ll), increasing doses of loop diurct-icszrreusuall)'ne eded in combrnarion u'ith other drug classes.
Cerebrovascular Disease. The risls
and benefits o[arcutclowcring of BP during an acutesrrolic arc still unclurr; control o[BP at inLermedizrtelevels (approxinulcly I60iI00 mm l-lg) is apprropriate
trntil the conclirion has stabiiized or inrproved. Recurrcnr strolie rzltesare lo\^/ereclby the combinalion o{'an ACE inhibitor and ihiazide-tt'pe cliureric.r5
Other 5pecial Situations. Mirroli6,
Populations.Blood i)ressure control rates
vzlD, in minoritv populat.ion.s and are
Iou'esl in Me.xican Americans and Native Americans.i in general. the treatment o[ hyrertension is sirnilar tor ail
demograi:hic groups, but socioeco-

G'20 03 Arneri can lt l e<iical .iissocia 1icn. illl riglils resen'cd .

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

C2003 ,4meriran lvledical Associarion. All righr.s reserv.ed.

ovval

(Reprinted)
JAI\AA,
May 2I, 2003-Vol 289, No. 19 2s67

Tr{EJNC7 REPORT
I

sion. ln man)' individuals, lor.vcrr

initial drug dosesma1,f. indicared to
avoid s)mpt-oms;hou'ever. standard
dcses;tncimultiple drugsare ne.eded
in
tlrc ma.jcritl,s1 older indiyidtials ro
reacirappropriateBP rarge.rs.
PosturalH-1?otelrsion.
A decreasein
standingqrstolicBP of ntore rhzr' 1.0
urm Hg, u'lren associatedu'ith dizzine.ssor faitrt.ing,is morc flrecluetrtirr
olde.rparit:ntswith s1'51elic
hilrertension. diarbctes,
and thoseLakurgdiurcrics,vcnodilators(eg.nitrates,cr-blockcrc.zrndsiidenafil-like.
dlugs.),anclsome
pslchotropic drugs.Blood tr'rressure
in
tircseindividualsshouldalsobe monitoredin the u1:rright
lrosition.Caution
shcluldbc usedto avoidvoiumc dcpletion and erccssivel)'rairiddose titrarion o[ antih;'pertcnsivedrugs.
Dcnrcnl.ic.
Dcncnria zrndco.qnitive
impairntenLoccur morc commcrnlyin
piltienlsu,ith h1,1rer[ension.
Rcducccl
progrc-ssionol' ccrsni tive impairmt'.nt
n1a\;r)ccrlr u'i rh c{'fcctivcan ti h1'pcrlcn-

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
Diuretic

f3-Blocker

ACE
lnhibitor

ARB

ccB

Aldosterone
Antagonist

ClinicalTrial Basist

Heart failure

ACCIAHA Hean FailureGuideline,ao

{?CtBlS,{?
i\4ERtTHF,"' COPERNTCUS,
SOLVD,'{ AlFiE.45
TRACE.rc'VaIHEFT.a7
RALESqE

Post-myocardialirr{arction

ACC/AHA Post-lvllGuicleline.ae
BHAT.el
-EPHES|JSt'
SAVE,5t Capricorn,rtr

Higir coronary disease risk

ALLHAT,:HOPE,3JANBP2,"-f'LIFE,3'2
CONVINCFI

Diabetes

NI(F-ADA Guideline,rt'??
UKPDS,s'ALLHAT33
NKF Guideline,22
Caplopril Triai,55RENAAL,56
lDl{T,s7REltJ.sMSK5e

Chronic kidney disea:;e

Recurrentsiroke Drevention
PPOGRESS3s
,olgual'o0s:AP"SK'AhcanAmeicanstLdYo,K|dn}'DNeasandHy"bnsnson;AcCvlsa.nnn,rancoleg()fc?.'1no|CEr,/Al're'!ca'lHarlA9soc
cofmngenzymeiAlRE.Aule|i,'clDnFan|pr|Efae$ALLtiAi'Annhypelns.GandUpil.LowinqTdamgniloPrd;fiHeanAda.kTlial:ANBF2'sodfsi6lan
!f]9118]sf'*r"j,T.,:l*IAFB'angD1en$n.rcepldbk]clgriBHAT.ii.EIodGrHaa'tAtricr<iriatldcg'ca|o!'nchanndr,ockeic|dts'ca(taclnst,rB|mr|d
StUt'icotwNce,cor,ri|sdonsav''dpamirr;galrorrolcarrrro..isirrrars4po,.i":'.co#i+.ricus'ca.ueorolprrspgrfeniiroomlzedo];"fi']ih]i#i

5lIE.S!'SJ.9*rTP'9F:f,'lYlpcadEi|^ta'd0nHedFalUrEt|icacyandsUri!a|SiUd!.;HoPE'Hga|toutco.nesPrev6rnonEva|t'lalnnslu
oeIrNlpnrpahy|fa:Ul-L'Lo5anan|rvrxionForEndpofxR6dUcioninti/5gr!nsionstudy:[.Rl.i.HF'Msloploio1cF,GRanc'om[6d|lIl;lonTm||ne$|
HeanFai|ureiNKF.ADA,Nalona|KicheyFo.nc|alEn-AmicanDEbe1sAs5ociaibfpnoenessjpe,inoop.4r'acl.ionlgii."rE"",i.i"rs-.r."st,ilrRALEs.Radd
A1dadonB/aiua1onsludy;flE|N'RarrllDtitEi|icacynNphopatlry$Udy:RE|vqAL.nealaon7l''opo.nts'nlon-.{nsr||n.ElpnGniDia
sqv+ andYgrr,j'culal
studyi
m:CEY-9#11919jgvE rosocr
EgqmemSruoy;soLvo, suoie ot Lsirvsrricua, qEiuncronir-FAcE.rranropdrcad.,c Elauar-on

Dab6teSldd),i Va|HEFT,VatsFnHeanFaiU Tnaj.

"Uoinpdnngrx'i.atonsoran|hypenerEvedrgsaJeba6donheniisl|!rnoUlcofr66tUdi6orxslingdncalgJidel|rithacompeilq|nd
iCondiiions fo:'whtch clinical tnals demonstrate cenfrt oi scecilic ciasses ol antihvpertensve drugs.

2568

JAMA, I-,ta,v
2t, 2003-Vol 289, No. t9 (Reprinted)

G2003 American Nledic'al Association. illl riglit.s resen'ed.

TI_IE-INC7 REPORT

tions ancl acuLetnrgct-organdanrase

(cs. enc'.cphalopath)/,
nl),ocarclialinBox 3. Causes of Resistant Hypertension
lirrcLion,unstable anginar,puimonarlr
lnri:roper blood pressllremcasLlrement
eclema,eclampsia,sroke, hcadtrauma,
Volume overloild rrnclpscndotolcrancc
li [e-tirrsr tcning arteritl bIeecling, or aorExccss-sodiumiutalic
Volume rett'.ntionfrom liidnev discasc
t.icdissection)rcquirehospiralization
Inadequatediurcric thc.rapv
iurd parcntcraldrug thcr-apr'.r
Patients
Drug-induced
or orhcr causes
u,ith nrzrrkc.dlyclcvartedBP bur u'irirNonadht'.rencc
ouI rlcutetarget-org;1n
dtlrn:rgeusuall\I
1n:rdequate
doses
do not rccluirehospiralizarion.
but thev
Inapprollriate coml-"'i
nutions
s h o u l d r e c e i v ci m m e d i a r ec o r n L r i n a N oustcroidal arrti-infl arllllraton'drugs, cy'clooxy'genrse
I inhibrtors
tion orzrlantih)llertensivctlrcrzrl:v.They
Ccrcainc,
anrpiretarnincs.
other illicit dnrgs
shouldbe carcfuil),cvarlwued
and moniSvrnparhomrmcrics(d ccongcsriln
[s, rlllorcctics)
torcd for irt']renension-inducc-cl
hcart
Olal cr-rntmccptives
zurdltidnel' damztgeand lor idenr1fiAclrcnal strroicls
abic ciluscsoi lrlpencnsion (Box 2).
Cvclt,sl-'rclrineand lacroliurus
Ilrvthropoietin
;\dditional Considcrarionsin AntiLico ri cc ( i n clr-rdi nr: s,-rurcclrcrvi ng ioira cco )
hlpertensivc Drug Clioiccs.An rihy-rerS c l c c t c . col v c t - t h e . - c o t t n t c .rri i r r a r v s u p l > l r n r r n r s a r r c l r n c c l i c i n c s t . c g .c p i r c d r a
tcnsivedrugs can havelavorabicor unma haunq. bittcr ornngc)
fi.rvorablc
cffecuon othcrconrorbidities.
.'\ssor:i:rtctJ co ncli Iio ns
Pot.cnti cil F at,or alsleEft'c ct.s.Th iat:i d eL)l-rcsitv
t1,1-'rc
di.ureticsare usclul in slon'ing deExcrss aicohoi inl.rltc
nri neraliz:trion in osLcoporosis.
B-Bkickl c l c n t i f i a l - ' r l c a u s c s , l f l r v p c r t c n s i r , r r (- sr c c i i o r : l )
n rs c an bc us elul in th e trc a tmc n to [
atrial ulchyalyfiyrhmias/fibrillarion,
nriI
g rai ne, thy'rotox icclsis (short- Lerm,),c_sserr[ialtl'entr:rr,
or pcl'ioireradvc
hyper.r- thcrapl' prescribecll:ry11'r.ntos[tztrc.{ul altcrationsin the plan slrouJ.cJ
bc docutcnsion.Cllciunr charrnt.I
blockcrsn'rav cl i n ici:ln u,ill crlntrol lr;ri:crtcns
iorr cini1, mcntecl .B Iooclprcssurcscl [-rn onit or I,rcusclulin ll;ll'naucisl.nclronre
and cer- i['thcpitticnLi.snrol-ivr.tLccl
to trltc Ltrepre- inq can alsobt: ust:lrrl.Pzrtients'nonircltain :lrrhltthllias,zltci11-bloclicrs
nrzrv scriltednrcdicationanclto csurblish
irnd I r c r e r r c ct o t . h e l ' a 1 :i sf i n t - r ' c a s c bc vl
l-rcuscltrlin ltrr:rstatisnt.
nrzrin tirin a hcaltlr- 1)rorrt-rtins I i fcst1'lc. mi sundcrstandi ng
o[ thc concl iiioror
i '
Potcntial Un_fuv
or ultlc E_[Jcct
s. Th i a- It'lo tir.'at
i o n inrprovcsu'he.npatlien
ts havc trcatnrent,denial o[ illrirss bcutusecif
: i c l t -d
. i u r c l i c s s h o u l d b e u s c d c a r u - posiiive erytcricnccsu'ith and trust in lacli oIsi,nrl]tonrsor perccptionof druigs
l i o u s lv in pat . ientus ' h o h a rv eg o u t o r their clirricians.Em1:arlrvbuilds rrust. as s1:111l1els
oI il] hcalth,laclt oI l]aLicnr
u'ho hlvc a history o[ significanth\'- and is a potcnt nrol.ivator.Tt
Partient
aL- involvenrentin thc carcirlan.or uncxponatrcnlia. B-Blockcrsshould gener- titudes zlrcsreatl)'irrfluencedby cul- pectedadverseeffccs of medications.
;rll1,bc avoideclin inclividuarls
u'iro have tural differcnccs,beliefs.;rnd prer.'ions Tlrc patientshouldbc madeto feelconrasthnla,reac[iveairvvay5disezrse.
or sec- cq:crienccs u'irh the hcalth care sys- foltirblein tclline the clinicianall conond- or rhircl-degrce
hcarr block. An- tem.io Thcsc attiiudesnrusi be uncler- ccrns and feurrsoI unexpcctedor disg i o tens in- c onv er r incSn z y n rei n h i b i - stood if thc clinician is to build rrtsr :rnd turbing clru.qrcacLiorls.
tors and ARBsshould noLbe givcn r.- :ncreasecommunicaLionr.r'ithtratienu
T h e c o s t o I m c d i c a t i o n sa n d t h c
\^'omenlilicll' to bcconrcpregnilnLa1l, .,nclfanrilies.
conrltiexitv o[ care (ie, transporl;ltrorl,
are conlraindicateclin those lvhcl are:
Failure Lotitrateor conrbinenredica- irati en L d i lfi cui L1'u' i th poI)'1]harnract',
ACE inhibirors should nor be uscd in rions.clexpiteltnoil,ingthe
rs.
ltatieni is nor difliculty in schedulineappoinLmen
i n d i viduals u' it - ha h i s to r),o I a n g i rr- ar.eoalBP.represents
clinicalincrtiaancl ancl l i [e' s conl peti ng denrzrncls)
ar e
eclenra.
Alclosleronc
anLasoniss
anclpo- must be overcomc.TT
Decisionsullport zrclditicinal
barriers[irat must be or.erLarssiunr-sparing
diureticscancausehy- s)/stems(ie. electronicand 1:aper).flor.r' conreto achievegoal BP.All nrenrbers
perlialemia and should generallv be shees,{'eedback
reminders,andirrvolve- of the.heal th care teanr (eg, i ihi'siavoidedin lratienrsu4ro har.,e
serun"tpo- ment o{'nurse cliniciarns
and'piranlra- c i a n s , n u r s e c a s e n t a n a g e r s o
, ther
tassiurnvaluesoI nrcre than 5.0 mEq/L cists can be helptLl.T$
nurses, phlr5isit. assistan15,
pharntau'hile nor taking nredications.
The patient and cliniciannrustagree ci sts, denti sts, regi stereddi erit izins,
on BP goais. A patient-centeredsrrar- optometri sts,and podi atri srs)m usr
lrnproving HypertensionControl
e$)' to achieve ihe goal and an esrinla- u'ork togetller to influence and reinAdherence to Regimens.Behavioral rion of tlr: iime needed[o reachthe goal force instn-ictions to improve patients'
models suggesrthat the nlosr effective are importanlT!)\,4henBP is above
-Q;oal, lifesryiesand BP conrroi.so
02 t--j
03 .A-rnerican ivlcciical Associa I ion . rlll ri slit.s reserved .

(Reprinted)
JAMA, \4a1'21,2003-Vol 289, No. I9
f

2s69

TI{EJNC7 REPORT

Resistanl

l-Iypertension.

Rc-sistant

(Drcushman);
ter' Memphis
Deparrrnenr
ot Fanrity (/v1aloctinjcandMayoMedicatschoot,
Roche5ter.

hvpertension
is rhelailureto rcachgoal [ili1i3;$1il,"jllll ",l,:lflf"J,.4l" ^*"' ,o,

ri'nn)icr3rdr.
wrso;.MA,MBA
(c i:cns
rorpubric

BPinpatienu
rvho
areadhering
rofult ry" ,1y""ity"in".i.i.i;;J1i,1ffi1i1?i
A'lH,::^flfi^fffrllHHJ:f":l'JEitrli:?i
doses
oranappropriare

3-drus
resi- !ffi"1,[*iil,,"T]l.E]4"*!1ffi:*iil1
ffi#[*9,il*f::f:[J*lt*i.Hli;

men tirat includes a diuretic. After excludiug porenrial iden tifiable hlper-

*"*r,, u"i*"rty
iloii.urc"ntor.
ru.l- staffJoanne
Karimbakns,
Ms,RDcAherican
hsti"ii,lr*iriilpi
son(Driones);
bepart'neni
;f M;cine,univeriry tutes
fornesearch
neatth
rrogram,
sitver
sprin',ivld).

(Box
rension
2),crinicians
shriuld
lrffH":x*:1ff;:gli:,"_,j1"#,[1"T:
iii:E^:ir,ilriii.fliilfu1f,ff.i#:,fl",ji,j:

carefullyexplorerezLsons
rvhv tl

'enrisnor
arsoar
Bprno*
;lJlnfl;l;:*ff1;::*lii[':,f,;;j'*.
r. r"liifi- ljr::"1j[!!l!1:i!1frffi.*'TJ:%;]:il;
rarattenrion
srrouJd

bepaidrodi- ;,ffi1',li:;il1l:Jil1?l;:i:J'J#'J:,#i
fliilii:.i,:lldlil!'lii,?iffi:h:I-.'il:i*#f:

il::'r:,il'li{liil:ir::ffiii';tt
ffi",#i:{tfllj"fft+l'Iffi
#)!l;iiliirF{ii:";iflti,3,i,H',il

easc"scction).Consulurionraith a hrr-

i.""i r"'oti*

i?tn"ra".

pcrtcnsion
spcciatisl
shoutd
becc:J;

ii
"iiijrrr,-,
additionarAdhors/Nationai;';;i;:i1"":1ffi;1")'
filiic'""l"tti,i"it;i,ii;l$ll;.!,;fiiifltt1l3:

Public Health Challenges

andBloodInltitute,Bethesda,
Md);CmrgcL.Batf;, tir] prir"r, irr"J"i, pfi"-r.i.""ti."r.. Claxosmith_
MD' HenryRBlack.MD(Rush
Presbytcna;-sl.LukF3
Khne,sot;ayluflimed).

Public healthapproachcs,
suchas rc-

,"J$j:f[l,"xTrl";,"#;";:,lj,,,t,xll,;cl;*
ffi,i,,iilr;.1!!:,.1,i,,T:,'"h:;:tl,i*:fr3
r,i"'.r H"orrr',
m[-i"""-.a,aurott,
err"on,

ered
irgoarir'.^.",;;.;;l;.j:'"
iilj"g,*l',ru:*?;j1.1.'H,j*:ffiH
iiiqisijliJ!;,::ifffitiqmln*nit
and
communiry
nrogiams

so.,-

i:'*:ij]."J:",tr*];*ff:**;t;e1t,L91s- 1it,

duciug
calorics,
iaturated
rat.
^ndsalt
in A;;J;Hi;;.
i]fi#:::1f,T""'',f3 l.llfjl,il',Xiill:
!lliji:5iE,J[iiX?,';,LT.:l
NcreraffiAnansMed.rcc'*
*qilffi.l*:

foodsandincrcasins
conroroccsscd
:X?,lZnHS';-#;":l;gj*,:f*;yni
n'unit)'andschoolouportunirl*r". I ili,Xi.ii???'ll?,lliTi"I!
pharma,
ff ,n ,,o*o,sis.Avenrii
phamaceuric,rs.
Kine
Gi(osmithrants,tremptrrs,_rennl.
xciii

PIrYsic]l-activit). carrachiclc a clownu'lrd shih in drc clistributionola popu-

c.[ii" r"iain""a.
i',to xr,*. e""r,""6!i-i^!ji,",ml:pr rzzcGoerrrinserta) Ravwcil
rnserhcim.
Mr;k.
An;-zeneca.
Novarrs.
craxosm'th.
ll;:Tfff,:f"t"#til:$orlcant

i,Ljc,n's
Bp.
,r'*i^i."i"li'-,..Lli"gtr'x*l'i:,_Till#?[*"""i$i"+Ul'gl
li:li;"'il,lk?',""i,iil,iili""ii,il*'.11]lli:
Molt!ull::,: squ'bb'
nrorbidity, mortaljtv, and tlre liferinre lil,],'1"ffi]lY1l1':
Elir.irly,
Forcst.
ataxoimithxtine.
Mona;h,
iTll.flTltl?

risr.
oran.incri'riJu"it"i","i,,*'r',r'i',i
l1*:i';1#Hiit;::fil,j8!rr;"'-,r:
fia,qary.n'h:i:litr###{Jif

lillT;.Ilili;tTf;
ru;;*ini:.g,#$#
?+1r'#
1#fl;#lffilr*.ts:1:s*r,rl;xhn:;isru

aLinil,euniicJstai*irr**.*"a," y-orrat.8u'rroschoororM*,""",r,;:",J:'I*Jil
sr1?,ffi1,]i.?fi,Tfl:.:XTiJ,r"T#Hri"r"T;
cmter' cah.
6raxosmithKrine.
sorvav/unimed)

c'pidcnriclcvels.Currentlv, 122 nril-

iliil;illii,l,l"-Tlirl,frEessippil4edical
liin adults
,." o'.*,.isn'o,lob.r.,ll*hjr*lllT3lgr$1y",",rr,^",,f#t,{1Tlj",
"r]ll:l'3ffi;:tff,::::;il"|ffflT:ljl?Jl
u'rrich
conrrir':utes
tothcrise
inBpand
'}:**i*li,tlil

rclatcd conditions.sl

TheJNC

7 cn-

i'iirlffi ll#r,iif;8lfJi;iff:n'J:,rfr:lxltlr**{*lli:ll"ll

veriLyof cotoredo
Hcalthscieccscr

p"r,u.i*-r,r,
,lorses
theA*erican
,,r"-;:[',r?i,l!:li[^il]:,1;i'"};?l,1iilinXi:*,fi'l',fl1illftll"J#;
a, yll* Il.j{it, {.9r19
sociation
resorution
rrrat
rhe
rood
manu_il{&,l'ili".Lij!"f:#fi}:":.f#,11"".,ij
l*tng,:;;3fi'Jl,.l:!}:"f
:::j:',,,iliHt
lacrurersand rcsuuran* reducesodiun
aroorningtonl,
nu"yr. /,, L;; ;"D,

i"1lflf[,i.jliil;i1,"#i,iilT*]#i#";li,:i:l

intherood
'";;tb';0%;;#il;

n*;"*T'#j::H'll*i#t#:itr!l.lil:
q4ren
next
decade.
pi,uri.
i'""iiiii,..- oo;r.r,".v
u.,,tn"
iriri";:il-l;il"cY"illlt',ll
1iil*:ffiff1flli"ifl1
Rilfli,:,j:irT'i^il+"];
vcntionsratesiesaddrcssthedivcrsitv
filrsfi:*tlllgiiilIir#ii:*,Ii*i+l
o[ racial,edrnic, cultural. linguisric, re- iijjillrlii,if;il:,ii!.fi?li'lLlif,I
s*.rarr",r.,n,w,ni,ir, roi.l?y.
io"r"ri,aaapr,,"cor_
phzr.
pha'naoa,
Tanabe.
snsrot_Mye^
squibb,

Iieious. and social facrorsin thc detivery of their seMces, ttre tit eiinooJ ^r

No_
tqeorodeq;Lhc/uedd",
ififii*;" p;,!;;;;
;"-;;;"f,#;;,;'#il#liiiu"y,,o.ooun,,rnuo,
oprriLMD(uftvenitvorAJabarnaatd'mingharn);
plizer,
ote- irayers
squb5,ueil.
ianofi,r.rovartis,
nresatt

f##'1.;#'$!#?t'1;,'#"Tr',?#ffi
:l*::;*lx*.,11iT1#i;.
:"'#:r'r^r':!i;ffiil1;";*""o
","-'
Dkecro*
ror
the
proaches
canp.#a"* ,,i.u"ii,=
,'.!"f;,l""1&1X,1ii#
,fii[,i"':li,:*:

,"?j,?ffiiiifj,f.itj*1,,:nor
illi:?l
"'p_
porruniry
roinrerruprand
preven,
the
l#,#R'J"i?,,.1Tlid,";,1il1}frH.l^T"^m
conu nuing cosd), c,vcleofmanaging ny_ Resources
i?:i1tr,'.1",3itrjifi:r:il:#f;,#{,fl:ifi
andserv'cesAdminiltrarjon.
R
penensroo
sowers.r*ocur.iv'cariii;;;lXtil#i];;
andrEcomplicarions. JamesR
lH"lj#:"ili!$"filHii1f',#i"t;:;"#H:

i:'i"r,i*ri#il::,?:nrff*r,iif-n:;ri,j;
fr*frfi*1,ft1,{flfr;*
itri,lflE.*tefrft1'':"rttt!ftff;
va**i:*,:r*il#tiy$.##";p;r
!"ti:'f,":i{3',"'jitiir"iftH*1'f#:r'ill
rrdfl##p;i?,:l-.fli,ffi,:*itlrn

caEolll(DRSakris
andBlack)i
velerane
Affai^Medi- Mo..MiH (ceorgeto,wn
u"'utiri irati."r c*t"r,
calcnler'Departmentsol
Preventive
MedicinF-and wastrington
uospialtent*,wiiJiil"ie-y
rtl"aiMedicine.UniverityofTnnesiee
Healrhktme cen_ ."t i""i"r, wrlfifr"",
ii6,'rLi'ilfiA,ir"""t,
mO
257O JAMA,lvlrr,v
21, 1003_Vol 2B9,l.ro.l9 (Reprinted)

a.rplia.pal,ror,ni. irair.,lro, rvrer.r

wayne state
universityschootof Medicine,
Derroit,Mich);EdwardD.Frohltdr,MD (OcknerClinicFoundation,
New

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.

Scheme Used for Classifrcationof the Evidence

Ivl lr4cta-anal,vsis:
usco[ statistical
metircrds
to comlline thc rcsuls {ron'rclinical
Ra Randomizcd controltrcdtrials: al-solinorvn as c.xpcrilrlcntalstudics
Rc Rctrospectiveanal.1'ses;
studies
also linou'n :ls ca.se-coutrol
F
Plosire.ctive
stud,y:also ltnorvnas cohort siudics.including [:istoricalor prospcctive.foll ou'-up studi e-s
X Cross-sectionalsun'e): also liirou'n ns prevalence.slLrdies
Pr Frcvious re\.iew or position statctrrents
(nonrapdomi:t'd)
C Clinical inten'enticrns
Theses)'mbc)lsare appendecito the,.
ciLlrions in rlic refcrencclist. Thr str-rclitsthat
oI tlris reporl \\'ereclassllied
evide
nce
tirr'.
supl)orting
icconrnr('.ndati()rls
i:rovidt:d
and revie$'edb1'the stafferncltirr: e.rccutivecomrniiiec. Tire classific:rtionschL]ne
is lronr theJNC \T rcport.l

REFERENCES
'1.
Joint l',laLionalCommittee orr Prevention Detection, Evaluation, and Treatmenl of High Blood Pressure. The sixth rencrrtof tlrc'Jclin[Naiional Cornrniti e e o n P r e v e n t i o n , D e i e c t i o n , E v a l u a i i o n .a n d
Treatmeni of High Blood Pressure.Arch lntern Nled.
1997,157 :24't 3 -2446. Pr
2. US Department of Heallh and Human Services,l'lal i o n a l H e a r t , L u n g , a n d B l o o d l n s t i t u L eN. a t i o n a lH i g h
6lood PressureEducationProgram. Availableat: http:
//w,wvr.nhlbi.nih.gov/about/nhbpep/index.htm. AccessedMarch 5, 2003.
3. Sheps 5C, Roccella EJ. Reflections on The Sixth
Report of the Joint NaLional Committee on Prevention, Detection, Evaluation, and Treatnrent of High
Dltrtrd Pressurc. Curr Hypertens Rep. 1999,1 .342345. Pr
4. RoccellaEJ.l(aoian NM. Interoretationartd evalua t i o n o f c l i n i c agl u i d e l i r r c sl.r r :l z z oi L J r , B l a c kH R , e d s .
Hvpertensron Primer. Dallas, Tex: American Heart Associaiion; 2QQ3:126 - 127 . Pr
5. Last JM, Abramst-lnJH, c:ds.A Diclionary ol Epidemtolttgy.3rd ed. New York, l.lY: Oxford Univers i f y P r e s s :1 9 9 5 .
5. \"'asanR5, Larson MC, Leip EP, et ai. Assessment
of frequency of progression l"o hypertension in nonhypertensive participants in The Framingham Heart
Study. LanceL 2001 ;358:1582-1 585. F
7. Vasan RS, EeiserA, SeshadriS, et al. Residual,lifetime risk for developing hypertension in middle-qged
women and men: The Framingham Heart Stuciy.
:
r A t u l A . 1 : t C 2 : 2 8 7 : 1 O 0 3 - 1 0 1 0F.
8. Lc,
r 5. Clarke R, QizilbashN, Peto R, Cqllins
R. Agr
: relevanceof usuai blood pressure[o vascular mr,. ..irly. LanceL 2O02;350: 1903 - 1913 . M i
9. Whelion PK, He J. Appel LJ, et al. Primary preyention of hypertension: clinical and public health advisory from The National High Blood PresslrreEducafion Prog,ram.IAIAA. 2Ct02;288:1882-1888. Pr
1o. Neal 8, M.rcMahon 5, Chapman N. Effectsol ACE
inhibitors, calcium antagonists, and other bloodpressure-lowering drdgs. Lancet. 2000;355;19551964. M
11. Ogcien 16, He J, Lydick E, Whelton PK. Longterrn absolute benefit of lowering blood pressure in
hypertensivepatients according to the JI.ICVl risk stratification. Hvpertension 2000;35:539-543. X
12. Cherry DK. WoodwellDA. NationalAmbulatory
Medical Care Survell: 2000 summa ry. Advance Data.
2OO2;328:1-32.Pr
13. lz.o iL )r, Levy D, 8la,:1:HR. ClinicalAdvisory Siatement: importance of sysrolicblood pressurein older
Americans. Hyperlension 20O0;35:1021 -1 O24. Pr

C2003 Arne.rican ltledical AssociaLiai.r. r\li rishr.s reservcd.

1 4 . C u s h m a nW C , F o r d C E , C u t l e r J A , e t a l . S u c c c s s
and prr:dictorsof blood pressure control in diverse
l.lorth American settings: The Antihyperl.ensiveand
Liprd-LorvcringTreatment to Prevc:ntHeart Attack Trial
(ALLHAT). I Clin Hypertens (Creenwicit). 2OO2;4:
393-404. Ra
1 5 . B l . r c kl J R , E l l i o t t W J , N c a t o r rJ D , e i a l . B a s e l i n e
characteristrcsand elderly blood pressure control in
the CONVINCE ltial. H\lpeflens,ot1.2OQ1;37 :12-18.
Ra
1 5 . W o d d H y p e r t e n s i o n L c a g u e . A 4 e a s u r i n gy o u r
b l o o d p r e s s u r e .A v a i l a b l e a t : h t t p : / / w v r w . m c o . e d u
/org/whl/bloodpre.html. AccessedApril 1, 2003.
17. PickeringT. Recommendationsfor the trseof home
(self) and ambulatory blood pressuremonitoring. Am
) Hypertens. 1996;9:1-11. Pr
'1
B . V c r d c c c h i a P . P r o g n o s t i c' r a l u c o l ; r m b u l a t o r y
biood pressure. Hypertensron. 2000;35:844'851. Pr
19. American Heart Associalion.Horne monitoring of
h i g h b l o o d p r e s s L r r.e A v a i l a b l e a t : h t t p : / i w w w
= 576. Ac.americanheart.org,/presenter.jhtml?icientifier
cessedApril 1, 2003.
20. Calculatorsand mcrdclingaids. CFR/1.73 M'? by
tu1DRD(*5UN and SAlb). Available at: http://www
.hdcn.com/calcf/gfr.htm. AccessedApril 1 , 2003.
21 . American DiabetesAssociation.Treatment of hypertension in adulLswith diabetes. DiabetesCare.2@3;
2 6 ( s u p p l 1 ) : 5 8 0 - 5 8 2 .P r
22. NationalKidney Foundation Guideline.Ki DOQI
clirricalpracticeguidelinesfor chronic kidney disease:
Kidney DiseaseOutcome Quality Initiative.Am l Ktdn e\t D i s. 2002;39(suppl 2):51 -5246. Pr
23. Thc'Trials of Hypcrtension Prevention Collaborative P.esearchGroup. Effects of r,veight loss and
sodium reduction intenreniion on blood pressureand
hyperterrion inciderrccin trvenveight people with highnormal biood pressure.Arch lnLern Med. 1997:157.
657-667. Ra
24. Hr: J, lVhelton PK, Appel LJ, Charle;ton J, Klag
MJ. Long-term effects of weigltt lossanci dietary sodium reduction on incidenceof hypertension.Hypertensiort. 2000,35.544 -549. F
25. SacksFM, Svetkey LP, Vollmer WM, et al, for Lhe
DASH-Sodium Collaborative P.esearchCroup. Effects on blood prressureof reduced dietary sodium and
the Dietary Approaches to 5l.op Hypertension (DASIJ)
diet. N Engl t liled. 2001 ;344:3-10. Ra
26. Vollmer WM, SacksF/v1,Ard J. et al. Effects of
diet and sodium intake on blood pressure. Anrt lnt e r n h 4 e d . 2 0 0 1 ; 13 5 : 10 1 9 - 1 0 2 8 . R a
27. Chobanian AV, Hill fvl. l'{ationalHeart, Lung, and
Blood InstituteWorkshop on Sodium and Elood Pressure: a critical review of current scientific evidence.
Hypertension 2000;35:858-863. Pr

(Reprinted)
JAtvlA,h4ry?I. 1003-_Vol289, No. 19 2571

TI-IE INC 7 REPORT

ing sieep. in most indiviciuals.BP clccreasesb)' l07o ro 20%cluringthe night;

are not
those in u4ro1r.such dc.crease,s
lor
cilrdiorisli
incre'a-scd
are
at
ilrerscnt
vasculareven6.

Box 1. CardiovascularRisk Factors

Major RiskFactors
ilf i:crtcnsionT
Cigarettesmoli.iug
O b c s i t l ' ( B M I> 3 0 ) t
I'hysical inactivitv
nriaf
Dvsliiricle
Diairetc.smc.liitusl
Microall-ruminuriaor cstimale.dGFR {(r0 rll/nrin
Age (>55 y'earsfor tncn. >65 r'carslor uiomctt)
di-sclse(tlt:tr (55 vt';rrs
Familv history o[ prctnrlurc cardiovascrrlar

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

Associaiicn. rlll rigtits reservcd.

t l r c s r l r r e r co l

Box 2. Identifiable Causes of

Flypertension
Slt'.cp;rpnca
l)ruq-inclucedor clruq-rclatcC
( s c eB o x 3 )
Chronic iiidncv discasc
P rinr arv al clclst trrr.tui snr
Renovascttlar discasc
Chronic steroid thcraPv
Cr-rshing svudrot-ne
Pheochronlocvtoma
Coarctation of tirc aorta
Th1'roici or parathvrr-riclcliscitsr

in C\D compliated \\,ith a clecrease

cations.ln paticntsu'ith hlpertension
or renal disease.the BP
u'ith cliabet-es
gozrlis lessthan i30/80 mnr l-1g.rr'rl
Lilestyle ]v{odiIi cations.Acloptiono[
healthy lifesn'lesb)'oll indiviclualsis
critical for d-repre.ventionof high BPand
part o[ the nranage-an indisirer-rsarble
nlcnt of those 1ryi1[filipertcnsion. Major lifestyle modilications shou'n to
lor.r'erBP include l\'eight reducdon in

(Aeprinted)JAMA, \'ta1'21.1003-Vol 289, No. l9

2563

JNC VII

JNC VII prevention, detection, evaluation & treatment

of High Blood Pressure
.:.

..

..

>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

:B[GRC KNBZ[KF FPK[PF IGM \GXNPF

\TRGP FBGVZG \GBKZC OGEKY

:\MKZTC

QKYRCJ FGI 'VGZV

FIV[PF KBVGZ EGDKB

2008 \ZGEFP

NBZ[KC \KBGVZF \GZE\SFF

\KBGVZ \GKRKEPN UDBF

OKRKK RTF QMG \

EGPT
5

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ZCE I\V .

8{6

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

BGCP .

13{9

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

OKK\R[ NKD ETG FEKNP .

OKR[ [[ ET OKK\R[ NKD .

16{14

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19{17

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12{7 NKD .

22{20

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

19{13 NKD .

28{23

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39{20 NKD .

35{29

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

64{40 NKD .

42{36

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

FNTPG 65 NKD .

FBVZPC \TRGP FBGVZG \GBKZC OGEKYN \GKIRF OG[KKN \GXNPF 1 'SP IVSR .
49{43 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \KRG[BZF
\GGXF \GKGNKTV HGMKZ FNKFYC OKENKN \TRGP FBGVZ NFGR 2 'SP IVSR .
50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . \KRG[BZF FBVZPC
52{51
53
55{54
56

. . . . . . . . . . . . . . . . . . .

\GI\V\F \MZTF 3 'SP IVSR .

OKKRK[F \[[T \TKRPN EKZGBGNV 4 'SP IVSR .

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. .

OKENK \GIKJC 5 'SP IVSR .

\GENKF NKDC \GBKZCF EZ[P N[ OKK\ZD[F OKRGSKIF IGN 6 'SP IVSR .

IGZ \GTGCTCB EDRM QGSKI NNGM OK[EI OKRGSKI 7 'SP IVSR .

65{57

. . . . . . . . .

70{66

. . . . . . . . . . . . . . . . . . . . . .

77{71

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

81{78

. . . . . . . . . . . . . . . . . . . . . . . . .

86{82

. . . . . . . . . . . .

106{87
3

. . . . . . . . . . . . . . . . . . . . . . . . . . . . .

\GNIP \TKRPN FRGCR FRGH\ 8 'SP IVSR .

\KRVGD \GNKTV 9 'SP IVSR .

CN \GNIPN QGMKS KPZGD 10 'SP IVSR .

QGMKS KPZGD BNN F[KBC K\EKN OGZJ CYTP 11 'SP IVSR .

. . . . . . . . . . . . . . .

FNKPDNG FTKRPN OKMZEFG QG[KTF KYHR 12 'SP IVSR .

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

ZCE I\V
\KRZEGPF FBGVZF .21=F FBPC FBGVZF N[ LZEF KRCBP QF \TRGP FBGVZG \GBKZC OGEKY
EIB .OKCZ OKRGZM OKCXPN KGVKZ FBXP BN LB \GCZ \GKBGVZ \GKTCN \GRGZ\V FBXP
.\GNIP \TKRPG FKKSGNMGBF \GBKZC OGEKY GRKF OKKZ[VBF \GRGZ\VF
FPK[PF \GIGM \GXNPF N[ OKRGMEKT NT QMG 2004 \ZGEFP NT \GSSGCP GH \ZCGIC \GXNPFF
,\GBKZCF EZ[P \GXNPFG \GBKZCF EZ[P N[ \GKPGBNF \GXTGPF ,OKBVGZKBFG ,OKBYKZPBF
\GRGT \GXNPFF \KCZP .NBZ[KC \GBKZCF \MZTP N[ OKKDGNGKPEKVB OKRG\RC \GC[I\F LG\
\GKIRF ZVSP (USPTF) KBYKZPBF FPK[PF IGM N[ B=G A DGSP \GXNPFN FEKPF \GPB NT
\GKZYIP \GKBZ FH CN[C \GPKKY BNG ,ECNC OKIPGP \TE \GGI NT \GRT[R QF[ UB GNNMGF
.Z\GK \GK\PXGT
1 FPZC \GXNPF NT OD \GSSGCP NGZJSNGM \YKEC B[GRC \GXNPFFG FNTPG 65 NKDP \GXNPFF
.(www.icsi.org) C"FZBC Institute for Clinical Systems Improvement ICSI=F N[ 2=G
\GRGGMP QFG \TRGP FBGVZC YSGT[ KP NMNG OKKRG[BZF OKKBGVZF OK\GGXN \GETGKP \GXNPFF
.FKKSGNMGBC NKDF \GXGCY NMN \TRGP FBGVZG \GBKZC OGEKYN
\GKZIBC OD OF OEYGP ZG\KB \GNGTVG \KRG[BZ FTKRP \GNGTV ,\GBKZC OGEKY KM OKZGCS GRB
.G\GBKZC \ZKP[C NKTV \GKFN LKZXF GPXT ZGCKXF
NT NYFN FETGR[ \K\KXP\ FNCJ QMG \GNGTVF N[ JZGVP ZGB\ OKKY NKD \XGCY NMC
QGDM OKKZYKTF OKPGI\C \GNGTVF \GFP \B OKJZVPF OKIVSR \ZCGIF UGSC .OK[P\[PF
.'EMG QG[KTF KYHR ,OKRGSKI \KRMG\ ,\GI\V\F CYTP
\TRGP FBGVZ ,FIV[PF \BGVZ OGI\P OKDKXR FC GV\\[F[ FETG \ZHTC FRMGF \ZCGIF
.OKVSGR OKPGI\P OKIPGP \GZTFNG QGKTN ZCTGF ZPGIF .OKENK \BGVZG ZGCKXF \GBKZCG
NNGMF IVSR GRVZX ,LMC TKKSN KEM .\KPGK OGKF FEGCTC OM\B [P[\ GH \ZCGI KM OKGGYP GRB
.\KRG[BZF FBVZPF N[ FSGPTF FCKCSC \GKIRFF OG[KKN \GXNPF
NKD \XGCY NM KCDN .\GXNPFF \GSSGCP FKNT[ \RMEGTP \GZVS \PK[Z \VZGXP ,OM\GKIGRN
.Z\GKC OKKJRGGNZF FKVZDGKNCKCF KZVSP OKPG[Z ,IVSR GB
GTKVGK BN[ OKRGMETG OKKGRK[ GRM\K QPHF UGNI OT QMNG ,2008 \R[ \NKI\C FRMEGT \ZCGIF
.\KRMET \GZVSC ZHTKFN [KG \BH \ZCGIC
,FINXFC

WKCGZMH EGE Z"E

EGDKBF Z"GK

QKYRCJ FGI 'VGZV

\MZGTF

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

BGCP
QGDZB .\GBKZCF K\GZK[ N[ OKCG[IF OKETKF QKCP ORKF \TRGP FBGVZG \GBKZC OGEKY
GKPGSZVCG "OKKVNBF \R[C NMN \GBKZC" KETK \ZDSPC FNB OKB[GR NNM KPNGTF \GBKZCF
[DE OGKM OKP[ OKNGIF \GVGYG \GBKZCF EZ[P .\TRGPF FBGVZF \GCK[IN EIGKP [DE Q\KR
FH CN[C QKB LB "2020 BKZC EK\TN" \PHGKG \GBKZCF KEEP \ZDSPC FNB OKPGI\ NT ZCDGP
.OG[KKN QPH Z\GK \BXYF
ZGVK[ ,OKKI \NIG\ \MZBF Z[VBN BKF \GBKZCF OGEKYG \TRGPF FBGVZF \GNGTV \ZJP
FNGMK BKF .("\GBKZC OKR[") \GKGNCDGPG \GNIPP \GK[VGI OKR[ Z\GK \ZKXKG OKKI \GMKB
.FNKFYFG FIV[PF ,JZVF \ZDSPC TXC\FN
:FTKRP \GPZ [GN[ \GPKKY

\ZKXK GB ,QGMKS KPZGDN FVK[IF \\IVF F\ZJP { (Primary Prevention) \KRG[BZ FTKRP .B
KGRK[ ECNP \NNGM \KRG[BZF FTKRPF .YHRF/FNIPF \TVGF \TKRP LMCG OFKVNM \GRKSI
.OKRKPJKGG QGHP KVSG\ Q\P NNGM TRGP K\GVGZ\ NGVKJ ,OKRGSKI OD ,OKKIF IZGBC
\GTRPKF QGDM OKKIF IZGB/OKNDZFC KGRK[ TXCN FKKSGNMGBF \[ZER \KRG[BZ FTKRPC
OKRGSKI \NCY ,FRGMR FDKFR ,FRGMR FRGH\ ,[P[N FZ\K FVK[IP \GTRPKF ,QG[KTP
.FZKES \KRVGD \GNKTV TGXKC ,OKPKB\P
FRGH\ ,QG[KTP \GTRPKF) 50% ET F\GP\ KZGTK[ \KIVFN Q\KR \KRG[BZ FTKRP \GTXPBC
.(\KRVGD \GNKTVG FZKFH FDKFR ,FRGMR

OZGD GB FNIPF ZG\KBG OEYGP KGNKD F\ZJP { (Secondary Prevention) \KRGKR[ FTKRP .C
.FNIPF LNFP \B \GR[N \RP NT Z[VBF NMM OEYGP CN[C OFC NGVKJG QGMKSF

,OE \GYKEC) \GRG[ \GYKEC \GTXPBC \GNIP N[ OEYGP KGNKDC \YSGT \KRGKR[F FTKRPF
,(Opportunistic screening) Case Finding \GNNGM TGXKCF \GJK[ Z[BM ,('GMG FKPEF ,E"IN
NY[P \KRG[BZ FTKRPN .OGHK QGPKH KEK=NT (Systematic Screening) \GKNNM FZKYS \GYKECG
.\KRGKR[ FTKRP \PGTN Z\GK CZ
FTKVGF ZCM[ ZIBN \GCZT\F KEK=NT \K[TR { (Tertiary Prevention) \KRG[KN[ FTKRP
.\J[GVP FNIP N[ FK\GMN[F OGXPXG OKMGCKSF \\IVF F\ZJPG YHRF/FNIPF

.D

:QGSNKG N[ OKRGKZJKZYF NT \GSSGCP FZKYS \GYKECN OKRGKZJKZYF \TKCY

Wilson JMG & Junger G. The principles and practice of screening for disease.
Public Health Papers 1968 WHO 34.

:OKCKMZP F[GN[ QGC[IC OKIYNR FZKYS \GNGTVN OKRGKZJKZYF \TKCYC

FNIPF CKMZP .B
.OKK\GTP[P \GBXPKFG \GTZBKF KZGTK[ .1
.FNIPF \ZPGI .2
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

.FNIPF LNFP KGRK[N OKTXPB OGKY .3

.\GCZT\F \Z[VBPF ,\K\GTP[P \KJPGJVPKSB FVGY\ \GBKXP .4
.NCGYPF NGVKJF KCDN LGPR \NTG\/QGMKS SIK .5

FYKECF/K\RICBF KNMF/KGNKDN OKTXPBF CKMZP .C

FVGY\C FNIPF KGNKDN (OKIGJC ,OKJG[V ,OKNGH) OKPKB\P OKTXPB OGKY

.FBKZC FKKSGNMGB CZYC \KRGPF FYKECN OKPKB\PF ,\KJPGJVPKSBF
.QGRKSF \YKEC N[ \KSIK \GFGCD \GKNGDSG \G[KDZ \GPZ
.FYKECF TGXKCN LGPR OKMGCKS ZGTK[
.LGPR \NTG\/QGMKS SIK
.LGPR \NTG\/\GNT SIK :FZKCS \GNT

.6

.7
.8
.9
.10

\KBGVZF \MZTPFG FKKSGNMGBF CKMZP .D

.GH FKKSGNMGBC QKIC\N FGCD (Predictive Value) BCRP LZT

.\GJNIFF KNCYP CZYC FFGCD \GPKEY NTC
.(FKKSGNMGBF KEK=NT FNKCY FYKEC) FKKSGNMGBF CZYC FNGTV UG\K[G \GTEGP \PKKY
.F\PYFN \GZ[VBF GB F\GBRG FPKB\P \KNGVKJ \K\[\ \GBXPF

.11
.12
.13
.14

\GRGZ\K QNFN .F\GP\ ZGTK[C FEKZK BGF FZKYS \KRMG\ \MZTFN Z\GKC QKPBF EEPF
:FZKYS \GYKEC \GRGZSIG

\GRGZSI

ZG[KBF \KNKN[ FCGHM BKF FYKECF OB

.(False Negative) FTJP \GBKZCN
FYGXPN \PZGD BKZC OEBN \KCGKI FBXG\
.(\GTJF \ZZC\P[ ET) FYKHP BKFG \K[VR
FRKY\ FYKEC \BXG\ Z[BM KCGKI YGHKI
BKCFN NGNTF FPGEP QGIJCN OGZDN FNGNT
.("ZESC NMFG K\YECR") FRICBC ZGIKBN
ZG\KB BNN[ OKKNGCDF OKNGIN Z\K=NGVKJ
.OKNVGJP GKF BN NNM OEYGP
.YHR OGZDN \GNGNT QPXT \GYKECF
.OKBKZC OK[RB \YKEC NT OKCB[P HGCHKC

\GRGZ\K

. F\GP\G FBGNI\ \\IVF .

.OKK\KPB
OKNGIN FHGRDGZV ZGVK[ .
.FZKYSC GZ\GB[
. KGVKZN KNYKEZ \GIV NGVKJ .
.OEYGP OKRICGBPF OKNGI

. BKZC OEBF[ YGHKI YKRTP .

.(reassurance)
. .NGVKJN OKCB[PC QGMSKI .

N[ \TRGP FBGVZN FPK[PF \GIGM N[ B=G A \PZC \GXNPF NT \GSSGCP GH \ZCGIC \GXNPFF
{ N[ 2=G 1 FPZC \GXNPF ,(2004 \R[C QMET\FN YKSVF FERY N[ Z\BF) ,FERYG C"FZB
\GKIRF ,OKIPGP \TEG \GZICR \GZVS \GZKYS ,\GKHKNRBFJP ,OKZYGCP OKZYIP ,ICSI
FKDGNGYRGBN ,FKZJBKEVN \GKPGBNF \GXTGPF \GXNPF ,\GBKZCF EZ[P N[ \GZMGP
.NBZ[KC OKIPGP \TE \GGIG NBZ[K \RKEPN \KRKKVGB FKDGNGKPEKVBN \GPB\GP FKDGNGKEZYNG

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

:\TRGP FBGVZC OKPGI\ F[GN[C \GKIRF F[CKD FETGGF

.\GRGB\G \GNIP \TKRPN \GBKZC OGEKYG WGTK \GNGTV .B
.(chemoprevention) \GNIP \TKRPN OKVSGR OKZK[M\/\GVGZ\G OKNKDF NMC OKRGSKI .C
.\GNIP N[ OEYGP ZG\KB

.D

SPGT KV NT UGETK\ BNN NKD \XGCY NMC \GXNPGPF \GKZYKTF \GNGTVN \GSIKK\P GRK\GXNPF
\KRMG\C FEKPT KM OK[KDEP GRB \BH OT .\GCZT\FF \GNKTGP \NTG\ \GNT GB FBGNI\
OF FRGMR FRGH\G FRP[F \TKRP ,FZKES \KRVGD \GNKTV ,QG[KT \YSVFG \GTRPKF ,OKRGSKIF
.\GBKZC OGEKYG \GNIP \TKRP \RKICP Z\GKC \GCG[IF \GNGTVF
NNMC OKBVGZF ZGCKXN :\GBKZCF OGI\C \GKTGXYP \GKSGNMGB QGGDPN \GETGKP \GKIRFF
,\GKRKEP KTCGYNG ,FBGVZN OKJREGJSN ,FNKFYC \GBKZC K\GGXN ,JZVC OKKRG[BZ OKBVGZNG
.FNB \GKIRFC ZHTKFN NMGK CIZF NFYF OD .OKNGIF \GVGYG \GBKZCF EZ[P QGDM
FBGVZF
NVJPFG
,\GSGPT
FBGVZF

\ZDSPC \TRGP FBGVZ OG[KKN OKCZ OKK[Y OKPKKY[ LMN GRB OKTEGP \BH OT
NVGJPF TGRM[ ZETF ,OKRG[ OKKTGXYP OKVGD N[ \GZ\GS \GXNPF :\KRG[BZF
\GYKJYZVG QPH ZETF ,NVGJPFG NVJPF N[ YKVSP TEK ZETF ,\GYKECF \GXKIRC
QGC[I NT \GVKZIF \GNIPC YGSKTF \B UKETFN KRG[BZF BVGZF NT OKTKV[P
.\TRGPF

IVSR GBZ) \GKIRFF OG[KKN \GXNPF GVZGX OKCMTPF OKPZGDFP YNI NT ZCD\FN TKKSN KEM
,\GVGYF N[ \GMKBF KEEPN GSRMGF OEYGPF ZG\KBFG FTKRPF \GNGTVP YNI ,USGRC .(1 'SP
[K KJPJSKS QVGBC GM[PK FNB \GNGTV[ \RP NT .\KRG[BZF FBGVZF K\GGX \B CKKIPF ZCE
\GZKMHP ,\GKIB ,OKBVGZ) FNKFYC KBGVZF \GGXF QKC \GKGNKTVF \B YNING QPH \GXYFN
.('GMG \GBKZC KPEYP ,\GKBGVZ

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

O KK \R[ NKD ETG F EK NP

(1, 2, 5, 11=8, 132, 572=575)

\GBKZCF EZ[P ,ZDC\PNG ENKN ,OBN FYNIPF NFRP K\KPB FRGK 'VGZV KEK=NT QMEGT

OEYGP ZG\KBG FZKYS

[EGIC .\GIB \YKEC OK[EGI 2{1=N \IBG BVGZ \GYKEC 3{2 TXCN WNPGP FR[ NKD ET
[EGIF L[PC LZTK\ BVGZF KEK=NT FRG[BZF FYKECF .OKKTGC[C OTV \GIB NXB ZGYKC QG[BZF
ET FR[ NKDP .OK[EGI 9 NKDC \K[KN[FG OK[EGI 2 NKDC FKKR[F FYKECF ,FEKNF ZIBN QG[BZF
.(2 'SP IVSR \GNGTV HGMKZ JGZKV) \GIB KEK=NT \GYKEC 3=G \IB BVGZ \YKEC \XNPGP OKK\R[
WGTKK ,[BZ UYKF ,LZGB \EKEP ,FNKY[ FKGXZ ,\GIBF NXB ZGYKC NMC FRG[BZF OKKIF \R[C
.OK[EGI 3=N \IB F[T\ \GI\V\F \MZTF .\GRGB\ \TKRPG \GZGF ,FRGMR FRGH\ B[GRC
OB\FC FNKED \MZTF ,\KNNM \KNYKHKV FYKEC NGNM\ FRG[BZF OKKIF \R[C BVGZ \YKEC NM
.FVGY\ NMN OKEIGKP OK[DE OT ,(3 'SP IVSRC JGZKV GBZ) \GI\V\F \MZTFG FNKEDF \GPGYTN
.(OKENKF NMN FYKZS \YKECM ZCRE QICP NT FXKNPP FRKB \KERYF \KBGVZF \GZE\SFF)
YVGE ,\G[GGBG CN \GNGY ,QDBF YGSV \YKEC NT [DE O[GK OKK[EGI NKDC BVGZF \YKECC
CYGT JCP ,QKT Z[Y \GI\V\F GYECK QM .FPGJSNCGRKJZG EGZK \NKN[N ZGB SYNVZG KNZGPV
FTKP[ KKGYKNN QGRKS \YKEC \TXGCP OK[EGI 9{7 NKDC .FTKP[ \KKTCP OKZGFF \GP[Z\FG
FTKP[ \YKEC TXCN [K ,QGMKS \GXGCYC OKBXPRF OKEGNK NXB KM QKKXN [K .CNIF \GVKJC
\GYGRK\ ,OKDV \GNNGM \GKZYKTF QGMKSF \GXGCY .Auto acoustic emission \JK[C FEKNF ZIBN
K\IV[P ZGVKS ,OKRVCG QHGBC \NGDNGDC \GKNPGRB OT \GYGRK\ ,D"Y 1.5=P \GIV FEKN NY[PC
.EGNKC YKR[\G OE \VNIF \CKKIPF FKPRKCGZKNKCZVKF ,KPIZ LG\ OGFKH ,\KCXT \G[ZKI N[
BKF LB FEKNF ZIBN OKEGNKF NMN K\ZDK[ QVGBC OGKM OKNGI K\C ZVSPC \TXC\P GH FYKEC
I\V\P OFC OKCXP OR[K[ OG[P OK[EGI 9{7 NKDC FTKP[F \YKECN UKNI\ FGGFP FRRKB
.OKNGIF \KCP EGNKF ZGZI[ ZIBN FTKP[C KGYKNF
NT (\GI\V\FG FNKED \MZTFG \KNNMF FYKECN JZV) [DE O[GK OK[EGI 9 NKDC BVGZF \YKECC
.\GDV GPM QGMKS KPZGDG \G[ZKI N[ K\IV[P ZGVKS ZZCN [K QM GPM .FTKP[G FNKHV ,FKBZ
\PZP \GP[Z\FG YGRK\=FIV[P=FZGF KEGYVK\G \GDFR\F \GTZVF GYECK ZGYKC NMC
.YGRK\F OT \ZG[Y\F
O[Z\FNG FGGNPF FZGFF NXB \GKTCG EGYV\F \PZN CN OK[N [K CYTPF KZGYKC \TC
.OBF NXB QGBMKE \GZ[VBP
.\GBKZCF EZ[P \GXNPFN OB\FC QKCGNDGPFF \PZ YECK\ ,FRG[BZF OKKIF \R[ UGSC
9

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

WGTK
[K L[PFC .(Z[VB OB FR[ KXI ET) OKRG[BZF OKKIF K[EGIC FYRFN FCZ \GCK[I [K :FRGH\
NHZCG D3 QKPJKG Q\PC LZGXF B[GRC \GIRFN [K .OKKRK[F \GI\V\F CXPG FRGMR FRGH\ YGECN
NKDP .OGKN D"P 210 OK[EGI 6{0 NKDC :\XNPGPF QEKSF \MKZX .FRG[BZF OKKIF \R[C
.4 'SP IVSR FBZ EKZGBGNV KCDN .OGKN D"P 500 OKR[ 3{1 NKDPG OGKN D"P 270 'I 12{6
\GZKVC QGHPF QGGKD NKI\FN WNPGP ,FR[ KXI NKD ET ECNC FNGPZGVP OKRGHKRF OKENKN Z[BC
.OK[EGI 6{4 NKDP NIF FDZEFC \GYZKG
YGRK\ \CM[F \XNPGP) \GRZTG FRK[ \TC YGRK\F \CM[F ,FRK[F KNDZF B[GRC QGEN [K :KNNM
CN OK[N [K .KCKSVF QG[KTF KYHR ,QKY\ UGD OGI NT FZKP[ ,FRGMR FXIZ ,(FRK[F \TC CDF NT
[GPK[G [P[N \ZYGCP FVK[I B[GRC \GIRFN [K .child abuse=G FIRHF ,KGYN K\IV[P EGYV\N
.FRDF KMGSKPC
OKZGFN Z[VBN \RP NT \GIBF GB BVGZF NXB ZGYKCF \TC "IG\V" QPH [KEYFN WNPGP
CN[ FGGFP YGRK\ OT FIV[P .\GZGFF N[ [EIF EKYV\C O\GB YHING ,OFK\GDBE \B \GNTFN
N[ FRK[ \GTZVF ,YGRK\ N[ L[GPP KMC .K\GTP[P KCKJPZGR ZC[PG OKKIF NDTPC KHMZP
\GYGRK\F \GIKJCN FCZ \GCK[I [K.OKIKM[G OKCG[I OKB[GR ORKF OKZGFFG YGRK\F
5 'SP IVSRC B[GRF JGZKV .EGTG \GVGZ\ ,KGYKR KZPGI \YIZF ,\GIKJC BSKM NNGM OKJGTVFG
.OKENK \GIKJC

OKRGSKI
OKRGSKI \KRMG\ NT FEVYFG FH NKDC OKRGSKIF N[ FCZF O\GCK[I KCDN OKZGFF OT QGEN [K
.FBNP
\B OKNNGM ,YGRK\F N[ OKRG[BZF GKKI K[EGI 24=C \GBKZCF EZ[P KEK=NT OKR\KRF OKRGSKIF
,B=G A SKJKJVF ,(\PGPF CKMZ\F) GKNGV ,KZNGNXB \NT[G SGRJJ=FKZ\VKE :OKBCF OKCKMZ\F
JZGVP OKRGSKI IGN) (MMRV) IGZ \GTGCTCBG \PEB=\ZHI=\CXI ,b FHRBGNVRKB SGNKVGPF
TXPBC \K\MNPPF OKRGSKIF \KRMG\N SRMK IGZ \GTGCTCB EDRM QGSKIF .(6 'SP IVSRC TKVGP
OK[EGI 12 NKDP IGZ \GTGCTCB EDR QSIN WNPGP G\SKRM ET .1.1.2007 KEKNK NGNMKG 2008 \R[
NIF 'B F\KMC OKR[ 7{6 NKDC Q\RK\ FKKR[ FRP .QMP ZIBN [EGI GB MMR=F QGSKI OT EIK
.7 'SP IVSRC IGZ \GTGCTCB EDRM QGSKIF JGZKV .J"S[\ OKEGPKNF \R[P
NNGM FPK[RF KMZE N[ \GKRGZM \GNIP OT FNB GPM QGMKSC OKENKN WNPGP \TV[ EDRM QGSKI
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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

12

OKK\R[ NKD ET FEKNP \TRGP FBGVZ

2

\GVSG\G OKRGSKI

OEYGP ZG\KBG FZKYS

WGTK

:[PGIPF QGSKIF [BZ UYKF ,FCGD ,NY[P

FNKMB KNDZFG FYRF
.DTap-Hib-IPV FNKEDG \GI\V\F \YKEC
,YGRK\C NGVKJ OKRGMR
1
A ECM \YNE EDRM QGSKI
\KEGSK \KRVGD FYKECG
,FXIZ ,FCM[F \ZGX
.B=G
,FRK[ KNDZF ,FN\IF
,\ZHI ,\CXI EDRM QGSKI
,QKY\ UGD OGI \ZKP[
IGZ \GTGCTCB ,\PEB
FRGMR FNMBF
(MMRV)
ORKB[ OKXNPGP OKRGSKI
QGSKI :\GBKZCF NSC
,\TV[ EDRM
EDR EPGXPF QGSKIF
OKYGYGPKGRV
Rotavirus EDRM QGSKIF
4
NKD ET D3 QKPJKG Q\P
,SVZP :OK[EGI NKDC
\KC \GRGB\ \TKRP
\GYGRK\N JZV { FR[
YVGE ,CN \G[GGKB
OKZPGIP \GTRPKF
.FNGPZGVP OKRGHKRF SYNVZ ,YGSKV ,KNZGPV OKXVIG \GVGZ\ .OKNKTZ
QKP KZCB ,FNKHVG ZGB
OKRMGSP
OK[EGI 4 NKDP NHZC Q\P
:OK[EGI 4{3 NKDC
\GIKJC C[GP
3
4
.OK[EGI 12 NKD ET OKK[EGI NKDC GPM FYKEC
.CMZC
QKT Z[Y \YKECG
:[EGI 11{7 NKDC [P[N \ZYGCP FVK[I
FNKHV ,\GI\V\F \YKEC .KCKSVF QG[KTF \GRMS
.FTKP[G =FIV[P=FZGF EGYVK\
:OKK\R[ ET FR[ NKDC
CN OK[N [K .YGRK\
.FMKNF \MZTF
.FIRHFG \GNNT\FN
QKCGNDGPF \PZ \YKEC
OKENKF NMN FR[ NKDC
BVGZ \GYKEC 2 { QG[BZ \GVKET ZESC .Q\GFPG \GYKECF \GVKM\ 3{2 IVSR FBZ
.FRG[BZF OKKIF \R[C \GKIZMF
.OK[EI OKRGSKI { 7 IVSRG OKRGSKI IGN { 6 IVSR FBZ
.[EGI 12{4 NKDC NHZC \\N [K { \GBKZCF EZ[P \XNPF KVN
NGVKJM NHZC Q\PC LZGX QKB { KPNGTF \GBKZCF QGDZBG OKENKF KBVGZ EGDKB \XNPF KVN
.NHZCC \Z[TGP FNGPZGV OK\G[F OKN[C \GYGRK\N TRGP
.OKENK \GIKJC { 5 'SP IVSR FBZ
13

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

2
3

OKR[ [[ ET OKK\R[ NKD

(1, 2, 5, 8=12, 14, 132, 166=169, 572=575)

K\KPB FRGK 'VGZV KEK=NT QMEGT

OEYGP ZG\KBG FZKYS \GYKEC

[PI NKDCG KXIG OKK\R[ NKDC :BVGZ \GYKEC K\[ \GXNPGP ,[[ NKD ETG FKKR[F OKKIF \R[P
.FR[N \IB \GIVN \GIB \YKEC QMG
\YKEC ,3.5{3 NKDC FKBZ \GEI \YKEC ,FNKHVN OKKRKT \YKEC ,FCGDG NY[P GNNMK \GYKECF
\YKECG OKKRK[F CXP \YKEC USGRC .ZGCKEG FV[ \YKECG ,2.5{2 NKDC \ZG[YK\G FTKP[
.OKM[BG \KZNGYSG=GKEZYF \MZTPF NT [DE OT FBNP \GMZTP
,\GDFR\FC \GTZVF ,ZGCKEC \GTZVF \MZTF ,\GI\V\FG FNKED \MZTF F[T\ FNB \GYKECC
GYECK .FIV[PC \GNGCDG \TP[P KB[GR NNGM FIV[P/FZGF=ENK KSIK QMG FEKPNCG \ZG[Y\C
.FRK[G FNKMB KNDZFG QGKYKR KNDZF

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

6{2 NKDP \TRGP FBGVZ

FTKRPN \GVGZ\G OKRGSKI

OEYGP ZG\KBG FZKYS

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

KRPKSN \EIGKP \GRZKT

\GTZVFG Child Abuse
\GDFR\F

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

.FTGCY OKKRK[ \YKECG KPGK OGK OKKRK[ IGXIX B[GRC WTKKN [K

NKDC \KRVGDF \GNKTVF .ZKTX NKDP FH NDZF \GRYFN P"T FZKES \KRVGD \GNKTV B[GRC WTKKN [K
12{9 NKD .\KCKJKRDGYG \K\ZCI ,(KPXT QGIJKCG KGPKE) \K[KB \GI\V\FN OD FCG[I \GENKF
EEGTN [KG ('EMG NSZGEM ,NDZGEM) \RDZGBP \K\XGCY \KCKJZGVS \ZDSPN \GVZJXFN OKB\P
\GK\GZI\ GB/G \GRDZGBPF \GK\XGCYF \GKCKJZGVSF \GZDSPC OKCN\[P ORKB[ OKENKN .\BH
,OKKRVGB \CKMZ ,SKRJ) OKK[KB JZGVS KVRT QGDM \KRVGD \GNKTVN \GZIB \GVGNI TKXFN [K
.KBPXT QVGBC GB \GRDZGBP \GZDSPC ('EMG GEG'DG FJBZY ,FKI[
\GNKTVF UYKF \B ZGCXN Q\KR .OGK NMC Z\GKG 'YE 60 L[PC \KRCGP \KRVGD \GNKTV TXCN WNPGP
\B \KIVFN EGBP CG[I .'YE 15=P \GIV BN N[ OKZXY \GNKTV KYZV KEK=NT NNGMF KPGKF
.9 'SP IVSRC JGZKV GBZ { (GBEKG ,C[IP ,FKHKGGNJ) LSP \GT[ ZYKTCG \GNKTV BNN \GT[F
,Y[R KNM QGSMB ,OKKRVGB NT FCKMZ \TC QDP \ESYC [GPK[G \GIKJC \GZGDI B[GRC WTKKN [K
JGZKV FBZ) [B KRVP \GZKFHG FKKI[C \GIKJC B[GRC WTKKN [K .OKNKTZ OKZPGIG \GVGZ\
FZJNGB FRKZY EDRM FRDF KMGSKPC [GPK[G [P[N FVK[IP \GTRPKF B[GRC WTKKN [K .(5 IVSRC
.\KNGDS

OEYGP ZG\KBG FZKYS

WNPGP QMG ,(11 ,7 NKDC OKR[ 4=C OTV \GIVN) NY[PG FCGD YGECN WNPGP 12{7 OKR[F QKC
.GH FVGY\C \IB OTV FTKP[G FKBZ YGECN
\GI\V\F NNGM ,\GI\V\FG FNKED \GKTC ZG\KBN OKR[ 3=N \IB ,BVGZ \YKEC \XNPGP ,QM GPM
QGDZB \XNPF KVN .(\GBKZCF EZ[P \XNPF KVN) \PYT NNGM FCKXK \GTZVF ,QKPF \MZTP
17

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

\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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

18

12{7 NKDP \TRGP FBGVZ

FTKRPN \GVGZ\G OKRGSKI

OEYGP ZG\KBG FZKYS

F\KMC QKNGYZCGJ QKIC\

,QGMKS 'CYC OKENKN 'H
OK[EI OKNGT ZYKTC

FTKP[G FKKBZ \YKEC

'B F\KMC \IB OTV

GKNGVG FKZ\VKE=SGRJJ OTV \GIVN FCGDG NY[P

'C F\KMC (Tdap-IPV)
OKR[ 4=C
EDR QGSKI Q\P \PN[F FNKEDG \GI\V\F \GYKEC
B=G A SKJKJVF
(\G[GGB ,OKM[B NNGM)

\RKKDKFG OKKRK[ \YKEC

FVF
\GNNT\F KCDN \GRZKT
OKENKC
FEKPNG \GDFR\F \GTZVF
QGMKSC OKENK ZG\KB
\GKRECGB \GKJRG QGBMKEN

19

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

WGTK

FCJZF) QGKYKR KNDZF

(Encopresis ,\KNKN
KNDZF ,FNKMB \GTZVF
.FRGMR FRGH\G ,FNKMB
\GNKTV ,FRK[ KNDZF
FT[ \GIVN FZKES \KRVGD
ZCJXPC OGKC
\GRGB\P \GTRPKF
\GZGDI \GCK[I ,\GTKDVG
QDP \GESYG \GIKJC
FZ\K FVK[IP \GTRPKF
[P[F KRZYN
.KGVMF QG[KTF KYHR
NKTVF QG[KTF KYHR
NKDP) NGFGMNB \KK\[G
(10

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

OEYGP ZG\KBG FYKZS ,FMZTF \GYKEC

.\IB OTV \GIVN OE WIN \GEKEPG OKK\R[C OTV NY[PG FCGD YGECN WNPGP GH FVGY\C
NKDC \GRC NXB) \SGG \KRKP \GI\V\F NNGM \GI\V\FG FNKED \MZTF TXCN [K GH FVGY\C
,FKSYZGRB GPM FNKMB \GTZVF YGECN ,OKZDC\PF N[ FRGH\F KNDZF YGECN [K .(16{13
OGYP [K .IGZ KCXPG \KRKP \GDFR\F QMG OKPSC [GPK[ KCDN YGECN [K .Z\K \RP[FG FKPKNGC
.QGMKSC[ FNB \B Z\BNG ZTGR KRC CZYC \GKRECGB \GKJR B[GRN \GTEGP \ZCDFN
[GBK ,QGBMKE \GCGZY OK\KTN QGZIBF [EGIC \[DZF OBF :\GNB[ 2 \GTXPBC QGBMKE ZG\KB
FBRF ZSGI ,QKKRT ZSGI \GCGZY OK\KTN \[DZF QGZIBF [EGIF LNFPC OBF .FGGY\ ZSGI GB
ZGZKC TXCN WNPGP ,\KCGKI BKF \GIVN \IB FCG[\ OB .OKZCE \G[TN QGXZ ZSGIG OKKIFP
.\GKRECGB \GC[IPNG QGBMKEN BNP
,OKKRK[F CXP YGECN [K .[P[N OKVG[IFG ZKFC ZGT KNTCC (nevus) OKSGCRN ZGT YGECN [K
.FTKP[G FKBZ

OKRGSKI
.QSGI OZJ[ KPN B=G

DGSP \KVKDR ECM \YNE EDRM QGSKI .1

(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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

19{13 NKDP \TRGP FBGVZ

FTKRPN \GVGZ\G OKRGSKI

\NT[=FKZ\VKE=SGRJJ
NIF 'I F\KMC (Tdap)
.J"S[\ \R[P
.OKZSI OKRGSKI \PN[F

OEYGP ZG\KBG FZKYS

=G FCGDG NY[P
OKK\R[ NM
\GI\V\F \GYKEC
FNKEDG \KRKP

BMI

\GIVN OE=WIN \YKEC

UKDR EDRM QGSKI
(HPV) K[GRBF FPGNKVVF FNBN EIGKPC \IB OTV
NKDP Z[VB) ECNC \GRCN
\GIVN OKZGFF EIB[
.(26=9 ZKTX NKDP E"NKC FYGN
OKZDC\P ZG\KB
N[ \KNGV FXPGI ZGEM
QGBMKEN QGMKSC
KRVN OGKN D"P 0.4 \GIVN
\GKRECGB \GKJRG
LNFPCG QGKZFN FSKRM
OKRG[BZ QGKZF K[EGI 3 FIV[PC \GPKNBN \GRZT
\GNNT\FG

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

OEYGP ZG\KBG FYKZS

2

.(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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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)

(HPV) K[GRBF FPGNKVVF UKDR EDRM QGSKI

(95%) NKTK QGSKI FRYPF NBZ[KC [EI QGSKI { (HPV) K[GRBF FPGNKVVF UKDR EDRM QGSKI
Z\GKC WGVRF OGFKHF BGF HPV=F UKDR .(KRDGRKXZY OYNI { 18 ,16 ,11 ,6) UKDRF N[ OKRH 4 EDRM
\B \KIVP QGSKIF .OIZF ZBGGX QJZSNG OKRJZS OGZJ OKTDRN OZGDFG KRKP TDPC ZCTGPF
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

39{20 NKDP \TRGP FBGVZ

FTKRPN \GVGZ\G OKRGSKI OEYGP ZG\KBG FZKYS
SGRJJ=FKZ\VKE KPTV EI { FCGDG NY[P
OE WIN \YKEC
OKR[ 10 NM
FKKSGNMGBF NNMN .B
OKNGIC FR[N \IB \TV[
\GBKZC KECGTG OKRGZM
QKRGTP[ KP NMNG

\PEB EDR QGSKI \PN[F

45{18 NKDC OK[RN
3
\GRSGIP QRKB[

FTKRPG WGTK

FRGH\G FNKMB KNDZF

,K\EKN CYTP ,FRGMR
FTKRP KTXPB
FIV[PF QGRM\G
QG[KT \YSVFG QG[KT KYHR
OKPSG NGFGMNB KYHR
\GYE 30 \KRVGD \GNKTV
.C TGC[C OKPK 5{3 OGKN

OTV 29{20 NKDP

OKR[ 5=C
OTV 39{30 NKDP
OKR[ 3=C
QGMS KPZGD OT FNB
OTV { CN \GNIPN
FR[C
HDL ,LDL ,NGZJSNGM LS
5=C OTV OKEKZXKNDKZJG
35 NKDP OKZCDN OKR[
NKVGZV { QGMKS 'CYN
1
FR[C OTV OKRPG[
QGMKSC OK[RN Pap Smear
2
20 NKDP OKR[ 3=N \IB

EDRM KEKZMSKNGV QGSKI

\GXGCYN OKYGYPKGRV
KRGRKCFG FGCDF QGMKSF
\GXGCYN Hepatitis B
OKTSGRN Hepatitis A ,QGMKS
OKZGHBC OKNKKJPG
,A SKJKJVFN OKKPERB
OKZCDNG OKPS KYKZHPN
OT QKP KSIK OKPKKYPF
QKKRGTP[ KP NMNG OKZCD
UKDR EDRM QGSKI
QGBMKE ZG\KB
NKD ET (HPV) FPGNKVVF FIV[PC \GPKNB ZG\KB
.26
400) \KNGV FXPGI Q\P
FSKRM KRVN (OZDGZYKP
OK[EGI 3 L[PCG QGKZFN
QGKZFF N[ OKRG[BZ

OKRGMR FRK[ KNDZF

\GT[ 8{6 \GIVN)
(FPPKC
\TKRP ,FZKFH FDKFR
\ZKDIG OKMZE \GRGB\
\GIKJC \GZGDI

:FKPNGZJSNGMZVKFN QGMKSC \GXGCY

.CN \GNIPN OKVSGR QGMKS KPZGD ,FKPNGZJSNGMZVKFG FKPEKVKNZVKF N[ K\IV[P ZGVKS
DGH KRC OT QKP KSIK OGKY ,OEYGP QKP KSIK \NI\F :OIZF ZBGGX QJZSN QGMKSC OK[R
.FVGZKB IZHPP \GNGTG \GCZ \GV\G[ GN GKF[ DGH QC OT QKP KSIK OGKY GB ,(3 \GIVN) OKCZ
.27 'PTC \RSGIP F[KB \ZEDF FBZ

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

OEYGP ZG\KBG FZKYS ,FMZTF

.OKR[ 5 NM

BMI

=F CG[KIG FCGD ,NY[P N[ \K\VGY\ FYKEC .1

.GH FVGY\C \IB OTV \GIVN FKBZ \YKEC .2

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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

DGSP \KVKDR ECM \YNE \YNE EDRM QGSKI .4

FSKJC FBGNI\ \TKRPG OKNKKJPN OKRGSKI KCDN { 65{40 OKNKDC OF OKCZ OKNKKJP .5
.15 'SP IVSR FBZ

33

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

64{40 NKDP \TRGP FBGVZ

FTKRPN \GVGZ\G OKRGSKI

NM SGRJJ=FKZ\VKE QGSKI
OKR[ 10

:FR[C OTV \TV[ QGSKI

OKNGING \GBKZC KECGTN
CNG FBKZ \GNIPC
NNMN .\GKRGZM
50 NKDP FKKSGNMGBF
.FNTPG
EDRM KEKZMSKNGV QGSKI
\GXGCYN SGYGYGPKGRV
QGMKS
ECM \YNE EDRM QGSKI
OKNKKJPN B=G A \KVKDR
OKIVSR) QGMKS \GXGCYNG
(16 ,15
D"P 75 QKZKVSB Q\P
OK[RNG 50 NKDP OZCDN
OTG \SGGF \YSVF ZIBN
CN \NIPN QGMKS KPZGD
\NTG\F NT ZCSF ZIBN
4
OKRGMKSFG

OEYGP ZG\KBG FZKYS

=G FCGD ,NY[P
OKR[ 5 NM \GIVN

BMI

OKK\R[N \IB OE WIN

,120/80 ET OEF WIN OB
OEF WIN OB FR[N \IB
.120/80 NTP

OXT \GVKVX \YKEC

OK[RN 60 NKDP (DEXA)
SKHGZGVGBKJSGBN QGMKSC

\KRG[BZ FTKRPG WGTK

FRGH\G FNKMB KNDZF

,FRGMR
8{6) OKRGMR FRK[ KNDZF
(FPPKC \GT[
QG[KT \YSVFG QG[KT KYHR
NGFGMNB \KK\[ KYHR
\KRVGD \GNKTV \GCK[I
\KRGRKC FPZC \KCGZKB
KPK 5 OGKN \GYE 30=M
20 \XZPR \GNKTV .TGC[F
GB TGC[C OKPK 3 ,\GYE
.OFKRKC CGNK[
FZ\K FVK[IP \GTRPKF
[P[N

5=C OTV OEC NGZJSNGM QGKEG ,ZCTPF NKD \GKTC

NNGM KRPG[ NKVGZV) OKR[
KNRGPZGF NGVKJ NT
(\GRGZSIG \GRGZ\K)
(OK[RNG OKZCDN LDL
\IB OTV D"YB SKHGZGVGBKJSGB \TKRPG
OKZC[G
SKSCM ,F[TR OZJ OB)
(FBGG[FN
OKK\R[N \IB FKVZDGPP
\ZKDI ,FZKFH FDKFR
OK[RN 40 NKDP) 50 NKDP \TKRPG \GIKJC \GZGDI
1
(FGCD QGMKSC
\GRGB\
FR[N \IB FBGXC KGPS OE
2
OK[RNG OKZCDN 50 NKDP
5=N \IB FKVGYSGRGNGY
3
QGMKS \XGCYC OKR[
OK[R OT QGEN Z[VB
FNKFYC QGBMKE ZG\KB
QJZSN FGCD QGMKSC FIV[PC \GPKNB ZG\KB
QVKSYGPJ Q\P NT E[F
DGH KRC QKCG
\TKRPN QVKSYGNZ GB
4
E[F QJZS
1

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

15 NKDPG ,25 NKDP FKVGYSGRGNGY TXCN [K \GKHGVKNGV BN \G[ZGP \GRGPSK\ N[ FZYPC

.(ZYGCP KRKNY ZYIP ZETFC OKIPGP \TE NT SSGCP) \[ZGP SKHGVKNGV N[ FZYPC
.17 IVSR GBZ

35

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

\KRG[BZ FTKRP/\GBKZC OGEKY .1

BKZC OKKI IZGBN WGTKK .B
GNBN OKYFCGP OKK\GBKZC \GRGZ\K \GPKKY ZDGCP NKDC OD .QG[KTP FNKPD B[GRC WGTK
.Q[TN OKYKSVPF

.\KRVGD \GNKTV TGXKCG FBKZC FRGH\ EGEKTN WGTKK

:OKVSGR OKXGTKK
.OKTGRVGBG OKKRVGB NT FCKMZC \GESYC [GPK[G \GIKJC \GZGDI \ZKDI ,FZKFH FDKFR

.[P[N FZ\K FVK[IP \GTRPKF

.OKKVGNI OKYGSKT \BKXPG FEGCTP F[KZVN FRMFF \GCK[I

.OKNGFGMNB \GBY[P \KK\[P \GTRPKF B[GRC WGTK

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

36

BKZC OKKI IZGB TGXKC .C

\GZVSC FR\KB FMKP\ \PKKY ,\KRVGD \GNKTV TGXKCG FRGH\ ,\GBCF \GNGTVF ZGCT :FZTF
\ZDSPC WGTKK N[ G\TV[F FIMGF OZJ ,LB .BKZC OKKI IZGBN Q\PGZ\N Z[BC \KTEPF
OZJ OB OD) "\GIKJCP" \G[KD \GPKKY ,\BH OT .KGXZF K\GDFR\FF KGRK[F \D[FN FBVZPF
KBYKZPBF FPK[PF IGM KEK=NT \GXNPGP Z[B ,("FZG[F QP NVJP"F ZGCT \GNKTKM GIMGF
.NVGJPF N[ L[GPP KGGKN LG\ \ZG[Y\ KXGZT ZVSP LZE WZPR WGTKK Q\PC ZCGEP .(USPSTF)
FBGVZG \GBKZC OGEKYN \GKIRF OG[KKN \GXNPF" IVSRF \B FBZ ,WGTKK B[GRC FCIZFN
.GH \ZCGIC "\KRG[BZF FBVZPC \TRGP
:OKBCF OKCKMZPF \B NKNMFN KGXZ \KPGKF FRGH\C .1
;\GYZK \GSGM 3=G \GZKV \GSGM 2 \GIVN

;OKMZXR[ \GKZGNY 1000 NMN QKCGS OZD 14

;(INP \KVMM) QZ\R D"P 2300=P Z\GK BN

;QPG[=KNE CNI KZXGP \GSGM 3

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

:(\KRVGD \GNKTV { 9 'SP IVSR FBZ) :\KRVGD \GNKTV TGXKC .2

FVXR[ KVM ,NKCYPC \GNIP N[ CZ ZVSP \TRGP ,ZDGCPF NKDC OD ,\KRVGD \GNKTV KM ZGMHN CG[I
OKZC[G \GNKVR M"M .NKDF OT OKZCGD QJZSG \KCCN FBGNI\ KZGTK[ .Z\GK OKZKTXF OKBNKDC
QGMKSF \\IVFC FNKTK FBXPR FZKES \KRVGD \GNKTV .[K[YF NKDF \B OKRKKVBP QDBC
\KRM\ \NI\F OZJ .OKZC[G \GNKVR \TRGPG \GKRGZM \GNIPP \PEYGP F\GP\G \GTZBKFN
\GKIRFF \GJZGVP GC[ 2005 \R[P KDGNGKEZYF EGDKBF N[ LPSPC TKK\SFN [K ,\GNKTV
.NBZ[KC \ZDGCF FKKSGNMGBN KCCNF JCKFC \GKBGVZF

:OK[G[\ BN OK[K[YN \GNKTV .B

ET FDZEFC \GNTFNG TGC[C OKKPTV \GIVN \G[KPD KNKDZ\ OT NKI\FN WNPGP
OKZKZ[F \GXGCY N[ \GIK\P TXCN [K .TGC[F \GPK CGZC \GNKTV OKTXCP[
.FIK\P NMN \GKR[ 30{10 ,\GNGEDF

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

,(TGC[/N"YY 1000=M) OGKN \GYE 60{30 ,\KRGRKC FPXGTC \KCGZKB \GNKTV

L[P \B OXPXNG \GVSGR \GNKTV KRKP CN[N Q\KR .TGC[C OKPK 6 ET 5 L[PC
.FMKNFF

37

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

\GNKTVF QHBPC \GC[IR \GK\ZD[ \GK\KC \GNGTV OD[ OKNVGJPN ZKCSFN [K

105) \KCF KGYKR ,(\GYE 30/N"YY 80) OKNM \VKJ[ ,N[PN ,OKNNGM GNB :KTGC[F
.(\GYE 30/N"YY 53) FRKDF \KKY[FG ,(\GYE 30/N"YY

:OKNKTV BN GB OK[G[\ OK[K[YN \GNKTV .C

.N"RM IGM KRGCG \G[KPD KNKDZ\

\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
.QGMKS \GXGCYN

ECM \YNE EDRM QGSKI (4

\TKRPG OKNKKJPN OKRGSKI KCDN QMNG K[KN[F NKDF KRC OF OKCZ OKNKKJP OGKM (5
.15 IVSR FBZ FSKJC FBGNI\

:TRGP K\VGZ\ NGVKJ .E

\ISGR KV NT NVGJPF N[ KCCNF QGMKSF \B C[IN [K .(OGK/D"P 75) QKZKVSB Q\P (1
E"N ,OEC HDL=FG NGZJSNGM LS KMZT ,NKDC C[I\PF OFDRKPZV N[ QGMKSF
.E"N Z\K \EZGFN \GVGZ\C NVGJP OEBF OB QMG ,QG[KTF SGJJS ,KNGJSKSF
http://hp2010.nhlbihin.net/atpiii/ :BCF Z\BC FKGXP QGMKSF CG[KIN FRMG\
calculator.asp?usertype=prof

GB OJGB) F[Y \KNKNM FNIPC CGZYF ZG[TC \GNIN 6% \GIVN BGF QGMKSF OB
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

(OGK/D"P 1200) QEKS Q\P (2

OKTRGP D QKPJKGG QEKS CGNK[[ LMN K\KKBZ SGSKC [K[ FECGTF UB NT :QEKS
KCDN \GTE KYGNKI \GPKKY ,\GESGPC OK[K[YC \GZIB \GPXTCG LZKC OKZC[
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

38

\GRGZ\K OKPKKY ,\BH OT .FNKFYC OK[K[YC OKZC[ \TKRPC QEKSF \GNKTGP

KTP QJZS \TRGP QEKS \MKZX[ \GBZP \GK\JK[ \GZKYS .QEKS \MKZXN OKVSGR
\SGGN [K .OGK/D"P 1200 N[ \GPMC QEKS Q\P BKF FXNPFF .OE WIN Z\KG SDF
.FRGH\C \MZXRF QEKSF \GPMN OB\FC USG\M \R\KRF QEKSF \GPM \B

:(OGK/'NRKC 'IK 1000)

D QKPJKGG

\TKRPC NKTK BXPR D QKPJKGG[ GBXP OKKRMET OKZYIPG \GZKYS :\NTG\ .B

OKKRK[F \NKVR ZGTK[ \B KXIC QKJYF ,\GESGPCG FNKFYC OK[K[YC OKZC[
KTPF QJZSN QGMKSF \B QKJYPG ,OK[K[YC KZKZ[ EGYV\ ZV[P ,OK[K[YC
.\KRGPZTF QJZSNG SDF
(25(OH) Vitamin D) OEC D3 QKPJKGG \GPZ KM \GKGET [K :OKKYF ZGSIPF .C
BN FMKZX N[ CGNK[ FBZRM QF LMN \GCKSF .NBZ[KC UB \GMGPR QRKF OK[K[YC
EIGKPC=\GKZJV ,OKRP[ OKDE) D QKPJKGGC OKZK[TF QGHP KZXGP N[ FYKVSP
FZJNGB KRZYN \KSIK FJTGP FVK[I ,(OKZ[TGP CNI KZXGPG ,[P[C G[CGK OB
\B ZGXKN U[IRF [K[YF ZGT N[ \\IVGP \NGMK OT EIK ,[P[FP NGDS
.OKRP[ GB ZGT=KFM OK[RBC Z\GK EGT FZGPI FKTCF .QKPJKGGF
,N"RKC/\GEKIK 600 LGZXN WNPGF \GRGZIBF OKR[C :WNPGPF D QKPJKG QGRKP
\TRGPF FPZ ,(N"P/'DGRBR)ng/mL30 N[ OEC D QKPJKGG \PZ FRYPF QGRKP
GBXPR QKKET OK[K[Y CZYC OKZYSC LB ,OXT \DKVSG PTH=F QGPZGF \KKNT
LB ,ZC[ GTRP BN OGK/N"RKC 'IK 400 N[ \GPZ .OEC D QKPJKG N[ \GMGPR \GPZ
N[ F\IVF FD[GF OGK KEP D QKPJKG N[ (IU) N"RKC \GEKIK 800 N[ QGRKPC
\NKJR KM QKKXN CG[I .FZE[F EGPTN WGIP OKZC[G LZKF KZC[ ZGTK[C 25%=M
BN OK[EGI ZVSP L[PC OGKN N"RKC 'IK 10,000 N[ OKRGRKPN ET D QKPJKG
\VSG\ B[GRC OKZYIP N[ FHKNRB=FJP OD FPSZGV FRGZIBN .OKYKHP GBXPR
800{400 QKC N[ KPGK QGRKPC (3=G ,2 D) QKPJKG \VSG\ KM F\BZF[ D QKPJKG
.QKPJKGGF CYT KBGGN \GTVG\ BNN \GCKSF NMP F\GP\ F\KIVP N"RKC 'IK

.D

D QKPJKG \GPM \B \GNTFN GBZY OGI\C OKIPGP ,N"RF \GKBZF ZGBN

KEM .OGK/N"RKC \GEKIK 2000=N ETG 800 QKC OKTRF OKRGRKPN \NJKRF \KPGKF
50,000 N[ QGRKP \\N K\TKRP NGVKJ \JK[ \PKKY ,TRGPF NGVKJF \B NTKKN
BKF GR\XNPF ,LMN=KB .OKK[EGIC OTV 100,000 GB [EGIC OTV N"RKC 'IK
[K[YF N[ FRGH\F KCKMZPN OB\FC ,OGKN/N"RKC \GEKIK 1000 Q\P NGY[N
.[P[N G\GV[IKF \EKPG

\KRGKR[ FTKRP .2
:(LZGXF KVN WGTKKG FYKEC CGNK[C) NGB[\ .B
.HGV[BP ZHGI NVGJPF[MG OK[EGI 6 KEP FZKYS :K\VGZ\ NGVKJ
39

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

:FYKECF KRVN [EGIF N[ FVGY\N \GSIKK\PF \GNB[ 2 \ZHTC FZKYS :QGBMKE

?FGGY\ ZSGI GB QGBMKE \GCGZY OK\TN \[DZF OBF .B
?OKZCE \G[TN QGXZ ZSGI GB QKKRT ZSGI \GCGZY OK\TN \[DZF OBF .C

.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

.FR[ KEP FTKP[C FEKZK GB FTKP[F CXP KCDN NGB[\ :FTKP[

: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
:[K[YF \MZTFC ZHTM [P[N \GNGMK QFG KRKNY \TE NGYK[G \GRZKT \[ZER LB FNTPG
NNM CZYC FRK[ KNDZF LKZTFNG ZZCN OGYP [K { FRK[ \GTZVFG FRK[ KNDZF \MZTF .1
\EKP \TKCYN OKRGNB[ .FPPKC FRK[ \GT[ 8{6=N BKF FXNPFF .OK[K[YF
.19 'SP IVSRC OKJZGVP FRK[F \GMKBG \GKRGR[KF
.20 'SP IVSR {
.21 'SP IVSR {

ADL

QGNB[ \GTXPBC KPGKF EGYVK\F \MZTF .2

Mini Mental Test

QICP \GTXPBC QGZMKHF CXP \MZTF .3

:\KRVGD FYKEC .C
.FR[ KEP OKKR\GP UYKF GB/G

BMI

\EKEP :NY[P=\\/FRP[F/Z\K=NY[P ZG\KB

(Z\K \RP[F \PGTN) Z\KF NY[P GRKKFE ,29.9{25 QKC BMI B[GR OK[K[YC[ ZGMHN CG[I
\ZMGSG OE WIN Z\K GPM FBGNI\N QGMKS OZGD FGGFP QM LB ,OKKIF \NIG\ ZXYP GRKB
BNB FRP[FG Z\K=NY[P YZ BN \GNDN FETGR FYKECF .EGYV\CG \GEKKR\FC FTKDVN OZGDG
.NY[PC FEKZK OD
QKC BGF OB { FR[ KEPG ,120/80> OEF WIN OB OKK\R[ KEP \GIVN OE WIN \EKEP
.(ICSI) 139{120/89{80

.QNRS IGN KV NT { FKKBZF \GEI \YKEC

YECRF KZGIBP P"S 60 OKEPGT FKVN F[KIN \YKEC \GTXPBC { FTKP[ \GEI \YKEC
,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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

40

KEK=NT BKF OKKRK[ \YKECN FXNPFF :[K[ FEKPC \GC\G\FG OKKRK[F ,FVF NNI \YKEC
.HBP FRMEGT BNG 1996 \R[P FTKRPN KBYKZPBF FPK[PF IGM

:QJZS KGNKDN \GYKEC .D

FKVGYSGRGNGY GB FR[C OTV { KGPS OEN FBGX \YKEC SDF KTP QJZSN FYKZS \GYKEC
.(13 IVSRCG 64{40 NKD 'CYC \GXNPF GBZ) OKR[ 10=C OTV {

FPK[PF IGM KVN ,\BH \PGTN .74 NKD ET \GBKZCF NSC FSGMP KGPS OE :FYKECN QGKNTF NKDF
.OKR[ 8 \GIVN BKF OKKIF \NIG\ OB ,80 NKD ET FTXCN WNPGP ICSI=FG KBYKZPBF
:(OKK\R[C OTV) FKVZDGPP

ET FTXCN [K ICSI=F KVN .74 NKD ET FTXCN WNPGP \GBKZCF NS KVN :FYKECN QGKNTF NKDF
.(NNGM) 75 NKD
\GBXPRF FNBG 65 NKD ET CYTPC GKF BN[ OK[RC :OIZF ZBGGX QJZSN FYKZS \YKEC
/G EGBP ZKTX NKDP QKP KSIK OGKY ,3 \GIVNG OKRDGP BN OKV\G[ OT QKP KSIK OGKY) QGMKSC
Pap) OIZF ZBGGX IJ[P \GYKEC 3 NGJKN [K { (\GCZ \GV\G[ GN GKF[ DGH QC OT GB
.NGEIN { OKKCGKI OKBXPP ZETKFCG OK[EGI 12{6=N (smear

.64{40 NKDF \GXGCYN \GXNPF FBZ :\GNI[F QJZS N[ OEYGP ZG\KB

ZHT \GYKEC .E
OK[RC ICSI=G KBYKZPBF FPK[PF IGM KEK=NT WNPGF .(DEXA) \GPXTF \GVKVX \ZKYS
.(17 'SP IVSRC SKHGZGVGBKJSGB JGZKV FBZ) .60 NKDP \GBKZCF NSC NGNM .65 NKDP

OKR[TP 74{65 KRC ECNC OKZCDC \KRJCF QK\GGF \XZVP N[ \KPTV EI \KNGY=NT FZKYS
NSC FNGNM FRRKB FYKECF .(OFKKIC \GKZDKS 100 \GIVN GR[KT) ZCTC GR[KT[ GB FGGFC
.\TRGP FBGVZN KBYKZPBF FPK[PF IGM K"T \XNPGP LB ,FZKYS \YKECM \GBKZCF

FECTP \GYKEC .F
NKD ET YECR OZJ[ KPN KPTV EI .(KRPG[ NKVGZV) LDL=G HDL ,NGZJSNGM LSN OE \YKEC
.CN \GNIPN QGMKS KPZGD { 10 IVSKRCG 64{40 NKDF 'CYC B[GRF JGZKV GBZ { .FH

\EIGKP CN \PG[\
FNB ,ECN OKZDF OKEEGC OK[K[Y QGDM ,FGCD QGMKSC \GXGCYN \EIGKP CN \PG[\ \\N [K
,\KNJRP FTKDV ,\GEKKRC \GNCDF OT OK[K[Y ,CGZY FIV[P QC GECKB[ GB FRGZIBN GRPNB\F[
.HGV[KBP ZCMP BN GZZIG[[ FNBG KRGTF GYN \I\P OKKIF ,FJKPN GB \KCN OKY\GZP
FIV[P KRC EXP OK[K[Y EDRM QMG DGH KRC QKC \GNNT\FG \GPKNB KCDN \GRZKTG CN \PG[\
.\G/OKNVJPG
Z\K CYT \GVGZ\ KNJGR ,FKBZ \GKTC ,FCKXK BN FMKNF ,\GPEGY \GNKVR :\GNKVRN QGMKS \GXGCY
.FJKPN OKY\GZPG \GEKKRC \GNCDF ,ECN OKZDF OKEEGC OKZDGCP ,OE WIN
41

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

+65 NKDN \TRGP FBGVZ

TRGP K\VGZ\ NGVKJ
ZHT \GYKEC
IZGBN WGTKK
OKRGSKIG
OEYGP ZG\KBG
BKZC OKKI
QKZKVSB N[ \KPTV=EI FYKEC
QG[KT \TKRPN WGTKK
LG\ (OGK/D"P 75 Q\P) OZJ[ KPN KRPG[ NKVGZV
\GNKTV \GYE 45{30
OKRGMKSG \GNTG\ \NKY[
YECR \GPK CGZC) OGKC \KCGZKB
KEP) OEF WIN \EKEP
OKK\R[ ET FR[
(OKMZTN OB\FC

KEP

=G FCGD ,NY[P
FR[

BMI

FBGXC KGPS OE
(FR[ KEP)
(OKK\R[ KEP) FKVZDGPP

QEKS Q\P
(OGK/D"P 1,200)
OB\FC

QKPJKG Q\P
\EKPNG FRGH\N
1,000) [P[N \GV[IKFF
(OGK/N"RKC \GEKIK
D3

K[EGIC \TV[ EDR QGSKI

(K\R[) GK\SF
EDR KPTV=EI QGSKI
SGYGYGPKGRV

(TGC[F
KZXGPC FZK[T FRGH\
KGGZ QPG[C FNEG ,CNI
INPCG SRBZJG
,\GZKV FNKMPF FRGH\
QKCGSG \GYZK

OIZF ZBGGX \YKEC

GB GYECR OZJ[ OK[RN
[EI DGH QC OFN [K[
\GPXT \GVKVX \YKEC [P[N FEGEP \GV[IKF
(DEXA) ,OGKF TXPBC \GYE 15)
FR[C \GNKVR KCDN NGB[\
(TGC[C OKPTV 4{3
\GP[Z\F ,FRGZIBF
FZKES \KRVGD \GNKTV
CKJG NY[PF KGG[P \G[KPD KNKDZ\ \GTXPBC
(FR[ KEP) FMKNFF
(TGC[F \GPK CGZC)
OKR[ 5=C Q\[ \JKYR KB OKPTV 4 ET IGM \KKRCG
\GRGZIB
TGC[C
\GPKNF KCDN NGB[\
KEP FKKBZ \GEI \YKEC
KEP K\VGZ\F NGVKJF
FR[
I"KCP FCK[CG FR[
FTKP[ \GEI \YKEC
KEP) F[KIN QICP KEK=NT KNDZF KCDN WGTKG NGB[\
FRK[
(FR[
\GTRPKF B[GRC WGTK
FVF NNI \YKEC
\GBY[P \KK\[P
(FR[ KEP) OKKRK[FG
OKNGFGMNB
2 \ZHTC QGBMKE ZG\KB
FR[ KEP \GNB[

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

42

13 'SP IVSR

\GZK BPP \G NIP N[ OEY GP ZG \K BG F TK RP

209=212, 224=247, 256=265, 375=394, 448=489,)
(496=500, 638=646

,EFN QGRPB Z"EG QKYRCJ FGI 'VGZV KEK=NT QMEGT

FKDGNGYRGBN \KPGBNF FXTGPF \GXNPFG JZRZ ED 'VGZV WGTKKC \GXNPFFP YNI

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
,OIZFG \GNI[F QJZS ,ZGTF N[ FPGRNP ,Q\[F \KIGVN[ QJZS ,\KRGPZTF QJZS ,FRYFG
.FKPYKGNG FZKBPP FPGVPKN
:\GKR\B 'CYG QKP KVN Z\GKC OKIKM[F OKNGEKDF N[ \GTZBKF KZGTK[ \NCJ QNFN

(2006 \R[N QJZS OG[KZN HMZPF KRG\R) 100,000=N QRYG\P \GTZBKF ZGTK[
\GZTF
\GKEGFKC 2 KV
OKEGFKC 1.5 KV
.OKCZT OKZCDC Z\GKC IKM[
\GKCZT \PGTN \GKEGFKC 2.5 KV
OKEGFKC 2.5 KV
2004 \R[P .\GKEGFKC 2=1.5 KV
OKZHDPF 2=C FEKZK \PDP
OKEGFKC 8 KV
OKEGFK OKZCD CZYC Z\GKC IKM[
\MZTP KNGEKD CZYC IKM[ \GIVF
.\GKEGFK OK[RC QKPF
OKZCD CZYC Z\GK IKM[
OK[R \PGTN

OKZCD OKZCD OK[R OK[R

OKCZT OKEGFK \GKCZT \GKEGFK
26.7

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
E[F QJZS
KVG SDF KTPF QJZS
*\TCJF
FBKZFG FRYF QJZS
\KRGPZTF QJZS
\KIGVN[ QJZS
Q\[F
OIZF QJZS
\GNI[FG
FPGRNP
FCKYF QJZS
OIZF ZBGGX QJZS
FZKBPP FPGVPKN
QKY'DEGF FRKB[
FKPYKGN

CZYC FKKNT \PDPG \KEGFKF FKSGNMGBF CZYC FEKZK \PDP \PKKY 2004 \R[P
.\KCZTF FKSGNMGBF
107

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

\KRG[BZ FTKRP
KV NT TXC\PF OEYGP KGNKD .OEYGP KGNKDN \GNGTV KRV NT \GNKTKG \GVKET QJZS \TKRPN \GNGTV
\GFGCD GK\GKGNTG FNIP TRGP GRRKB LB F\GP\G FBGNI\ \KIVFN ZGPB ORPB OKRGKZJKZYF
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
.FTKRPN OKR\KRF OKK\CKCS OKPZGD KEK
.OKKIF \GIZGB KGRK[ KEK NT FTKRPN OKR\KR QJZSF KZYPP ZMKR YNI LMN KB
Q[TP \GYIZ\F ,QG[KTP \GTRPKFN FRGKNT \GCK[I [K QMNG OKR[TP QGKNKPM [K NBZ[KC .1
\YSVF N[ Z\GKC CGJF JYVBF .GRPP FNKPDG QG[KT \YSVFG KCKSV QG[KTPG \GKZDKSF
\KIV\ 50 NKD ZIBN QG[KT \YSVF OD NCB OK[GN[F \GR[ LNFPC F[TR OB D[GP QG[KT
FRYF QJZS QF QG[KTC \GZG[YF \GKZYKTF \GZKBPPF \GNIPF .QJZSN QGMKSF \B
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
QJZS ZYKTCG QG[KTC \GZG[YF \GNIPF \GIKM[ FNTPM IMGF KGVMF QG[KTF .QG[KT BNN
GBZ) OKKZGCKX \GPGYPC QG[KT ZGSKB NT EKVYFN [K LMKVN .GN OKVG[IF NXB ,FBKZF
.(12 'SP IVSRC QG[KTF B[GR JGZKV
KIF QP QPG[F \MKZX \RJYF LG\ ,\KZGNY FRKICP \RHGBPG FBKZC FRGH\ NT FZKP[ .2
JGZKV GBZ) FRP[FP \GTRPKFG OKKZJF \GYZKFG \GZKVF \GPM \NEDF ,NGFGMNB \MKZXG
.(FRGCR FRGH\ { 8 IVSRC
FKI[ GB OKRVGB NT FCKMZ GB FXKZ GB ,FMKNF \NNGMF NKD NMC FZKES \KRVGD \GNKTV .3
OGKN \GYE 60{45 N[ \KRVGD \GNKTV .TGC[F KPK \KCZPC ,\GIVN OGKN \GYE 30=M L[PC
.(\KRVGD \GNKTV { 9 IVSR FBZ) QJZS KRVP \VSGR FRDF CKR\ TGC[F KPK \KCZPC
OKZCD CZYC FPGRNPP F\GP\C 1.4% N[ \K\R[ FKNT \PKKY NBZ[KC :FPGRNP \TKRP .4
\GPMP 80% KM OKMKZTP .\GRGZIBF FR[F 30 L[PC \GKEGFK OK[R CZYC 1.8%=G OKEGFK
NNGM ZGTF N[ OKZKBPP OKNGEKD \TKRP .18 NKD KRVN \[IZ\P OKKIC [P[N FVK[IF
10.00 QKC \GPIF \GT[C [P[N FZ\K FVK[IP \GTRPKF KEK=NT \G[TKFN FNGMK FPGRNP
OKB\P EGDKC ,[P[ KVY[P BNN [P[C \GF[P TRPKFN ZGT KZKFC NT .X"FIB 16.00=N
\TKRPN [P[ KRRSPC [P\[FN OKJGTVG \GYGRK\P NIF ,OKNKDF NMN WNPGP QM GPM .TCGMG
WTKKN [K .OKPC OKEZGK ORKB[ OKRRSP NT EKVYFNG B=G A DGSP \KNGDS FZJNGB FRKZYF
[GPK[ NT EKVYFNG ZKTXF NKDC [P[N \GV[IKFC[ FRMSN O\GTEGP ZKCDFN OKZGFN
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

:E[F QJZS N[ FTKRP .5

IKM[F QJZSF GFHG OK[EI OKZYP 4000=M E[F QJZS \GTZBKF F\KKF 2006 \R[C NBZ[KC
GRF E[F QJZS KM LM NT TKCXP \GCZ ZYIP \GR[ LZGBN ZCJXF[ KDGNGKPEKVBF TEKPF .Z\GKC
N[C \PZDRF FNIP QJYF GYNICG OKK[KB \GDFR\F KSGVE KEK=NT \PZDRF FNIP GZYKTC
KZYP NNMP 10%=MC FZK[KF \KJRDF FTV[FF \B EGPBN NCGYP .\GKVKXVS \GKJRD \GNY\
\GDZEC E[F QJZS N[ K\IV[P ZGVS NT ZVSN \GNGMK \GNGIF NNMP USGR [KN[MG E[F QJZS
OKR[F LZGBN \ZMKR FKKNT F\VXR I\GVPF ONGTF \GRKEP \KCZPC[ FECGTF .\GRG[ FCZY
N[ FKDGNGKJBC \GDFR\F KPZGD N[ KHMZPF OGYPF NT FTKCXP E[F QJZSC \GNGIF ZGTK[C
:OF E[F QJZS NT OKTKV[PM GBXPR[ OKPZGDF .FNIPF
:QGMKS OKZKCDPF OKPZGD
.\SGGF \NKI\ N[ OEYGP NKD

.\SGGF OGKS N[ ZIGBP NKD

.QG[BZ ENK \EKN N[ ZIGBP NKD

\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

.NGFGMNB N[ Z\K \KK\[

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

.\GEKN ZETF GB \GEKN JGTKP

.QPG[ \ZK\T FRGH\

.(DN J'D) \VTKN FVK[ICG \GZP[PC FEGCT CYT QKRGJNPF OHKNGCJPC [GCK[

OKRDC ODVG E[F QJZS N[ K\IV[P ZGVKS { FYKJRD

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

:E[F QJZSC \GNIN QGMKS OKRKJYPF OKPZGD

!(BNP QGKZF ZGCTN CG[I) .OKCZ OKENK \EKNG 20 NKDC QG[BZ ENK \EKN
109

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

.FYRF

.FZKES \KRVGD \GNKTV

.\GYZK \ZK\T FRGH\

:E[F QJZS N[ \KRG[BZ FTKRPN \GXNPF

:\GBCF \GNGTVF KEK=NT E[F QJZSC \GNIN QGMKSF NT TKV[FN Q\KR K[TP QVGBC
QG[KT \YSVFG \GTRPKF

.TGC[F KPK \KCZP OGKN \GYE 60{30 FZKES \KRVGD \GNKTV TGXKC

.FRP[FP \GTRPKFG OKRPG[ \NE FPKB\P FRGH\ ,QKY\ UGD NY[P

.OKNGERKB OKNKMPFG OKCKNXPF \IV[PP \GYZK N[ \ZCDGP FMKZX

.NGFGMNB \KK\[P \KSIK \GTRPKF

.FEKN NM ZIBN FYRF

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

SDF KTPF QJZS \TKRP .6

FTKDF 2006 \R[C FNIPF \GTZBKFG NBZ[K \RKEPC G\GIKM[C KR[F BGF SDF KTPF QJZS
.OKNGI 3500=N
OKR[ 5=N \GEZ[KF) Z\GKC K\GTP[P \KPP NBKXRJGV \GNTC OGJYZFG SDF KTPF \GKGZKBPP
KCKJYVB OEYGP KGNKDNG \KRG[BZ FTKRPN NBKXRJGVF \BH OT .(50% { NKDZ KGNKDC
:OF KTPF QJZSN OKKZYKTF QGMKSF KPZGD .NGED GRF FNB \GKGZKBPPC
K\NC CZ OKRPG[ ZYKTCG OKRPG[ ZK\T ,\GKZGNY ZK\T QGHP \MKZX \NNGMF FKGYN FRGH\
.ECGTP OGEB Z[CG OKKGGZ
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

110

.\KRVGD \GNKTV ZSGI

.([NI Z[Y) NGFGMNB \MKZX

.SDF KTPF QJZSN KBPXT OZGDM FBXPR { Z\K \RP[F

:\NGINIFG SDF KTPF QJZS N[ \KRG[BZ FTKRPN \GXNPF

.OKDGSF NMP \GYZK EIGKPCG \GZKV N[ FFGCD FMKZX

.(KTPF QJZS KRVP FRKDP FTV[F QEKSN) .\KNGV FXPGIG QEKS ,OKCKS \MKZX

.FRP[F \TKRPG \GKZGNY \NE FRGH\

.TGC[F KPK \KCZP OGKN \GYE 60{30 FZKES \KRVGD \GNKTV

OKZYIP) \GCZT\F KZYIPG OKDGNGKPEKVB OKZYIP N[ CZ ZVSP :OKK\VGZ\ OKNGVKJ

QRKB[ \YNE \GEDGR \GVGZ\ GB/G QKZKVSB QKC Z[YF YECR (OKZYGCP OKKBZYB
QGMKS OK\KIVP COX2 OKHRBF N[ OKKCKJYNS OKPSGI NNGM (NSAID) \GKNEKBGZJS
KCDN QM GPM .KTPC OKVKNGV \GR[KF KRVP FRKDP FTV[F QKZKVSBN KM BXPR .KTPF QJZSN
\GZPN ,QJZS \TKRPN NKTK BGF LGPR QGRKPC[ LMN FIMGF QKKET QKB QKZKVSBC NGVKJF
GCGIC B[GR FGCD QGRKPC NGVKJ .NBZ[KP OKZYIP \GBXG\C NNGM \GZVSC \GCZ \GPDEF
KNGICG QGMKS \GKSGNMGBC KTP QJZS GTRP KM BXPR COX2 KPNGC KCDN .OKPGPKEN OKRGMKS
QKB QMNG \KCCN FBGNI\N OKRGMKS O\KB OKB[GR LB (FAP) \K\IV[P SKHGVKNGV \NIP
KCDN \NTG\=\GNT KCK[I\C .KTPF QJZSC TRGP NGVKJM OFC [P\[FN OGKM FXNPF
TGRPN P"T OKR[ 5 L[PN OK[RB 962{471=C NVJN LZGX FKFK KM BXPR QKZKVSBC [GPK[F
KIGP OGPKE N[ EIB TGZKB FKFK GH FVGY\C OKNVGJP 800 NM NT Z[BM EIB QJZS FZYP
.(NGMKTF \MZTPP KCKSP OGPKE N[ OKTGZKB 2{1=G

\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

\GZKBPP \GNIP N[ OEYGP ZG\KB

\NGMK \B ZV[NG OKNGEKD O\GBP F\GP\G FBGNI\ \KIVFN BGF OEYGPF ZG\KBF \ZJP
OKNGEKDF NM \B OEYGP Z\BN Q\KR BN .OKKIF \GMKB \B OD GPM \GEZ[KFFG FPNIFF
\GYKEC QKB OKNGEKDFP YNIN .Z\GK FCGJ \GBKZC EKP\ G[GZKV QKB OEYGP ZG\KBG .OKZKBPPF
.\GKRGPF FYKZS \GYKECM \GTXC\P Z[BM Z\K QGMKSC \GMGZM \GYKECF[ GB \GRPKFP YKVSP
OZGD YZG F\GP\G FBGNI\ \KIVP GRKB OEYGPF ZG\KBF YNIC ,\NTG\F NT FNGT \GNTF YNIN
QNFN .OEYGP KGNKDN \GNGTV KRV NT \GVKET QJZS \TKRPN \GNGTV QMN .\GZ\GKP \GEZIN
:OKIKM[ \GIVG OKIKM[ OKNGEKD ZVSP N[ OEYGPF ZG\KBN \GSIKK\F
111

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

E[F QJZS N[ OEYGP ZG\KB

TGXKC KBR\C FNIPFP F\GP\F \EZGFC IMGPG K\KPB LZT [K E[F QJZS N[ OEYGP KGNKDN
.OKK\GMKBG OKKREVY
OKNKDC OKK\R[N \IB FKVZDGPP TGXKC BKF OEYGP ZG\KBN OGKM Z\GKC \XNGPPF FJK[F
KM GBZF Z[B C"FZBG FERY ,FKNDRB ,FKEC[P OKZYIP 8 NT \SSGCP GH FXNPF .74{50
N[ OKZGTK[C E[F QJZSP F\GP\G FBGNI\ \KIVP FKVZDGPP \GTXPBC OEYGP ZG\KB
\KRMG\G FR[ 15 FHP KVZDGPP KGNKD LZTP NBZ[KC OKKY FNB OKBXPP \GCYTC .40%{20%
OK[RF \KKSGNMGB NNM N[ \K\JK[ FYKZS \KRMG\C NIGF 1996 \R[C .FR[ 11 FHP \KPGBN
NM N[ \GMKB \ZYCG OK[RF NMN OGHK QGPKH \NNGM \KRMG\F .FKVZDGPP \GTXPBC 74{50 NKDP
\GNKTV \GR[ 8 ZIBN 60%=N FTKDP NBZ[KC FYKECN \GRTKFF .B[GRN OKZG[YF OKMKNF\F
TGXKC NT FEVYFC BGF USGR K[GY .\GCZ \GKCZTP \GRKEPC 80%{70 N[ \GRTF \PGTN
OK[RC ,E[C OKZKBPP OKNGEKD 1000=M FR[ NM FNDP \KRMG\F .[ZERM OKK\R[N \IB FYKECF
2000 \R[C ,\BH OT .\KSIK OEYGP CN[C OKND\P OKNGEKDF \KCZP .OKEK[IP OKRPKS BNN
SSGCP ZPBP 2000 \R[C Lancet=C GPSZV Gotzsche PC & Olsen O [EGIP QGKEN B[GRF I\VR
OKKGYKN GKF OKZYIPF \KCZPC KM BXPR :FYKZSF KZYIP \GBXG\ N[ \[EGIP FMZTF NT
F\KKF O\RYSP .OEGCKTG OKRG\RF UGSKBC ,\GYECRF \ZKICC \GKBZYBF \JK[C OKDGNGEG\P
FJPG \G[EGIP \GMZTF ZIBN .\YZGS FKVZDGPP N[ \GKPGBN \GKRMG\N FYEXF QKB KM
\ZYGS FKVZDGPP TXCN BKF FXNPFF ,OGKFN QGMR .GH F[KDN \GKGEDR\F G[DGF \GVSGR \GHKNRB
.74{50 OKNKDF IGGJC BKF FYKECF \GNKTKN Z\GKC FYHIF \GETF .50 NKDP NIF OKK\R[ NM
.B[GRC FRGZIBF FNKPF FZPBR BN KM YVS QKB
ZG\KBN FYKZSF \GYKECN \GZG[YF \GVSGR \GEGYR ZVSP KCDN \GTEF \GYGNI QKKET ,USGRC
:E[F QJZSF N[ OEYGP
\KPGBNF FXTGPF .FKVZDGPPF \YKECN CJKF \TXGCPF BVGZ KEK NT \KREK FYKEC \VSGF .1
\YKEC NT OKXKNPP ORKB C"FZB N[ \TRGP FBGVZN FPK[PF IGMG NBZ[KC FKDGNGYRGBN
.OK[RF \KKSGNMGB NNMN FYKZS \YKECM \KREK E[
NNMN FYKZS FKVZDGPP TXCN FXNPFF KCDN \GYGNI \GTEF { 49{40 NKDP FKVZDGPP .2
NT FH QKB KM [KDEP LB LM NT WKNPP C"FZB N[ FPK[PF IGM .FH NKDC OK[RF \KKSGNMGB
\TRGP FBGVZN KERYF FPK[PF IGM .\KJKNGV FJNIF CYT BNB (EBM) \KBGVZ \GET LPS
.NBZ[KC FKDGNGYRGBN \KPGBNF FXTGPF OD QMG OK[RF \KKSGNMGB NNMN LM NT WKNPP GRKB
FKVZDGPP \ZHTC \K\R[ FZKYS ,49{40 OKNKDC OK[R 160,000 GV\\[F GC ZYGCP ZYIPC
\YFCGP F\KKF BN FBXG\FG OKR[ 10 LNFPC 17%=C F\GP\F \B F\KIVF EEGC JCP OT
49{40 NKDP OK[RF \KKSGNMGB NNMN \K\R[ EI FYKECC OKRGMKSF .\KJSKJJS FRKICP
\GKNTNG \GYECRF CZYC FCZ FDBEN \GPZGDF FFGCD \GIKM[C \GCHGM \GKCGKI \GBXG\ OF
.FRKZYN FVK[IF CYT ZIGBP QJZS \GI\V\FN FFGCD FRMS QMG \GBKZCF \MZTPN \GFGCD
E[F QJZS KZYP ZGTK[ NBZ[KC :45 NKDP FZKYSF \KRMG\ \B CKIZFN [K KM OKRTGJF [K
ZGTK[ .324 59{55 NKDPG 273 54{50 NKDC ,F[KB \GR[ 100,000=N 217 GRKF 49{45 NKDC
BKF ,Z\GK ZKTXF NKDC FKVZDGPPF \YKEC \GRPKFP QMG 49{45 OKNKDC Z\GK QJY OKZYPF
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

FKDGNGYRGBN \KPGBNF FXTGPF KV NT

KGNKDN \KPGBNF \KRMG\FP LMN ZG[KB GNCKY[ OKRGMPC YZ TXC\\ FYKZSM FKVZDGPP \YKEC
OKBXPRFG ,QJZSC FPINPN FEGDBFG \GBKZCF EZ[P KEK=NT \NTVGPF E[F QJZS N[ OEYGP
.03=8887175 QGVNJC TEKP NCYN Q\KR .\KRMG\F N[ \KRKNYG \KRMJ \GMKB \ZYC \I\
N[C CYTPC OK[RCG ,F[ZG\C \ZCTGPF E[F QJZS \RGPSK\N CYTPC \GBXPRF OK[RC
BVGZF N[ KTGXYPF GNGYK[ KVN FKVZDGPP TXGC\ ,OIZF GB FNI[F ,SDF KTPF N[ \GZKBPP
OKIPGP \TE NT \SSGCP GH FXNPF .Z\GK FFGCD \GZKE\CG Z\GK ZKTX NKDP NNM LZECG NVJPF
.\BH QIC[ ZYGCP KRKNY ZYIP ZETKFC ONGTC
113

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

\GGXN FMZEF \GZDSPN DGBEN [KG \KNNMF \KRVGDF FYKECFP YNI FRKF \KRKNY E[ \YKEC
.\GBRF FTGXKCN KBGVZF

SDF KTPF QJZS N[ OEYGP ZG\KB

IKM[G OK[RG OKZCD CZYC FPGE ZGTK[) .OK[RG OKZCD CZYC Z\GKC WGVRF BGF SDF KTPF QJZS
\GZKJV 1500=N FTKDP SDF KTPF QJZSP F\GP\F KZYP LS .(\KEGFKF FKKSGNMGBF CZYC Z\GK
.(\GBKZCF EZ[P ,BRI ZC Z"E) FR[N
FIKM[ FNIPF :FZKYS \GYKEC OKYKEXPF OKZYKTF OKRGKZJKZYF \B BNPP SDF KTPF QJZS
ZYS \GYKEC Z[VBPF QPH ,OKR[ 10{5 BGF QJZSN KRJZS=OGZJ TDRP ZCTPF QPH ,\KRNJYG
OG[P FCZ \GCK[I OEYGPF ZG\KBN KM ZGZC LMN KB .OKNGEKDF \\KZMG OEYGP ZG\KBN
,\GPGREB ,ZYKTC BNB O\GGF\F \NKI\C OKZKBPP OKNGEKD YZ BN OKZ\BP GRB G\GTXPBC[
KFP BGF \YGNIPC KGR[F B[GRF .QJZS \GI\V\F OKTRGP LMCG OKKRJZS=OEY OKCXPG OKVKNGV
?75{50 OKNKDC \KNNMF FKKSGNMGBC KTPF QJZS N[ OEYGP ZG\KBG FTKRPN \KCJKPF F[KDF
\YKECM FKKSGNMGBF NNMC \XNPGPF FYKECF DGS KCDN ONGTCG NBZ[KC \GTEF \GYGNIG
.FZKYS

:\G[KD ZVSP \GXNPGP OGKFN QGMR

FOBT \JK[C KGPS OEN FBGX \YKEC TGXKC KM BXPR OKZYGCP OKKBZYB OKZYIP ZVSPC
.1
FBGX N[ \GCYGT \GYKEC 3=C ZCGEP .KTPF QJZSP F\GP\F \B 33%{15%=C F\KIVP
FNBN FKVGYSGRGNGY TGXKCG FKKSGNMGBF NNMN 74{50 NKDP OKK\R[C OTV ET FR[C OTV
\G[KDZ \GNTC \GMZTC YZ [P\[FN CG[I .\KCGKI BKF KGPSF OEF \YKEC \BXG\[
.KTPF QJZSP F\GP\ F\KIVP GH FJK[ KM GBZF OKCZ OKKCKJYVSGZV OKZYIP .FFGCD
OE \YKECC FEP\F BKF \GCK[IF Z[BM OKR[ ZVSP ZIBN \GRTF ZSGI BKF \GK\KKTCF
BGF QGZ\KF .FFGCD FRRKB OKVKNGV ZG\KBN FYKECF \G[KDZ QM GPM .FR[ NM \ZYGS KGPS
.\GVGYF NM N[ OK\GZK[F NSC \BXPRG \KR[NGV BNG FJG[V FYKECF[

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

QGMKS ,\GFGCD \GKNT ,\KR[NGV FYKEC) FYKZS \YKECP OK[ZERF OKRGKZJKZYFP

OKTXCP ORKB[ FNBN FKNT WKNPFN OGYP [K EEGCF FNGIF \PZC .(KTPF \GCYR\FN
.50 NKDP OKR[ 10=N \IB GB 65=55 OKNKDF QKC OKKIC OTV \GIVN FBGXC KGPS OE \YKEC
.(LGPR QGMKSC FKKSGNMGBN FZKYS \YKECM OK\GZK[F NSC QKKET \BXPR FRRKB FYKECF)
FPGE C"FZBC FBXPR FYKECF :\C[IGPP FKVZDGPGJ FGGNP \KNBGJZKG FKVGYSGRGNGY .4
OK[RBC FNTPG P"P 7 NEGDC OKVKNGV QGICBG KGNKD LZGXN FNKDZ FKVGYSGRGNGYN F\GNKTKC
FRMFC LZGX ,\GR[NGV N[ \GRGZSI [K FKVGYSGRGNGYN GPM GH FYKECN OD .OKJPGJVPKSB
FIMGF OZJG GND\K[ OKTDR YKIZFN \NGMK ZSGI .FKXYKEP=FZV ,OKRYGI \GTXPBC
QDRJZ \RKZYC FYKECF FMGZM QM GPM .F\GP\G FBGNI\ \\IVFC GH FYKEC N[ F\GNKTK
.FCZ
FBGVZN KBYKZPBF FPK[PF IGM .\GRGZSIG \GRGZ\K 4{1=P \GJK[FP \IB NMN ,ZGPBM
NT WKNPP KBYKZPBF OKDGNGZJRBGZJSDF EGDKB .FVKETF FYKECF KFP TKZMF OZJ \TRGP
OE \YKEC NT WKNPP \TRGP FBGVZN KERYF FPK[PF IGM .OKR[ 10=C OTV FKVGYSGRGNGY
EGDKB .OKR[ 5=N \IB FKVGYSGEKBGPDKS GB 50 NKDP FR[N \IB FBGXC KGPS
\YKECM OK\GZK[F NSN FKVGYSGRGNGY \SRMF NT WKNPP NBZ[KC OKDGNGZJRBGZJSDF
\KPGBNF FXTGPF .75{50 OKNKDF QKC LGPR QGMKSC FKKSGNMGBF NMN OKKIC OTV FZKYS
FR[N \IB FBGXC KGPS OE \GYKEC TGXKC NT OKXKNPP \GBKZCF EZ[PG FKDGNGYRGBN
.74{50 OKNKDC
OKZG[YF OKKJRD OKTGZKB N[ NKVGZV KGFKH NT \MP\SP IG\KVC \BXPRF F[EI FKDGNGRMJ .5
,GH FKDGNGRMJ UKNI\ EK\TCG QM\K .OKYECR N[ OGZSC GB FBGXC \GFHN Q\KR O\GB ,NGEKDN
.\GPKKYF \GJK[F NM \B ,IKNX\ OB

:FH CN[C GR\XNPF

TGCY QVGBC (OKK\R[C OTV N[ \GZ[VB OT) FR[C OTV KGPS OE \YKEC TGXKC L[PF .1
TGXKC \KCGKI FBXG\ FBXPR[ KPNG .FKKSGNMGBF NMN FZKYS \YKECM 75{50 OKNKDC
.FKVGYSGRGNGY
,KTPF QJZS N[ K\IV[P ZGVKS OT FNB NMN 40 NKDP OKR[ 5=C OTV FKVGYSGRGNGY TGXKC .2
GB OKIB ,OB ,CB NXB \GKRGZM \GK\YNE OKKTP \GNIP GB FNI[F GB OIZF ,E[F QJZS
QICGB GC NKDFP \GIV OKR[ 10 BGF[ NKDC FKVGYSGRGNGYF TGXKCC NKI\FN [K .\GKIB
TXCN [K (HNPCC) \GKHGVKNGV BN \G[ZGP \GRGPSK\ N[ FZYPC .FIV[PF QC NXB QJZSF
15 NKDP NIF (FAP) \[ZGP OKHGVKNGV \RGPSK\ N[ FZYPCG 25 NKDP FKVGYSGRGNGY
.(OKZYGCP OKZYIP BNN OKIPGP \TE NT \SSGCP FXNPFF)
OD SDF KTPF QJZSN ,FZKYS TXCN Q\KR[ 50 NKD NTP FNGI NM TEKKN [K { \KRJZVF FPZC .3
GRKB[ KPN 55{65 KBNKDC \IB OTV \GIVN GB OKR[ 10=N \IB FKVGYSGRGNGY \GTXPBC
\GBKZCF NSC FZKYS \YKECM FNGNM FRKB FKVGYSGRGNGY .FR[ NM KGPS OE TGXKCC QKKRGTP
.LGPR QGMKSC FKSGNMGBN
115

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

ZGTF N[ FPGRNP N[ OEYGP ZG\KB

OK[RG OKZCD KM LMN OKTEGP \GKFN [K \BH OT .FPGRNPN \PEYGP FYKZSC \NTG\ FIMGF BN
OPXT OKNGIF NTG OKBVGZF NT .FPGRNPN FGCD QGMKSC OF OKVKJB OK[PR OTG ,ZGT KZKFC
TCXC KGRK[ ,OKZKES BN \GNGCD ,FKZJPKSB GPM \GZKBPPN OKEG[IF ZGTC OKTDRN OKRZT \GKFN
FERYC \TRGP FBGVZN FPK[PF \GIGM KV NT .\GZKFPC GR\[F GB GNED[ OKTDR GB TDRF
FBGNI\ F\KIVP FRRKB FKKSGNMGBF NNMN FZKYS \YKECM BVGZ KEK NT ZGTF \YKEC ,C"FZBCG
FKSGNMGBC OEYGP KGNKDN FYKZS \YKEC TXCN FYEXF QKB[ BKF FXNPFF QMN .F\GP\ GB
\GPG[ KGCKZ ,FPGRNP N[ K\IV[P ZGVKS OT FGCD QGMKSC FKSGNMGB KCDN NKDZ QGMKSC
QKC [P[N OKV[IRF FNBG FCGZYF FIV[PC GB JZVC \GKVKJB \GPG[ \TVGFG \GKZJKXGRNP
.ZGT \YKEC \XNPGP ZYGCP KRKNY ZYIP ZETFCG ECNC OKIPGP \TE KV NT 14{8 \GT[F

\KRGPZTF QJZS N[ OEYGP ZG\KB

GC FYGN OFP YNIG OKZDGCP OKZCD CZYC Z\GKC IKM[F (NGEKD) \B[F BGF \KRGPZTF QJZS
\KREK FYKEC { \KRGPZTF QJZS N[ OEYGP KGNKDN \GJK[ K\[ \GPKKY .\KPGJVPKSB FZGXC
QG[BZF FCN[C FNIPF \B FNDP FRKB DRE=F \YKEC .PSA=F QGCNI \YKECG ,(DRE) \KNJYZ
CN[C FNIPF \B QICBN FNGMK PSA=F \YKEC .FYKZSN FMGPR \G[KDZ \NTC BKFG (STAGE A)
KGNKD[ \GET QKKET QKB OGKF ET .ECNC 60% N[ \GKNGDSG FFGCD \G[KDZ \NTC BKF .OEYGP
JYVB GBZF BN DRE KCDN OKZYIP KR[ ,FNIPFP F\GP\ QKJYP \KRGPZTF QJZS N[ OEYGP
\KRGPZTF QJZSC NGVKJF .\GEZ[KF \ZV[P FRKB BKF UB ,OEYGP ZG\KBN PSA \YKEC .CKJKP

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

FNI[F QJZS N[ OEYGP ZG\KB

TGXKC ,(Ca-125 ZYKTC) OEC NGEKD KRPS \YKEC :\GNI[F QJZSN FYKZSN \GJK[ ZVSP \GPKKY
OYGPPF QJZS \BKXPN FMGPR \GNKTK \GNTC \GJK[F NM .\KREK FYKECG KDGNGYRKD ERGBSZJNGB
\GTXPBC OEYGP ZG\KB ZYIP .(KGVKZN Q\KRF \GNI[F QJZS N[ KEKIKF CN[F) FNI[N
CG[KIC .QJC \IK\V N[ OKZ\GKP OKIG\KR 5%=C OKK\SF \GKJPGJVPKSB OK[RC ERGBSZJNGB
(Stage A YZ BN) FNI[F QJZS KZYP 40 GBXPK 45 NKD NTP OK[R 100,000 N[ FYKZSC KJZGBK\
ZVSPC .\GKVGYSGZVNP OKMGCKS 160=G OKKGD[ OKCGKI OKBXPP 5,000=P FNTPN N[ ZKIPC
EZVRC CA-125 QPSG KNRKDG ERGBS FZJNGB \GNKTK GYECR 2007 \R[C GPSZGV[ OKZYIP
N[ (specificity) \GKNGDSF .FNI[F QJZS N[ OEYGP ZG\KBN OK[RF NNMN FYKZS \GYKECM
FKRJKZCC LZTR F\T .98.7% ERGBS=FZJNGBF \YKEC N[G 99.8% F\KKF CA-125=F \YKEC
,OK[RF NNMN FYKZS \YKECM CA-125 QPS+KNRKDG ERGBSFZJNGB N[ CGNK[F \B YEGCF ZYIP
OK[RC[ BXPR FRGZIBN .FKKSGNMGBF NNMN FYKZS \GYKECN FYEXF QKKET QKB FH CN[C LB
117

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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[

OIZF ZBGGX QJZS N[ OEYGP ZG\KB

ZBGGX QJZS N[ OEYGP ZG\KB NT OKXKNPP FERYG C"FZB N[ \TRGP FBGVZN FPK[PF \GIGM
KSIK OGKY NKD \NKI\P OK[RF NMN (Pap Smear) OIZF ZBGGX IJ[P TGXKC \GTXPBC OIZF
3=N \IB \GKNKN[ OBG \GYKEC ZVSP L[PN FR[N \IB BKF \GYKECF \GZKE\ .65 NKD ETG QKP
Z[VB \GRKY\ OBG \GYKEC 3 TXCN WNPGP ,GYECR OZJ[ ,FNTPG 65 NKDP OK[R KCDN .OKR[
.YKSVFN
.QKPF \MZTP KNGEKD QKCP Z\GKC ZKERF NGEKDF BGFG IKM[ GRRKB OIZF ZBGGX QJZS NBZ[KC
FXTGPF KEK=NT WNPGP GRRKB NKDZ QGMKSC OK[RF \KKSGNMGB NNMN FYKZS \GYKEC TGXKC
.FKDGNGYRGBN \KPGBNF
QKP KSIK OGKY \NKI\ ZIBN OKR[ 3=N \IB OIZF ZBGGX KIJ[P TXCN BKF OGKM FXNPFF
QKP KSIK OGKY GB ZKTX NKDP OKCGZP OKRDGP BN OKV\G[ OT QKP KSIK OGKY) FGCD QGMKSC OK[RN
N[ \YCN[ GPM KRKP TDPC \ZCTGPF FNIPN GV[IR[ OK[R ,\GCZ \GV\G[ GN GKF[ DGH QC OT
.(QKPF KZCB
OGZJ OKCXP \Z\BP GH FYKEC[ ,BGF OK[RF NMN FZKYS \YKECM FYKECF TGXKC ETC QGTKJF
FKDGNGYRKDN KNBZ[KF EGDKBF .IKM[ GRKB OB OD QKJGNIN QJZS TRGP OFC NGVKJF[ ,OKKRJZS
3 YGECN .18 NKDP GB QKP KSIK \NI\F OT OIZF ZBGGX IJ[P TXCN NKI\FN WKNPP \GENKKPNG
\IB FYKECN ZGCTN \GYKECF NMC OKKNKN[ OKBXPPF OBG \GVKXZC OKK\R[ L[PC \GYKEC
\GVGXZ \GYKEC 3 NGJKN WNPGP OEGY CYTPC F\KKF BN[ 65 \C F[BC .65 NKD ET OKR[ 3=N
.NGEIN OKCGKI OKBXPP ZETFCG [EGI 12{6=N \IB
.54{35 OKNKDF QKC OKR[ 3=N \IB OK[RF NMN OIZF ZBGGX IJ[P NNGM \GBKZCF NS
OZGDF (HPV) FPGNKVVF SGZKG EDRM QGSKI \GBKZCF EZ[P KEK=NT [GPK[N Z[GB 2007 \R[C
\NKI\ KRVN OK[RF \B QSIN KGXZ .26{9 NKDC OK[RN Z[GBP QGSKIF .OIZF ZBGGX QJZSN
\KRMG\ \ZDSPC GRRKB QGSKIF .18{13 OKNKDC QSIN BKF OGKM FXNPFFG QKP KSIK OGKY
OKIGJKCF \ZDSPCG \KJZV \ZDSPC G\GB [GMZN Q\KR .\GBKZCF EZ[P N[ OKRGSKIF
.(OK[EI OKRGSKI { 7 IVSRC JGZKV FBZ) .OKPKN[PF
BNB ,NBZ[KC OK[RF \KKSGNMGB NNMN OIZF ZBGGX IJ[P TGXKCN FXNPF QKB :OGMKSN
OIZF ZBGGX QJZS \TKRPN HPV EDRM QGSKI [GMZN Q\KR .NKTN ZBG\PM ,ECNC QGMKS \GXGCYN
.(26 NKD ET)
FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

118

FBKZF QJZS N[ OEYGP ZG\KB

.OKR[TPC \GCZN F\GP\ \EZGFC \GNKTK BNM GIMGF FIKN \KDGNGJKXG FHI OGNKX \GYKEC
N[ OEYGP ZG\KBN FYKZS \YKEC FGGFK FBKZF N[ KNYKNF CT TGXKC OBF YECR FRGZIBN
ZG\KBN FYKZS \YKECM GH FYKECN OGYP QKB KM BXPR FH CN[C .OKR[TP NXB FBKZF QJZS
FYEXF QKB \NTG\=\GNT KEEP KV NTG F\GP\ \EZGFN FIMGF QKB .FBKZF QJZS N[ OEYGP
QG[KT \YSVFN OGYP [K .OEBN \VSGR \GMKB \R[ NMN $116300 QF FZKYSF \GKNT .LMN
.\GZKBPP \GNIPG OE KNMG CN \GNIP \TKRPN

QJZSN FGCD QGMKS KGFKHN \GKJRD \GYKECG KJRD WGTKK

KBGVZF HMZPF ,\KBGVZ FYKJRDN FEKIKF ,EFN=KGN \ZVB 'VGZV ,\KJRD \XTGK ,KBCD \ZVB
.YEX=KZT[
OB ,FZGZC \K\[ZG\ FCKSP OKTCGR OKIKM[F OKZKBPPF OKNGEKDFP 10%{5=M KNNM QVGBC
,NBZ[KC FNI[ QJZS KZYPP 30%) Z\GK FGCD FH ZGTK[ QFC \GKVKXVS \GKGZKBPP QR[K KM
\GZKBPPN E[I [K QFC \GIV[PC .(SKZ\F \JGNC N[ KZNGEP QJZS KZYPP 25% \GIVN

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

\K\[ZG\ \GZKBPPN KRKNY E[IN OKRGKZJKZY :1 FNCJ

\GZGE ZVSP V"T OKRG[ OKDGSP GB DGS G\GBP QJZS N[ OKCZ OKZYP .1
.\CIZGPF FIV[PC
FRG[BZ FDZEP FIV[P KCGZYC OKZG[Y QJZS KZYP KR[ \GIVN .2
(\/QC ,\G/IB ,OKZGF)
(FR[ 50 > CGZN) FNIP F\GBN TXGPPFP ZKTX NKDC QJZS \TVGF .3
E[F QJZS N[ OKCGNK[ QGDM ,CGZY FIV[P QCC OKZCB ZVSPC QJZS \TVGF .4
.SDF KTPF QJZSG OIZ QJZS ,FNI[FG
,QGMKSC KGXP GRKB[ KPG KGXP[ KP QKC QKICFN Q\KR[ LMN \GET [K OB \YEXGP \KJRDF FYKECF
\GYKEC KCDN OGKM IMGP FH CXP .OKB[RC OKNKTK OEYGP KGNKDN GB FTKRPN \GZ[VB FR[K OBG
:\GKGZKBPP ZVSPC \GKVKXVS
OKEGFK ZYKTC) \GKSGNMGB QR[K WZBC .BRCA1/2 OKRDC \GKXJGP \YKEC=FNI[G E[ QJZS .1
,OKBKZC OKHRM[B NXB .FNB OKRDC \GIKM[ \GKXJGP [K QFC (KYZKT GB KHRM[B BXGPP
119

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

B[GRC KJRD WGTKKN FKRVFN OKKRKNY OKRGKZJKZY :2 FNCJ

K\IV[P FNI[/E[ QJZS
FIV[PC FFGHP FKXJGP .B
OKZG[YF OKZIB OKRD GB)

BRCA1/2

OKRDC FKXJGP F\FGH O\IV[PC[ FIV[P KRC

.(K\[ZG\ FNI[/E[ QJZS OGZERKSN

:E[ QJZSC GNI[ OK[R .C

KEEX GE E[ QJZS \NGI NM

40> NKDC QICGB[ E[ QJZS \NGI

FNI[+E[ QJZS \NGI

NKD NMC KYBZKT / KHRM[B BXGPP E[ QJZS \NGI

:N[ K\IV[P ZGVKS OT E[ QJZS \NGI

FIV[PC FNI[ QJZS .B

NKD NMC \GVSGR E[ QJZS \GNGI K\[ .C
50 NKD KRVN FRICGBG E[ QJZSC F\NI[ \VSGR FCGZY

.D

FNI[ QJZSC GNI[ OK[R .D

FNI[ QJZSC F\NI[ F[KB NM

:FNI[/E[ QJZS N[ K\IV[P ZGVKS OT \GBKZC OK[R .E

FNI[ QJZS+E[ QJZS OT FKKR[ GB FRG[BZ FDZEP FCGZY

KEEX GE E[ QJZSC F\NI[ FRG[BZ FDZEP FCGZY

FIV[PC E[ QJZS OT ZCD

(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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

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

HNPCC (Hereditary Non-Polyposis Colon N[ KJRD ZGZKCN OKRGKZJKZY :3 FNCJ

.(2004* QGMET) FES\C N[ OKRGKZJKZYF :Cancer)
.50 NKD KRVN QICGB[ \NGINI/SD KTP QJZS FNGI .B
.60 NKD KRVN QICGB[ ,NGEKDC MSI OT \NGINI/SD KTP QJZS FNGI .C
[ZVFC GB QPH G\GBC) **\RGPSK\N KRKKVGBF EIB QJZSP Z\GKC FNI[ FNGI .D
.NKD NMC ,(QPH
GNI[ (FRG[BZ FDZEP OKCGZY) OKJZV 2 \GIVN NNGMF K\IV[P ZGVKS .E
.50 > NKDC FNI OFP EIB \GIVN[ ,**\RGPSK\N \KRKKVGB \GZKBPPC
\KRKKVGB \GZKBPPC GNI[ OKJZV 3 \GIVN NNGMF K\IV[P ZGVKS .F
.(FKKR[ GB FRG[BZ FDZEP OKCGZY) NKD NMC ,**\RGPSK\N
.Umar A et al Natl. Cancer Inst. 2004 Feb 18; 96(4):261-8 *
,FKNKMF QDBG FMVG[ ,CNCN ,FNI[ ,FCKY ,OIZ ,\NGINI ,SD KTP :\GKRKKVGB \GKGZKBPP **
.YE KTP ,keratoacanthoma ,QPG[ \GJGNC N[ \GPGREB ,IGP ,FZPF KMZE
QJZSF KZYPP 40%{25=C :RET \GKXJGPN FYKEC { SKZ\F \JGNC N[ KZNGEP QJZS .3
GB EEGCP QVGBC TKVGFN OKNGMKG RET QDC \GKXJGPP OKTCGR SKZ\F \JGNC N[ KZNGEPF
121

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

OD NNGMF (2Multiple Endocrine Neoplasia) MEN2 N[ OGZJYVSFP YNIM

\NCGYP RET=C \GKXJGP KB[R NXB .EKBGZK\=BZBVF N[ FPGREBG FPGJKXGPGZMGBKV
.\GENKC ZCM SKZ\F \JGNC N[ \K\TKRP F\KZM
OKKZYKT FKKGJKC .Von-Hippel Lindau OGZERKSN QDC \GKXJGPN FYKEC { FKNKMF QJZS .4
,FPGJKXPGZMGBKV ,FKNKMF QJZS) OKB\P K\IV[P ZGVKS OKNNGM \RGPSK\F N[
KEK NT OKPZDR OKZYPFP 20%=M .(\GPGRKJZ ,OKCXTF \MZTPC \GPGJSNCGKDRPF
QJZS N[ OKZYPC OD KJRD WGTKK WNPGP QMNG K\IV[P ZGVKS BNNG F[EI FKXJGP
.KEYGP CZ GB KEEX=GE FKNM QJZS GB/G ZKTX NKDC FKNMC
N[ CZ ZVSP .QJZSC \GNIN QGMKSF \B EGBP \GNTP \GK\[ZG\ QJZS \GRGPSK\ :OGMKSN
CG[I .YKGEPC QFN \PZGDF FKXJGPF \B Z\BN Q\KR NGEDF QYNICG ,OGKF \GZMGP \GRGPSK\
OGZERKSF KGFKH O[N KJRD WGTKKN FKGG\F FR[K \KZ[VB FRKB \KJRD FRICB OB OD[ QKKXN

.OB\FC FTKRP/CYTP \KRMG\ \TKCYG K\IV[PF

\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

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

122

20 'SP IVSR

ADL KPGK EGYVK\ \MZTF

EGYKR
YECRN

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
.4

OGMS

159

FIV[PF KBVGZ EGDKB { \TRGP FBGVZG \GBKZC OGEKY

QKJGNIN KBPXT

QKJGNIN KGN\

100 :QGKX
0

:
. , , .
.50%
=< . . :
, , , , , 7-11 , . A+D ) ( , 4-12 2-6:
, , ,... :7-12
, , , ' :

4
6

24-30
'
'
'

DTP
) ,
(

)(IPV

H.
influenza B

MMR

HBV

HAV

9
9
9
9
9

9
9
9

9
9
9

9
9
9

:13-19
,BMI . . " , , , , , :20-39
.:. o 5 ,20-29 3 .30-39
o
- 5

Pap smear , 3 ) 20 , (
. :40-64
BMI . . 40-49 .50 5 .. 50 40 . ,50 5 , 50 75mg 40 75:
BMI .. ) (ADL :
, .
, , , , , , .
US .B ,A ,15
.
, )< ,(6mm ) ,
( , , .
. o

o


) (
HRT 5
.

BRCA 1, 2
. ,
/ .
, HRT .
:
. .50-74
:
o "
o 40 40
. ,
5
.
o
.

, ,
.
. . . .
5-10.
:
o ) ( .50-75
=<
o 5 ,
, //
. , 10
. HNPCC
25 FAP .15
o 10
55-65 .
. . ) (
,
.8-14
stage A .
.
PSA PSA
. ,
.
TRUS + PSA 50
70 .
" pap smear ,65 ,
3.
. 3
. 65 ,
3 6-12 .

. .
5-10% .
.
:
o =< BRCA1, 2
o =< APC .
HNPCC
) / ,
50
(.
o
RET
o Von Hippel Lindau
) , ,CNS(
/ " .
:
.1
.2
.3 .
.4 .
:
10% . .
55-75" . .

:
-

.

. .
5
) 3% , , ," , HDL ,
.(...
75-100" .

.

.
) ,(CVA ,PE ,DVT .
.BRCA 1

o . 0.4mg/day
.
o
carotene .
.
E ,C ,A
.

. B6 ,B12 , . .
.
, .
,
.65
HRT .
=< .
,
, , , ,
, .
) (
) ( .
.
HRT
.
,
.
effexor 37.5" .

.

, :

40% 55 10% .65

:
19>BMI DXA ) .(30
:
.1 =<
T score ).(-1
.2 )=( )(-2.5)<T score < (-1
.3 )T score < (-2.5
.4 3
. =< 25 X .
:
60 ,50 : o
o
19>BMI o
o .
60 . .

:
. . "
, ,
.
. , ,
. 1200mg/day 400
D3 10 .
.
.D3
.
Evista Raloxifen .a
. ,
.
.b D3 800 600" .
Fosalan (Alendronate) .c . 50%
. .
.
Calcitonin nasal spray .d "
. .
PHT .e
. .
):(ADL

0
0
0
0

2
2
1
1

12

20

0
0
0

3
2
1

8
5
3

12
8
4

15
10
5

)
(

5
5
3
3

5

8
8
4
4

10
10
5
5

10

10
15

Table 8-1 Genogram Format

A' Symbols to describebasicfamiiy mernbership
and slrucrure (include
c'n genograrTr
significant others who Ived with or cared
for famiiy
rr,crrlbers-placelhern on tie right sidc of tfie genoSram
with a no_
tationaboutwho they are).

r-rrc

fematc
O

t]

Indcx
Pcrson
(Ifl:

birth derry'

d.",h ;.,,.

X
Drh - X

l " { r r r i a g e( g i v ed a r e )
( H u s b a n do n l c f r ,w i f c o n r i g h r ) :

Uving togerhcr
R c l e t i o n si ,pho f I i e i s o n :

M a r i t r l S c p a n t i o n( g i u cd a r c ) :
Divorce (gr'vedatc):

l-__l n
t r \ - /, |
.

7l

tr.,o
t//'

C t r i l d r e nU: s r i n b i n h o r d c r ,
b c g i n n i n gw i r ho l d e s or n l c f r

noo
hor,-J

Fr:tcrnal lwins

Adoprcd

o r r o s t e r c.en
h i r d rt]
en
q-;1

o-

Idcndc.al twins

Stillbinlr

li

I
I

,,

tr on
I

ll

-oo

lcontinuadon page l6El

/65

from pagei 65]

[condnued
B' Family interac[ion
patterns.The fo]iowingsymbolsareoprional.
The
clinicianmay.prcferto notethem
on a seprrrteii,e=t-Th.y areamong
the leastpreciseinfcrma.ij""J; th.'i"nogram,
but may be key indicatrcrs
of relationship
patlerns[hecrincianianr to rernember:
Yery closerelationship
[:O

Conflicrualrelarionship
[2r,^,o

D i s t a n tr e l a t i o n s h i p

t'

tl - - - o

[;-;:',?;"_Utoff a!-r

--o

FusedandconflichralfEeGO
C ' M e d i c a l h i s t o r y 'S i n c et h e g e n o g r a r n
i s m e a n t t o b e a n o r i e n t i n gm a p
of the family, therc is room to i.ai.It"
ontv tt,. most imporrantfactorr
T h u s , l i s t o n J ym q j o r o r c h r o n i c i l l n . r r . ,
* d p r o b l e m s .I n c l u d ed a r e si n
p a r e n t h e s e sw h e r e f e a s i b l eo r
a p p l i c a b l e .u s e D S l v { - l I Ic a t e g o r i e o
sr
r e c o g n i z e da b b r e v i a t i o n sw h e r e i , . ^ i l u b r . ( e . & ,
c a n c c rc a ; , ' t o r . . C v a l . ,
D' other family informationof special
importance
Ls'rlv
'may
rrs/
calso
u J L be noted on
""r-vr
genoSram:

the

l. Ethnicbackground
andmigrationdate
]. letigion or ieligiouschange
3. Education
or unemployrnenr
1. .Of:."parion
5. Militaryservice
6. Retirement
7. Troublewirh law
8. Physica-l
abuseor incest
9. Obesity
10.Alcoholor drugs.buse
(symbol: tr Ol
I l. Smoking
12.Datesfamilymembersleft home:LH '74
13.Currentlocatjonof family members
It is useful to have a space at the bottom
of the genogramfor notes on
other key information: Ttris ''rould
include critical events,changedin the I
family structure.sincethe genogr?m
was made, hypotheses,and other notations
o f m a j o r f a r n i l yi s s u e so r c h a n g e s .
T h c s e n o t a t i o n ss h o u l da l w a y sb e d a t e d ,
a n d s h o u l db e k e p t t o a m i n i - r u m ,
s i n c e e v e r y e x r r ap i e c eo f i n f o r m a t i o no n a
g e n o g ' r a mc o m p l i c a t e si t a n d t h e r e f o r e
d i m i n i s h c si t s r e a d a b i l i r v .

lr
fr

li
lrl,

;l;

rli

:l

rl.

ll t
lI

tl:

il,
t;

lli

lll

It,

llr

il.
lli

lil

166

t-

r-

r:

q l 2 g r : . c r ^ . : - : = :, l '

_3

j!

'.-

T
>1
i
, ! ' - r :- ^- ci _^ ;o, =^ a
- =: : = 2 : -

i;

t=';Cr:-;:=-='
r;-=91-b:u'^_:.\r-t=
-)1..--rr.a-J3*

:ElF,t;'r:

.i -:I - 3 - . ' - l t c ^ l

FF

tr E z

I
:
i ? E n ? i i E
Fr 2
n-;23E4:tl-r\c;

rt(',rt-F5:B:

= q

o:

.2:GbF-r:!-?'-ql
_e'.F71
. ce A F ? E E , , 1 c o ^ c r : ,

'

=r:

i,

)r

; ^!r([i5:
o-atrt;^^FE ';
.
I
b

: =e

E i
'

o ,

5 .

F:

*cr

F:

c ^
l',

; cF f , : ; "

Lcrtll:6,F__E

Feo

f\

e.

iE

F?

E F

F I

f F

2 ic

i,

,".

: F
:.r\ir:

7.

=FFFz,-1er-c

!
F

FAE

t=

-?elEl

7 sLFrr!:7
a ci

F:
,_

; t

F 5 i

-t-on;f!i

E=I-'N=E'^'x!trc"c

:i

. n = . ^

F'c ^'^:

t= r-

i;

,'

;
:

eEl:coc-'c,=

^-c;?E,-32E"r-l
c;3^5FE=^r

g F F i:
n

tar

-rn^O;

tr

i E

? r

'c

'=:I.^
ar.e.t

?t'^n"'nc
'FaE^E:El=c._sn^E

i=3=t

;3 (F E6 E;:irF
F= E 5 FE;;?:48
'r
i.
iE rii i jiii
F6c'\.Fi-aq,:,-i

H
.z
= :
E ;
c= a ;^ l i
if
E!
i;,
E
;
r--;-5A;-ai=
!
,
r
A
3
f ::EE
ry-'-;X3-cir-?o.r''li

?:

F.s

i:

F;
E n

F i
;r o

7
a
;

tr

r:

F
I

r; - -

e :: b
E c.l
E i;:
a F ; 5F a
E a!

5
F

|
i

^.i

!
r:

3
f;

2
c'A

)
F:
o.
n

E f; e

5
'

i -Fi;si
. 1n

r,

l.;
^r\c11

F
i
G

iF

z.rl

r:

r
F;

._ = C t r r - . ^ . C t n J \ E

t-

Fo;6 ih

n 2i

(:iI-3=nr.l=E-t?
Fic:r'.oo
Frra.'=F:tr-El^F
F
F n' I6P--E3q3i'?r r ?
= :E; ii -t 'P: e

F
E

;-i:Z:q;t9c.'Giosc;
=.-3

F i,i
E

F;;ii'E

ri - k - ;
i
c

CiiAnctutr,:-an'_,:oF;
gcre;=?-cFr

;2
?:

tr

Ei Fi F
i5:r;
3;i;F

i
i

ns
Fi

n t
::'

F
z

E
5

E c;
':

B'

'

F F

i 5 i
o

'(

^J

-^

';a..1r''.,7

-r l,*?' n' d
- r- a)

l-

:i

anF-t

'FAr 2' ,l =' ' !: ^' C

t -

af-;
at;;or:J
'=l'-=
'-rle.-

1.,claQC
=-C3
I
'n

E
7

t t

'

r\

-^--

r.2.

- d : - L

nl
.
.

f,r==

a f

tr

r\-

. T

ct
cl

7
r - t- -- .= c r

f
- P E

-l

Ft'
t- rl l

arl

'f','an
Lrc
lrl

LC

3',

'l

'l

--

unla
J?.
!l-C-

_f:.

I
SJ

!
2

-c
,' '
c'

'r'

F
' t li -Pl i1' e
" Ff
nnc

"^?

a '

o-

{c -

6ll
EI

- - - f t '

rl

Ltf

Cl

Ic
:' *?.

^-

*l

t_.a.n^

;; 7 Z i='b;e
;; : ry -iF--FRl

-l

t t

i^',r i

f
- f l r

6tl

'-'l-^

'

; i 7iA2'"7i
;Z
= 7 - .I t
' ;":??'7i =z7i a

r l

. L

-l

:-

r ! r

- l

..oL-:

CC'27

ll

t -

-A

a:

-\"
r\
=
' a: -- 7F 3; c

2:i

E 7
--

)^7e.

'r =

=r

ts-

l -

E ! l - r _

r l

i-t
--

;?iz7aE?:?i?;
^o:='FliF=?za
i
It''E 7iizi.t"

^nnA,
L I - L E "

(-5
i{(nJ\=
5xr1.':

,t

j=rF:1 =i2-272-i

. r f . ? a l ? s

';c;n

r - L
.

'2

fCCrr

;J

7F.ia;a
=
7c-cl

:
I

6l
-L:nt-(1

n.
:'

a',

=A.l\/\'r'=a
(-.=I-.1

?
o

r
-

^-

t:

EI

I
n

n
?
^r:LreJtr]=5de

r:

(= '

'-;"Ot^ncrE.F

(=

t\

:f

A F ? ? t l

n
-,

'

-f!
t'F

' NN -- " c l - .

eC2a
C C'-

t'

^ e .

tzz.

'r 'i -'e.a ( 7

l'-

'' Cof:'=4r
-e t (l
n
.'r
.cl n
2'
-2.
- f \ ' r '?A( '
.r-=l
. . r - ' e r 4- I \ ?
,.
o
?

-r .\
f-

' : " - * ; . r re A
E.;;:
-1v

'=

nr?f'
t
OOI.e
.1
1^L r l h

ea
.Q

3'_7i')
7e'i6

2'='

:lha

'EF!

I
7
E

l-

,
I

' -;il:
Itc

il

FCon

CrO

f:

_i^

i:l

r-

F'i'p
'-

;
I

E
-

"

d
r

?.

,.

c
1

I-

e1
e
3
4

'E

n
r

q
d

-_

"" ?

E
Z

,
o

ir

: ;
v2

(1

;; 7
C

11')

\i
I

t
ri

.{
.I

iv
.l

i F

,;;i

^- ':

',-

n
;

i] l.tE

E ;eZ

l - r l -

C3C
.-nC
r r.-

'

:' ^
, =E" -_ c
i

=.' llq
'";7

( . r

r-

^- ,- |Fr ;r -t s ^

i'

Z^.

-=='-r

H
a

;a

;-c"fi=

C^

EF

:x' .?F
;:ol ./ F
- 1a -t C ^

--

lF=Aei

=-

r::l?e

. c

t - ( 1

'

13:??27

ir

Eb-:?'iE a '

E ' 5F?- -r :

iibE

.e'co;;

f
- t u f

ac

: i

".

'

2' ?

. - '4f \

"F
' ' ..-.=- '.3- 'G
d ja==

l-nn-taC
n^-nq
o7

i_i

e
? ,

't
r

? T 5 E E
1 t 2 A 2'. 'r

.{

ii

,}

{t

r-ll '

^ r r J t

' I t f
t

lf

F l -

t
d -

4
a

.:

F A

-t
o

'

O n- r'
.isr
-t:C.

-[

.l

:
:t

nl

rl

rr

nl

n
r

dl

'^l
'rl
?l
I
11l

I
T
C
I

4 l

nl
r l l

-l

.l

rl

F I

;l

rl

. . 1

l - l t a -

r
n,

F r

c,

E-nr=.g;!-

r
r
n

E a n

z.

='-

;:

.r

r
r
n

2
c n
q

tr

e .n'

--

tr

)-

^-

o,

EaTi-.ccE;EEE;F2.tr.5
,,."F"
6r6f:Az;ntrr:
rrrn'.:i'r'gen
r
Ur;-rg.n-?

lnn.nn'-r:;l-lE
-

!.

rr.tzr]t?zFr\

:E=eHE._E':F
id c : ' - r : 3

G
-SisxAi"

LrPr.1;.

')
-l

ol
r-l
7l

' { f

t1 r- ra1 ? l
"

F.
I

:tr

tr7-

- l
o l

nf

c=ol
37r

-'

rl
ctl

(=c
':

YJ

>-

! l

{-

)r ' -- r
a

;r
:l

rl i;

5 ;F:

:i 5 !

,-,

,rTl G

; -=; i

H/5 i i;
3i
E

s;

=','1i:il-r
/\o,'::!-l-=;'.

,i:

=?ii:=:E='_=L)
?-5^'-*!--;-l
c

' 1

t:

i,:

L;;E,\r.';gil;
o'.'fl!S:r-F1:
=c
;G
t=c/.!c.

rl f F ;to . ;i5
'D2cg

::9.

61

l;/v::

F Fi;

FtrE:::-Pt'4

xE..,oF-','FEi

E:ii

5[:?

-r:-i,rg'-e;r,r
^ E -

F:i;;ix

_c^l_:

lo'

:r-c*E

r:nESE5E'-r1;c;
fr

e=:cd';nfir
t-?
cn^;idF'^cE
Ccx-F.-C>3:(to
)t.i-.x'.fh:{
;lccniA-.,'

ra;'Cu,

tr Fi
! ', -

i
E

're

5
?

;
I

= ":
fl .' I

3:

-l\-!ci<o

'-e:.Fl-.vl

'

.arcr ._r 1x .v! ,- s e

Et;fiqu

"F

qf
-,t
-rl
r:
ul
c
-l
dl
nll al
o
-,1 H,
ol
al ..
u[Cal-lol'cl.-i3q

ol
6l

tl

.
.

Pl
-l

l a = l - l u( Jl t

o{
ql

Cl
ol

ol
t{l

tdt

cl
ol
<l

t:
.l
:i

-tl
irl
el

^
r:
.

^i
dl
ul

rl
ol

ul
el

ljl
ol

dl
t.ll

c
E
C
a

!l
<l
>l
trl
f.ll

tr
C
f
tr

tr

.tlol
^
o.

|
:r
|
tl^
!]il2cz.n.Crn'/jnE
f.-C.n3r.l
f:-n-n-Cro
')l
^
C
f:
.r--e-=
e

u i,

J:

>r

co'Ful

rl
r

l
e

'^ r :
3
o

n
^

q^s
l\

f.

F =' .

- L . - {

l-=FFnrlcl;ir't
crf-lc,rr1or:^ra
-r:,-ncorg>-Tri

E ^

tr r

6li3.r'tc.!\Z!;
--n-qr.n^An;
.
.o
C
!_3ory=Cc.^-o3:lnr:Ca..,:
eo"aCotCE
fao^r.Eao3i
cEo|:c3--nEc
niz6lnn;.;5.
.lr^l:ryr^^-Qr13{'r,ter:;ch
.
^
A
^
n
.'o
.
Er-cz^oofi
(IL:_C3C3r.3?
'-n{t.-_a-l:rc
r:3EEar"

tr

r:

C
,

!'.i
-

..

$r5

';
cF . C ) r C 42/ - F - e 3 r ' '

o ':

e I

)t-fE3-..
6|:Cr-naco.
Etrna.co
f:r7-f:,e
Cd
ce..,
n2OCI\-nE
C,-lFn.on..E
. : trroC- C
c o. n.3|:.'\.
/\Czc
- C' -raqC3 ,71, 1e a . .
n

5triior.
r9ulrt

a ?

rl

"Fa-

rl
'l:>l

^.

^t\

 - 8
20% . .

.1 , , ) (
.2 ) ,(BZ ,
) , ,(Trazodone ,TCA ,
.3 , ,,
, , ) (
.4 ,CRF ) (
.5/ ,
. ) (
.6 - / CHF .
. SAS .
.7 ,CMV ,EBV Postviral CFS ,Lyme ,SBE ,TB ,HIV ,
.8
(CFS) Chronic Fatigue Syn. .9
- CFS
, , < 6 ,
.
5-10% - . ,20-50 3.
' , , , , ,
/ . ' , Postviral CFS <1-
.2m
. ,EBV ,
, ,IBS , ,TMJ ,
) " ,(CFS-
.
DD
2/3 1/4 . 3% ,CFS 5% ..

.1 .DD-
. .
.2 , DD-
.3
. ,ESR ,CBC .TSH ,
heterophile test ,HIV ,EBV- .. .
CFS
) Major (2 , ,< 6 ,
/ , ) (
) Minor (4 , , , ,
, , , .
: )( , , , .

.1
.2 . SSRI TCA , . BZ+SSRI
.BZ
.3 CFS 75% CBT - 12 .
, ,
// .NSAIDs
12-18.

 -9
: 5% .
,3-10% . ,
. , )
(.
: , , ,.
:
.1 BMR : , , , .
.2 BMR - , , , .
.
:
intake .1-
.a .15-30% - , .
.b - ' .
.c - .
.d - , GIT
" .
, . 7-10%
) (.
HIV .e intake - , , , ,
.
.f : , , ,PUD , ) ,NSAID(,
, , , , ,CHF ,
, , .
.2 -
.a ,IBD -.
.b -'.
.c : ," , blind loop syn= bacterial ,
,overgrowth )( ,.
.3 - ) ( , , ,.
.4 - , , ,,
,.
:
. - .DD .

 . - , .wasting
.-
intake .1 - ) , ,( , ) (,
,HP-.
.2 - , , ) (,
) " ( , ) xylose
'' ( ,secretin ,
) stimulation test ( ,' , ) (,
.bacterial overgrowth-
.3 - .
.4 ,TSH - CMV ,HIV , .
-isolated involuntary weight loss .5
. .25-40%
+CBC+ESR
. CT .
:
: , , , ,
)) MCT ,(bacterial overgrowth ( , )
( , , ,ADEK .B12
: 15" , .
: ) ( HIV .

 Evaluation of Overweight and Obesity - 10

55% .
:

II

"
,
,
,leptin, -MSH . )
- (
) 30% .(exercise -
- . , .
:
- 10 )
( . - 10 ) (.
- 5-10%- :
B, central sympatholytics (clonidine), -
glucocorticosteroids, antidepressants (TCA, SSRI), antihistamines
- ,Stein-Leventhal syndrome ,
-
- ,
-
) , (.
BMI : ,
. - ,
) bioelectric impedance analysis , , (.
: - .
- 0.8 1.0
) - (
) , ,(
Relative risk for
DM2, HTN, CAD
Normal
Increased
Increased
High
High
Very high
Very high
Very high
Extremely high

Waist circum.
Men < 102cm
Women < 88cm
Normal
Increased
Normal
Increased
Normal
Increased
Normal
Increased
All are increased

-1-

)BMI (kg/m2

Class

18.5-24.9

Normal

25.0-29.9

Overweight

30.0-34.9

Obese

35.0-39.9
40.0+

Morbid obese

, ,
. , , , ,
, -" ,
, , , .
- ) dexamethasone suppression test ( .
. - .
) HDL ,TG - (.

,
)(.
- = ,
.

-2-

 11
: ) ,(TNF/IL
. .
PGE2 .

, , , ) "
" ( , , , ) ' (.
-CNS , , , ) , ( .
" . factitious or drugfever , Thyphiodfever
.fever
HSV )= (feverblister
.

" ,40.50 C " , "
). (basalmetabolicrate
42.10 C ,DIC , . ,
, , ".

DD
, , . officesetting "
,UTI/URI , ) ( .
/ : ,HBV ,,
, , ) , ,( "
) (.Ehrlichia
2-1 Pelebsteinfever ,
. Hodgkinsdisease
)" (:
) FMF -,, (.
) HyperimmunoglobulinD=HID (.
) TNFReceptorassociatedperiodicsyndrome=TRAPS, (
3/1 : , - .
3/1- . ) (.
HIV .mycobacterium,PCP
, , ). (11.2
"" FUO " .

) .( 11.3
3 : ,
.
- , ' ,, ,HIV, ,,
,sicklecell,/ )( .
- .1: -
/.2 ,-.3 , ,catscratch ,,psittacosis -
,salmonellosis - .4 bartonellaQuintana,Hepatitis ,HIV ,TB -
" .5. : , ) (: , -.
: , // ' .
? ?Abx ? )"
(

, , . ,
.
- .rockymountainspottedfever
.infectiousmono
.
Splinterhemorrhages
Ecthymagangrenosa
/ . .vibriovulnificus
Erythemachronicum .lyme
- erysipelas .FMF
),choroidal tubercles of miliary tuberculosis ,(Rothspots
.Candida septicemia ,retinopathy of connective tissue disease

.
.
,CBC ) , CSF ,'( ,,
).... , (.
ESR , :, ,. -
.temporal arteritis
HID ,(MEFV gene) FMF .mevalonate kinase
-
enzyme-linked immunosorbent assay and Western blot testing - HIV .1
anti-DNAase B titers - rheumatic fever and other streptococcal infections .2
heterophile test-infectious mononucleosis .3
widal titers- salmonella .4
HID .5 IgD (> 100 IU/mL) and IgA

FUO
0

3 38.3 C .
) drugfever 72 (.
3 ,RF ,ANA,ALT,AST ,CBC : ,
,EBVHIV ,CMV- ,.. 85%.
FUO .11.1

 : TB ,.
: , ,,adultjuvenileRA ,
.deepveinthrombophlebitis .
CT) /( ,
) (, ) ,TEE ( US , ),(DVT
) ( )/
() BMA , (.
trial data . ,
) (.
" -Secondlook "
FUO ) ,HIV () (11.2
) HIV (100> CD4 , .
,
. , .
, serumcryptococcalantigen .
, - CT .

.
. .
.1 - salicylates ,acetaminophen-
" " .PGE 2
PO . 1.2 " ) . 4(
":" acetaminophen- ,salicylates- " .
) , ' (.Thyphiodfever -
.2 " , " , / . .
.3 ) ,(41 .10C .ER
.4 ) ,(11.2
. 38.30 C .

 Screening for Hypertension - 14

20% " ") . (.
31% , 17% , 29% ,
, 23% .
, .
50%" . " 55 .90%
,50 .
Pulse Pressure , -.
" . ,2
60 .
- "
. , ,
CO .
,70 .
- " . , " ,
) . , " ,
( . , , , 80% ,
50% , 320% .
,18 5 " . ,
,Sleep apnea ".
" , " .
" ,
" .
".
" , "
- , " ) . .(...
: , , .LVH-
20mmHg 10mmHg
115/75 .185/115

" . .
70% 20% .(140-159/90-99) I ,
15-30% . , .

3-10 - ,
. , " , .

 Screening for Hyperlipidemia-15

.
:, " , , ,
LDL HDL-.
:,
,CRP ,a.
20%- 20 240-"/"
.
50%- 200"/" - .

. 2 -"/"
, .65 , . 45
55 .

,50 2-
. .HDL ,
. 60 .

- .
, .
.

.LDL-
, , .
. . ,
.HDL-

,LDL B-blockers .
HDL- . HDL
.
HIV- .
, ,
. HDL .HDL
.HDL " HDL-.
, , LDL-
.


55 65.


.
.
240"/" . 300 .4-5 LDL- "
.
LDL
LDL " 2/3- ,
.LDL- LDL 100- . -

 LDL . LDL 160

.
HDL
HDL- .LDL- 10
"/" HDL 50% . HDL 40-
. 60- "" .
HDL- . ,
HDL ) .(60-100 /HDL
. 5 . 10-20 .
4.5.

.HDL

.LDL
. 3
.1 : 102" 88-" .2 .
- HDL .3 .150 40- 50- .4 ." .5 . 135/85
110.


LDL- 30%- ,
. 10%- .LDL-
HDL- ) (5% /HDL .
) ( , HDL-
.LDL- " " -
. ,
" .
.

(25-60%) 2-3 .
) ( , ,40%
.30%-
. ) (
. 30% , -
, LDL ).(150-190

LDL, HDL - .VLDL-
,HDL- VLDL-" ) 5- -
(400 .LDL-
.
. ,
.

20 5 , .

, . ,CRP
) ,(a .
) ,
( . , .
65 . .


12-14 . ,
. ,400 .LDL-
LDL-
.
CRP
, . CRP
) ( . CRP- .
CRP- , )'
- CRP (.
CRP- , -
CRP .

.
.
, " , "
.
, , 25%- .
.
,
, ,
.

 -19
:

"
" 1
" 2

)"(
120 -
120-139
140-159
160

)"(
80 -
80-89
90-99
100

" :
95% "
" 30-50
"
, 1
: , , , , ...
) hypertensive
( encephalopathy
" , :
" 20 ,60

"
"
) , , ,
, , , , , (...
DD ":
" 95%
" 5%
2.4%
- 1%
1%
0.8%
0.2%
0.1%

:
:
o
o "
o

:
o , " , , ,
..
o "

:
o + BMI
o : , ) ( ,
) (
o : ,
o : , , ,
o : ) ( , ,
) -( ,
) (
o : , ,
,
o
o

o ) ,CBC ,BUN , ,,,
( ECG ,HDL ,
o :
:
24 ) 250 ug/d
(
) " (
: CT
:
24
, CT
:

o -
!
o
o ) 20 ,
50 (

-
: Renal arteriography
Magnetic resonance angiography
CT angiography
Captopril renal scan
Doppler US
:
o ) A ( : -,
- ,
o ) B ( : ,
- , .
o ) C ( : -
, , , .

:
o "

o "
o
o
o -

 - 24

.
. ' . : ,
) , ,' ( ,Jarisch reflex (an extra Bezold-
.strong cardiac contraction in reaction to decreased preload triggering a vagal response
. , ,
, , . , , .
.
-Situational Syncopes )
( , ) ( , , )
(.
, )<20"
10< ," ( . , , .
) , '( .
. , , ,
) . Postprandial hypotension .TCA , .
<20" . .
Neuropathic postural tachycardia syndrome . . ,,
, . - . . .
.
. .
. .
- ' RAS-
, " -Subclavian steal syndrome .
.
Aortic stenosis - .
PE .
.
.VT ,complete heart block (Stokes Adams attacks) - VT
,IHD QT .
, , .SCD
SVT .
, .SCD
,
. .
,
. , .


- .18-33% -
.6-12% , .
, MI- .
vasovagal, situational, orthostatic, and medication-induced 45% ,
,10% ,4% .37%
Initial Workup , " 50%- .
. 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 .
, . . ..
EEG 50% . .
2-3 , PPV
50% .

. .
, . , ,
. . :
.midodrine, indomethacin, and yohimbine ,phenylpropanolamine
Postprandial Hypotension , , ,. .
, , , .
octerotide- .
- . .
.

 Cardiovascular Rehabilitation and Secondary Prevention of - 31

Coronary Heart Disease
5% - 10% .

. :
. ) (Functional capacity
. ) , , -(
.
, -
. .

.

.
.
:
, 20%
25% , .
35% . .
, ,
.

) .(Training Effect
.
.
25% - 50%
- . HDL-
8% ,25% - ,22% - ,
.

.
. ,
-.


.
. , .

.
.
I
)( )"
-
( . ,
. -
.
II 3 6 .

. "
.
,
.
.
.
III . 3 6

/
.
,
.
. .
IV /
. 6-12
. ,

.
?
70% - 85% , 4
30 .
. 30
) , "( 30.
,
70% - 85% . ,
.
) (compliance . ,
30 - 3-4 .

.
1:112,000 1:294,000 - .


,
.
. , .
.

.
:
-

) " 140 -"(

LDL 70 -"/"
.
3 .

.50%
,
, ) (.
:
-

.

.
.
CRP CRP
,CRP
.CRP
CRP CRP - .
.

.
.STRESS
ESRD .
,
, .

) (HRT
) (
.

.

- ) ,(26-39% ) (23-28%
.MI
) , "(
ACE . ,
- . ACE
. ACE - .ARB
.
)
( . .
)
( . ,
.APLA IIb/IIIa
.
- ICD
. ICD ) (EF 30% - -
.31% -
ICD ICD . -
CLASS I - -
.

.
.3-
, . C
20% - .
TG ,LDL .HDL
, , HDL -
.
- ) , , , ,
, ( .33% -


.
-
CABG PCI
. .
) (risk stratification -
. , , -
-
.
ST - PCI .
3 .
ST .
)
(...TIMI
- 6
.
.
CABG 40%
) , , ,
,left main - ( . ,
.CABG -
CABG PCI )
,left main - LAD - ( . ,-

.
- ,
PCI - )( . ) ,
,ACE(
)( .
-
,
".



. .
5% 7% - .
50% 5 .
.- .

METS 3- .
.METS 5 - METS 3-5 .
.


.
- " . .
ST
.

 - 41 -
. :
.1
.2 -
postinfectious .
.3 - .
-
.
,gastroesophageal reflux , .post nasal drip

.
, , ,
. " ,
.
:
.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%

 ,4% gastroesophageal reflux .4%

- , ACE inhibitors
- ,gastroesophageal reflux , post nasal drip .

56% ,52% postnasal drip

.40% GERD
, , .
,
ACE inhibitors
, , , ,
.
, ,

chronic rhinitis - ) (postnasal drip..
,
.
" .
, , ,- ,
.
.
4-6.
CT 1 6
. .
.postnasal drip
. " .saline
/ ,acid fast stain,
,- . ,eosinophilic bronchitis
10-15% ,
.
.
- ,gastroesophageal reflux ,
.postnasal drip ,

, - pH H2-
blocker - GERD

. , ,
.
: ,
- , , posttussive ,pneumomediastinum ,pneumothorax ,
,syncope .subconjuctival
77% 17%

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

 Approach to the patient with acute bronchitis or pneumonia in - 52

the ambulatory setting
:
.

. , ;
; " .
:
: / , , ,.
"" , , .
) , ,( ,
. "
: , 25%
. :
, .
, ,:
+
o ) 30-50% (
. , .
: ,
1/3 . . ,
. .
o . 10% ."
,
) ,( . . .
.
, , ,
, , ,.
-GAS o . , , .
.

Heamophilus influenzae o ,
.untypeable ,
type b , .
Klebsiella pneumoniae o ,
, .
) ,(currant jelly ,
.
Moraxella catarrhalis o ,
COPD , .
, , ,
. . " .
Bordetella pertussis o 20
3 : ,,
( , )( .
Legionella pneumophila o . "
.
URI

.
, , .
. " .

. , , gag reflex , .
, ,
. aspiration pneumonia"
) (.
Mycoplasma pneumoniae
. , .
, , . ,
.erythema multiforme .
" . ,
.Guillain-Barre ,
Chlamydia pneumonia .
, . .
, .self-limited , ,
,psittacosis - .
Coxiella burnetti .Q fever " ,
" . , 1/3
.
80% .
. influenza, adenovirus, RSV,
CMV .parainfluenza ' SARS .
, , , 10- ,CPK
15%.
, , ,
, histoplasmosis
.coccidioidomycosis

:
) ( : ,H. influenzae ,
. , DD :hypersensitivity ,
,pneumonitis , ,PE , , ,.
:
-/ , , , , , ,
:/ ) , -
( , , " , , , .
: ,40 ,,
30 . ,
, , . ,
, .
AP .
, ' . )
10%( . , "
) 10 PMN 25
( . 50% .
) (

 , . , ,,
,.
:
(1 :
, , ,
PORT . PORT
) 30( , , ,
. )> ,(50
.I I ) II 70( IV , V
) 90( , III .
(2 .
. .
, , .
) " .(395
10-14 . :
)> ,(60 ) ,
( ) ,,
,( . . )
( . 10-14.

, , , .
( , .
III II
)/(.
. 80% .
)
( .
,
) 7-14 ( ,
. .
. ,,
. .
/ ,.
(3 , . )"
(dextromethorphan " ,
.
.
:
, , . ""
3 .
50% .
.
:
: ,
< ,65 ,COPD ,CHF , . ,
65
5.

 -60
- )
\( ) ( \
-\+ -.
- , .
.
:
.1:
-Transfer (oropharyngeal) disphagia .
.\ . ,
, . .
: \\ . ,
) ,L-DOPA ,BDZ( . ,
-.
-Achalasia . . , .
,
" .
- ,
, gastroesophageal sphincter (LES)- .
- . LES-
. )(
. , , ,
. : ) 80%
( , ) \ (,
) ( . 10-15%-.
gastric
-Carcinoma induced achalasia - ,
.adenocarcinoma .
,50 .
. - LES
. ) DD- (,
) 20%-( , 75%- CREST-
) , , , (.
-Diffuse esophageal spasm . )
( , -
. )
( nonpropulsive (tertiary) simultaneous contractions
10%- .
) ( .
.
-"Nutcracker esophagus" .
, ' )
2 ( . ) 50%-
( " ) ,(?GERD
3-5% .
.
LES . - LES-
, 50%- '.
. - -
. ,nontransmitted , ,
\ , , .LES-
. - . )
( . . 50
. .

 .
.
. - . , ,
) ( . : ,
) , , NSAIDS , ( .
) ( .
.
- CMV ,HSV , ) (AIDS
.
.self-limited- ,,
, .
. - ) globus hystericus ("-
" ) ( , .
. - , .
.IBS "Nutcracker
" .esophagus
)( , )( , ) ( , NO- ,
) " ( .
. \.
:DD

) 60.1 .(451 ,
) ( .
,globus ,"Nutcracker esophagus" ,
.hystericus . 1910-:
28% . -
36% ,""Nutcracker esophagus 48% 10% , 2%-.
:
: 80%- . \ ,
, \ , \ ,
. : , , ,
, , , ,
, . : ,
, , . -
. ,
. .
) .(Schatzki's ring , ) ,
, . (;
) (;
) reflux esophagitis- (;
) , , .
(; ) ,
(; .
. , , .
. .
.
: : , , )
( . ) AIDS (,
, . ) ,( ,
. : , , . ),
( . : , , , , ,
) GAG(.
: \ .
: , \ ,GERD .

 ) LES ( .
. , transfer -
.dysphagia )
( , , , ,
, , .
- .transfer dysphagia- ) ( ) -(,
) ( .
) ] 2/3 , ,
LES , [ ]
[LES- ( . "
- . , "
.
: . )
, ( . ,
. nutcracker esophagus- .
: . .
. .
.1 - .
, 24h-.
.2 -edrophonium " .
." :,
, ,
pH : pH 24h- . ,
46% . 19%-
.
. .
:
: .
, , .
\ .
)
, " (LES-
) , (.
, ,
. . -
.
) (
.
.
.
,
) (.
:
, , .
.
. .
.
\
.
)' ,Zenker's diverticulum
( , )
(.
" "globus hystericus , .

 :
10%
.
"
.
.
.

 GERD - 61
: LES , .
. mmhg12-30 : )
( , , ,
. - " .
: :
* * LES * LES
*. *. *
.
: hiatal hernia
. , - , , ,
,) (.
.tetracycline ,quinidine ,NSAID -
H.PYORI .GERD
:
.
* 30-60' ) ( .
. ,
) .(angina like
*- . ,
, .
* , - .
.
*- ) ( .
* . - , - ,
, .
* - .
-Barrett's esophagus : -
). 10%- 20(.
-Adenocarcinoma BE 1%- 5low -
grade dysplasia 10.high grade-
:D.D- , , , , ,
.
: !
* PH 24 - -
.
* - , , .
* ) ( - ,,
, , .
: :"stepwise approach" -
-step 1
) ( - ,
, , -
, , , ,
, .
:
Step 2 H2 .PPI- H2
-PPI .H2

.
. PPI- ) atrophic gastritis
( H.PYLORI .

 -Step 3 -Metoclopramide -promotility -

.LES. CNS- " .
-Bethanechol - ,LES- , " .
-C\I.
-Step 4- . gold standard
65% . nissen laparoscopic fundoplication PPI-
.PPI-,
PPI- GERD BE-
. - .
-Screening for BE and adenocarcinoma
, ,.
,BE 2- 3
. . PPI- BE- ,
PPI- .
BE low grade dysplasia- 6.
-high grade.

 - 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
: , , , , , , , .
.listeriosis- ,
, . " ,
' . .
: , ,
rose spots , ,typhoid- , ,
.
: , -
. , )"
( , .
. giasdiasis-
.
:
: LLQ -.
- ,RLQ
.
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 .

:
Impaired colonic transport .1






,

2

Impaired evacuation.

:
:
- , ,..
? ) (
GI , , , , , ..
, ) .. (
.
, , , , ,

,


) , , (
) , , (
:
, ,
- , ) , ( ..
- , , ,
-PR , , , ) ,
, ( ,
,..
- , , ..
- , ,..

- , ,..

 :
,
.
:
-
- .
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

,

4. Stimulant/irritant laxative (e.g. diphenylmethane (bisacodyl), anthraquinone

(senna), cascara)

) Laxative abuse syndrome-
.(
fecal impaction .5

 Management of Peptic Ulcer Disease - 68

: 2% " 80% .M>F . .
.45-64
: : )
,(Zollinger Ellison- H. Pylori ,
) .(NSAIDs : , , ,,
.
: .
, "
.
2-3- . ,
- . ,
) 25%(.
: H.Pylori 95% ,
4-6 . relapse- 5%
H.pylori- 50% .
:Workup (1 : H.Pylori
(2 . cost-effective.
" ?? ) "(
) , , , , -
.(40
:H.Pylori
" silver .gold standard-
(1: : , , 71%
.85% , relapse
(2 . :
.91%
.
* 4% . ,
1" .
: (1 : (2 (3
(1 : ) NSAID ,( (2 . (3 .H.Pylori
(4 .
:H.Pylori " FDA-
- . :
PPI/amoxicillin/metronidazole ,PPI/amoxicillin/clarithromycin-
.PPI/clarithromycin/metronidazole .80%
7-14 . .

 / :
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
:
.
: ,
.

Approach to the Patient with Diabetes Mellitus - 102

PATHOPHYSIOLOGY, CLINICAL PRESENTATION, AND COURSE
Diagnostic Criteria
The diagnosis can be made based on the presence of any one of three glucose abnormalities found on
two separate days:
Fasting plasma glucose 126 mg/dL or greater
Random plasma glucose 200 mg/dL or greater in a person with diabetic symptoms
Two-hour-postprandial plasma glucose level 200 mg/dL or greater after administration of the
equivalent of a 75-g glucose load
The normal fasting plasma glucose was lowered to less than 100 mg/dL and impaired fasting glucose
was reset to 100 to 125 mg/dL. Similarly, impaired glucose tolerance (IGT) was redefined as a fasting
glucose less than 126 mg/dL and a 2-hour PG between 140 and 200 mg/dL.
Impaired Glucose Tolerance
The risk for the development of overt type 2 diabetes is increased (1% to 5% annually), as is the risk
for cardiovascular disease. Microvascular complications do not develop in those who do not progress to
frank diabetes.
Gestational Diabetes
Screening is suggested at 24 to 28 weeks of gestation, although earlier if there is a high degree of
suspicion. A plasma or serum glucose equal to or above 140 mg/dL at 1 hour after oral administration
of a 50-g glucose load is abnormal.
Clinical Presentation and Course
Sometimes, fatigue is the predominant symptom. In patients with more significant hyperglycemia,
polyuria, polydipsia, and polyphagia with weight loss are encountered.
Complications
Most correlate with the magnitude and duration of hyperglycemia; there does not appear to be any
glycemic threshold for the development of such complications.
Macrovascular Disease
major reductions in the risk for coronary events and stroke can be achieved by correcting other major
cardiovascular risk factors, such as smoking, hypertension, and hyperlipidemia. Effective treatment of
such risk factors appears more important than normalization of glucose per se in the prevention and
limitation of cardiovascular complications.
Microvascular Disease
The risk for microvascular complications can be markedly reduced by achieving tight glucose control.
Diabetic Nephropathy
Subclinical and histologic findings for diabetic nephropathy are present long before the stage of clinical
proteinuria. With persistent proteinuria, hypertension becomes established and glomerular filtration
begins to decline at the rate of 1 mL/min per month.
Renal failure eventually develops in 30% to 50% of type 1 diabetics and 6% to 9% of type 2 patients.
Glycemic control is effective in mild to moderate nephropathy.
Retinopathy
The cumulative incidence of retinopathy can be reduced by more than 50% with intensive insulin
therapy. Glycemic control is effective in mild to moderate nonproliferative retinopathy.
Neuropathy
Autonomic neuropathy most commonly presents as impotence. In contrast to other diabetic
neuropathies, mononeuropathies resolve almost completely within 1 year of onset.
PRINCIPLES OF MANAGEMENT
Prevention
metformin proved effective in preventing type-2 disease, but less so than lifestyle modification,
underscoring the importance of lifestyle change. metformin is probably preferred over rosiglitazone for
prophylaxis, having the better safety profile.
Treatment Goals
maintaining blood glucose concentrations close to the normal range (e.g., HbA1c less than 7.0%) delays
the onset and limits the progression of the long-term microvascular complications of diabetes.
Treatment Strategy
fasting glucose level is the most important determinant of daily glycemia, efforts to normalize it are
given top priority.

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.

Biguanides (e.g., Metformin)

Impaired renal function (creatinine greater than 1.5 mg/dL in men and greater than 1.4 mg/dL in
women) is a contraindication for use.
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.
Unlike the sulfonylureas, metformin is effective even in severe fasting hyperglycemia (greater than 300
mg/dL).
They are also the only group to show a reduced risk for macrovascular complications
Adverse Effects
The most common side effect of biguanide therapy is dose-related gastrointestinal upset
Lactic acidosis represents the most potentially serious adverse effect.
weight gain does not occur.
Patient Selection
Obese patients are particularly good candidates for metformin therapy.
The typical candidate is a moderately obese person with type 2 diabetes who has persistent moderate
hyperglycemia (fasting glucose between 140 and 240 mg/dL, glycosylated hemoglobin greater than
7.0%) despite a full program of diet and exercise. Other candidates for metformin include obese
patients who do not achieve tight control while taking a sulfonylurea at maximal doses.
Some diabetologists use metformin to supplement an insulin program in obese type 2 diabetics who
require large insulin doses and have difficulty losing weight.
Thiazolidinediones
The main sites of action are muscle, fat, and liver, with improved sensitivity to insulin.
About 25% of patients manifest no benefit.
Adverse Effects
The most worrisome adverse effect is idiopathic hepatocellular injury.regular monitoring of
hepatocellular enzymes is recommended.
Weight gain
Edema.
congestive heart failure.
Alpha-Glucosidase Inhibitors (Acarbose)
Its efficacy is about midway between that of diet alone and that of oral agents.
its gastrointestinal side effects (see later discussion) limit its clinical acceptability for long-term use.
Adverse Effects
The principal side effects are gastrointestinal.
Use with oral hypoglycemics or insulin may increase the risk for hypoglycemia, which must
be treated with glucose.
Concurrent use with metformin is problematic because acarbose potentiates the bioavailability
of metformin and exacerbates its gastrointestinal side effects.
Glitinides
This new class of hypoglycemic agents act like a rapid sulfonylurea.
Drug Therapy: Insulin
Insulin is the drug therapy of choice for:
diabetics in whom ketosis develops.
for patients with symptomatic type 2 diabetes whose disease cannot be controlled by diet
alone or a program of oral-agent therapy.
for diabetics in whom near-normalization of blood sugar is a goal of therapy.
Insulin therapy should be initiated with a human recombinant insulin preparation.
insulin analogues provide improved performance characteristics that can be important in selected
patients.
Standard Preparations
The standard short-acting insulins, regular and Semilente, have an onset of action of 30 minutes, a peak
at 2 to 4 hours, and a duration of 5 hours. Principal use is for prandial glycemic control.
The intermediate insulins, neutral protamine Hagedorn (NPH) and Lente, have an onset of 2 hours, a
peak at 6 to 10 hours, and a duration of 8 to 24 hours, making them useful for basal glycemic control.
The standard long-acting preparation is Ultralente, used principally in intensive regimens to provide
basal insulin by means of a once-daily administration.

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.

Basic Management for All Diabetic Patients

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.

Patients with Type 1 Disease

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.

Patients with Type 2 Disease

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:

Begin oral-agent therapy with either a second-generation sulfonylurea or a biguanide. Choose

metformin if the patient is obese.
If after 4 to 8 weeks of monotherapy glycemic goals have not been achieved, then add a
second oral agent from a different class (e.g., metformin if a sulfonylurea was given first and
vice versa) or add a small dose of an intermediate-acting insulin taken before bedtime. If the
sulfonylurea was the starting drug, reduce the sulfonylurea dose to avoid the risk for
prolonged hypoglycemia.
If after 4 to 8 weeks of two-drug oral-agent therapy control has not been achieved, then
consider adding either a dose of intermediate insulin before bed or a third oral agent.
If adding a thiazolidinedione (e.g., pioglitazone, rosiglitazone) start with a low dose and
monitor liver function (ALT) monthly for at least the first several months, halting therapy at
the first sign of persistent elevation. Until proven hepatically safe, consider thiazolidinediones
only if all other attempts have failed to achieve reasonable glycemic control and the patient is
reliable, free of underlying liver disease, and willing to have close monitoring of liver function
tests.
If a program of insulin supplementation is considered, be aware that initially supplementing
oral-agent therapy with a small bedtime dose of insulin may suffice, but usually latter stages
of type 2 disease require insulin as the mainstay of the treatment program, supplemented by a
thiazolindinedione or metformin to reduce insulin resistance and keep the insulin dose
manageable.

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:

Begin insulin therapy with an intermediate-acting insulin preparation at a modest once-daily

dose (e.g., 10 U before breakfast).
Specify human recombinant insulin for newly treated diabetic patients to minimize the risks
for insulin allergy, insulin resistance, and antibody development.
Advance the insulin program according to glucose monitoring results with reference to target
levels.
If high doses of insulin, poor control, and weight gain become problems, consider adding
metformin to the insulin program to improve tissue responsiveness and reduce insulin
requirements and weight gain. A thiazolidinedione can also improve insulin responsiveness
and control but does not halt weight gain.

 Approach to dysuria and UTI in women - 133

: 50%-
UTI , 0.5-0.7% .
25-50% .

.
: , .-
20% . -
UTI .
RF : ) 30%( , UTI ,
, UTI , .(a-,b-) ,(a+,b-) lews
" ) staph. Saprophytus 74%-( .
!!.
: acute urethral syn- .pyelonephritis- ,,
, /.
-Acute urethral syndrome (symptomatic abacteriuria) .1 10-15%-
,UTI 105- /" .
,UTI- 70%- ,WBC=2-5
"G " . 30%-
, ,
interstitial cystitis .
:symptomatic bacteriuria .2 : , , ,,
. : , , .
.
:recurrent infections .3 relapse (1) :
,AB ) reinfection (2 ,
" (80%) , , .
: , ' , ,,
.
) :( :vesicouretral reflux <- <-
<- ) .RF <-( : prematurity ,
)( DM .
:DD ,UTI : ) ,( , ) .(HSV ,
.
,renal colic : .
:Workup

:Acutely ill patient

. ,DM : , -
papillary necrosis ,sloughed papillae
renal colic .
:Dysuric patient , .STD
UTI 95% <-.
" : , , ,
.
(1) : : ) ' ,(885
. , -
75% (2) .82% 105 : , .
, .
,staph. Saphrophyticus 5-15% ,e.coli 5-90% : :
.staph. Aureus, enterobacter ,GBS

 : .
:
Acutely ill patient .1 / : , , IV ABx-
ampicillin + levofloxacine : impenem + ceftriaxone
. IV AB
PO- 14 . : PO
.
.2 : , 10-14
" TMP . "
. " .
:Uncomplicated lower UTI .3 , 3- " ,TMP
.amoxicillin, fluroquinolone ,DM , ,
, < ,65 7-10.
:Acute uretral syn. .4 : ) ,(3 "
5 . : ) , (phyazopridne uricet
:Recurrent inf. .5 " .
AB :/
/TMS . : .
TMS
.
.6 .
.7 :/ / PO .
Netrofurantine .
.AB
: , ,
,UTI- .

 - 147
.
. :
97% / 70% / 10%
/ 4% / 3% / 2%
1%
1% / 0.7% / 0.01% 0.3%
- 2% / / /
- ILIAC CREST . ,
, , . ,
".
,
, . " .
) ( SCIATICA,
) ( . ) S1 L5 (S1
, , ,543 , , .plantar flexion L5
) ( L5 L4 , .12
. .
- Spinal Stenosis , .
, . ,
.
) .(pseudoclaudication - 15% 70%, ,
10%.
Spondylolisthesis 10% , L5-L4
,S1-L5 .
, , .
95% - L4 .L5
, , ,GI , , , ,
)80% .(50 ,
' . ) ( .
, ,
, ) UMN , , , (
.
, ,UTI , , .
.LP , ,
ESR , , . .Staph. Au.
ankylosing spondylitis, psoriatic arthritis, IBD, reactive
.arthritis . . ,
,27HLAB , 3 , , .
, .
. .
Cauda equine syndrome L2 ,
, , , .

, , , , , ,
, , . ,
, , Straight Leg Raising Test . .

 . 30-70
. .90
20-30 .
) ( .
. . 80% .40%
.L4 , ) UMN,
,( . S1 , , .
L5 , , , . L4 ,
, . " - ,
, , , , ,
. MRI .
. ,
. MRI , , , .
MRI .
, ..EMG ,

. 33% 7
66% ) ( . ' - , NSAID
) ( , NSAID
. ,
BZD ) ( . ,
. 20
."
. , )( ,' 3-4
,
. )( , . , ,
. , . .
, , .
, ,
' , ,
MRI . .1
' .2 4-6' . DISKECTOMY
. .GOLD ST 6%
80% 6% .
.
.
. 3-4'
) 25-50%(.
.75% .
- 20-30 / /
.
. , .
. .
.
.
.
SSRI TCA .
" .

 NSAID/ .
.
,(SSRI) DUOXETINE ,TCA .Nerve Block ,
- Spinal stenosis ' NSAID , 60% .
, .50% NSAID
. . .
- " NSAID , .
. , ,
' . .
' ".
" - ,
. , . '
) ( . ' ,
. ' ...
.

 Approach to the Patient with Headache - 165

1% - . :
, , .
: Pathophysiology and Clinical Presentation
/
.
: Intracranial Sources (I
,5,9,10 , , ,
) ( anterior and middle meningeal
. ).(pain sensitive
, .
" ,
.
: Mass Lesions (1
" . , .
" , . : , ,,
, . . ,
.
, , , .
.
( : Brain Tumor
)
( . ) mass lesion -
(.
( : Chronic Subdural Hematoma
. ,
.
( : Pseudotumor Cerebri
. : , -
.CT
: Nonmigrainous Cerebrovascular Sources (2
:" , . ,
AVM . "
.
, , . ,
2" . , .mass lesion - ,AVM
10-15% , . ,
.
: Migraine Headache (3
10% , 3 . , )
( ." . .
. . ) ( : / .
. : , ,
) , ( . )
( . , .
. : :( : , , ,.

( : ) , ,( , , .(
: . 24-48 .( : , ." 12
)/ ( .
: Meningitis (4
, , .
" "
.
: Postconcussion Headache (5
.
: Post concussion syndrome , , , ,
. .Tension-Headache
.
: Extracranial Sources (II
: , , . ,
.
: Tension-Type Headache (1 . 90%-
) (band-like . , ,
, . ,
. : , .
: Sinusitis (2 . )?(
. , : DD .
, .mass lesion -
: Giant Cell Arteritis (3 ) < .( 50
) ( . .
, / . .
jaw claudication ,
.polymyalgia rheumatica
)/ ( . )
50% (.
: Tempromandibular Joint Dysfunction(TMJ) (4 . ,
malocclusion )( . :
, . .
: , ,
. Molar prominences - .
: Cluster Headachce (5 . )
(. : , ,- ) (
, , .20-40% -
.
30-90 . / , ,
/ . 10% - Chronic Cluster Headache
/ . : DD . ,
.

: Indomethacin-Responsive Headache (6
: Chronic paroxysmal hemicrania , . ,
) 10-20 ( 20 30 . Ice .
: Prick Headache . , Hemicrania .
: Continua .
: Systemic Infection and Fever (7
. : . : ,CO
.
: Hypertension (8" - ) < 110" ( )(
. . .
: Ocular Sources (9
. ,
. , Acute .
: Glaucoma .
: Cervical Radiculopathy (10" .
. ) ( .
. .
. " .
) ( . : Occipital neuralgia :
, " .
: Trigeminal Neuralgia (Tic Douloureux) (11 .
.
' . : ,,
.
: Syndrome of Chronic Daily Headache (III 15 -
.
: DIFFERENTIAL DIAGNOSIS . . : /
.Tension-Type ,Cluster ,
: WORKUP / .
, . WORKUP -
.
: History
, , , , .
: , , , , ,,TMP/SMX ,
/ , . "
: , ,nalidixic acid , ,TMP/SMX ,,
.
: Headache of New Onset (1 , ,
. , . , gait ,

 ,ataxia .midline cerebellar hemorrhage

Hypertensive Encephalopathy .
, , .
. .acute glaucoma
.temporal arteritis ,migraneous epiphenomena
, , drug withdrawl ,CO - .
12 -
.
: Recurrent or Persistent Headache (2 : ,Tension-Type - :
. , mass lesion - .
.Tension-Type
. , )
( . ,
Tension-Type . ,
. , , .
.
TMJ - Jaw claudication . .GCA
.Cervical Radiculopathy .
, , , ,substance abuse ,: Rebound Headache .
,
. , .
: " , mass lesion -
. . "
) , , ( " ,
. Cluster Headache - .
: ,ethinyl estradiol ,,
, , , . :
: , ),
, ,(renal cell , .
Physical Examination
: Acute Headache (1 " ,' , , ,
, ) ,( acute glaucoma ,
. : , , .
: Chronic or Recurrent Headache (2
" . :
Trigger Zone ,Trigeminal Neuralgia -
TMJ ,
. Tension-Type Headache -
, .
. mass lesion -
. : , ,
, .
Laboratory Studies

 : Acute Headache (1 ,
, ICP - .
CT , ) midline ,CNS -
.( cerebellar hemorrhage LP" )
ICP( . ICP - ,< ,60 ,
,CNS .
,GCA , ESR
.
: Chronic or Recurrent Headache (2
, .
, .
:( ) recent onset 6 -(
.( Tension- -
.Type( ) mass lesion -( .(
.(
) ( ,
CT MRI -.
PRINCIPLES OF MANAGEMENT
Migraine
,
.
: Prophylaxis (1 ' " .
" . ,
.
.
( : .
. ) (.
( )( : .

. ) (2 .
: BB , .50% -
.
: CCB . .BB
.sustained-release formulation -
ACEi : Angiotensin Blockers ARBs - 50% -
. .30%
: TCA . .
: NSAIDS . , .

) AEDs ( Valporate :
. :.
: ) 400 (VitB2" .
: Abortive Therapy (2
. ,
NSAIDS - .ergot compounds - stepped :
care Stratified care .
, MAOI , ,
.
( ) ) : Triptans ( Selective 5-HT1B/1D Agonists(
. ,
) ( .
.rebound phenomena - /
.
, MAOI :" CAD , .
. SSRI .
40% : .chest-related .
( SC, IM, IV : Dihydroergotamine . ,CAD,PVD,TIAs :
.
( NSAIDs : .
. , .
( : , , NSAIDs - ) (
) ( . 30
, , , .
(3 : .
.
: Cluster Headache ) 5-8 10
( Ergotamine .
. ) ( IM/IV ) ( SC .
) ( tapering -
.
:
, , sphenopalatine ganglion block , Radiofrequency .
trigeminal rhizotomy .
: Tension-Type Headache tension-headache - ,
) , ( NSAIDs , .
. :
.

 :
(1 , ,
.
(2 .
(3 .
.acute glaucoma -
.Elective Referral
) (.

 - 166
:

Acoustic neuroma (and other tumors ,Ototoxins ,Meniere's ,BPV
)Acute labrynthtis (vestibular neuronitis) ,of the cerebellopontine

,Migraine associated Vertigo ,Vertibrobasilar insufficiency ,MS
Drugs
volume depletion and ,Carotid sinus hypersensitivity ,Critical AS
,Autonomic insufficiency (drugs, diabetes) ,severe anamia
Diminish vascular reflexes of the eldery
,Cataract surgery ,DM ,Cervical spondyliosis ,MS
Cerebellar disease
Psychosis ,Depression ,Anxiety

hypcapnia / hypercapnia ,severe hypoglycemia ,Hypoxia

aortic stenosis AS ; benign positional vertigo BPV ; multiple sclerosis MS

)" " " , "( .

, . /
.

:
- .
' :
BPV

) 60 >(

,

'
6-

semicircular-

) (diabling positional vertigo
, ,
, ) (
' ,
' /

-
semicircular

Meniere's

Acute labrynthtis

(vestibular
URTI , ,
)neuronitis
) (
3-6 ) (
vestibular neuronitis HSV-1
Ototoxins
peripheral apparatus- )
(
, , ) ethacrynic acid
(
th
Acoustic
benign schwannoma of the 8 cranial nerve
neuroma

(and other
, )(
tumors of the

)cerebellopontine
cerebellar-pontine angle-
) ,
, ( , !

? ,

:
, 1
. ' :
MS

Vertibrobasilar
insufficiency

Migraine
associated
Vertigo

,
'
, MS

MRI

) , ,
, , ,(
inferior cerebellar -
) artery TIA (CVA-

(ischemic pontine rarefaction) Pons-
)
(aura

? /
, , ,,
,

1 , , , , ,

Drugs

-
) , (
) , (

? ),
(

) ,AS ,
" ( . )"
(.

, .
, .
) ,( .
, ) , ,
( . ,
. ,
, , midline cerebellar -
.hemorrhage

. , , , )
( .

. ,/ ,
.CNS-

, )( , "
, , ) .( 2 Rinne ,
Rinne 2 8 .
- ) speech
discrimination , .
20%- , 70%- ,
(

 , AS
.
, )
,(5,7,10 , , ).(Romberg

:
.1
.2

.3
.4
.5

30-120
) (

)
(
/
/
Fukuda-step test ,

Dix-Hallpike (Baranay) Maneuver
. , ,
.
)" ("...

) (Dix ,Romberg ,Rinne :

(1

(2
(3

Romberg- /

:
(1
(2
(3
(4

3- !
) Dix- 3-40(
) 30-(
) !(

:
Electronystagmography and/or audiology testing
.1
acoustic neuroma- brainstem auditory evoked
.2
response
3
MRI cerebrllopontine -
.3
) angle
(MRA
) (:

BPV

) 80% Epley (canalith-repositioning maneuver
30% , ) (


(meclizine, promethazine) vestibular-suppressant
.
.

,dimenhydramine
Vestibular Neuronitis

,

meclizine-
BPV
Meniere's
) 1 (
acetazolamid


Lorazepam

3 abuse vestibular
schwannoma .1:9000- .1:600

Epley

AS


,
) (SSRI

 - 199
.self limited-
.
:
" . .
:
(ciliary flush) cornea- cornea- .
.conjunctivitis
5- :
conjunctival pathology .1
conjunctivitis . , )
( , , , .
) .(H.aegyptius -
.
, ,
. .
, ,atopic dermatitis .
) ( .
.
, , .
corneal disease .2
,ciliary flush , . .cornea-
:cornea- , , , .
uveal track disease .3
uveitis , ,ciliary flush , ! .
.slit lamp , ) ,JRA' ,
(.
.4 orbit-
orbital cellulites ,chemosis , , , ,
.
intraocular disease .5
acute glaucoma ! ,ciliary flush ,
, , , , ." .angle closure glaucoma
:
: , , .acute glaucoma ,cornea-
.cornea-
:
Conjunctivitis , " .
, ,
. .
Corneal disease . cornea- !
.
-Iritis , .
Acute glaucoma 500" 120" .
, . !

 -219

.
.
7-10 .
. : , , ) ( , ,,
.
: , . -

, , . 2-3.
:' ,.
-
.1 ) -(OM OM . , ,
) .(Pott's puffy tumor .
.2 - .
-Cavernous sinus thrombosis .3 . ,
, ,3,4,6 .
.4 - , ,
Workup
- . :
, , , , )
(.
. - .

- , , , .
- ) ( , ,
- ) , 60%-( .
.
-CT . .
.gold standard - .
- ) .self-limited (
:
.1
.2 - 7-10 . TMS
7-10
.3 / -
.4 - , ,
:
.1 -
.2 -
.3 -

" ..
.1 - , , , , ,
, . "
.2 .. : , ,
) 3(

 Approach to the Patient with Pharyngitis - 220

: ) ,GER , (sleep apnea ,irritants
: , )' ,( , )(.
,strep. Pyogens RF .
Group A-Hemolytic Strep Infection

.strep group A-
o : , , , , ,
.38.3
o ) URI ,( 25%- .
o " 7-10.
o:
) '(peritonsillar ,peritonsillar cellulitis :
) scarlet fever ,abcess .(strep. A
:Acute rhematic fever" ,5-15 "
:Acute GN " .

Other Streptococci
Group C, G . . .
.
Viruses
adenovirus, parainfluenza virus, and rhinovirus .
(IM) EBV 5-10% . 50%- , 33%-
. ) ' (IM
HSV ' . .
) coxsackie A infection (herpangina " .
HIV ) (acute retroviral syndrome .IM
" ) . (
Meningococci 5-15%- . .
Diphtheria- . .
Pneumococci and Staphylococci , . .

... Fusobacteria
,' ). " Candida
( ,
WORKUP
:strep. Pyogens group A-
, 0-3 . , - : o
. , + "
, , : o
.GAS-
: o
sensitivity ranges from 85% to 90% and Rapid Strep-Antigen Testing
.specificity from 95% to 99%.
. Throat Culture
. :
Suspected S. Pyogenes Infection
: o
Centor score, in which one point is assigned for each of the following:
temperature greater than 38.0C (100.4F), absence of cough, swollen or
tender anterior cervical nodes, and tonsillar swelling or exudate.
Recognizing the lower prevalence of streptococcal infection in adults, the
score subtracts one point if the patient is age 45 years or older
.ARF , o
.
. o
: o
single intramuscular injection of 1.2 million units of benzathine penicillin

10-day course of oral phenoxymethyl penicillin

In the patient allergic to penicillin, oral erythromycin
:
Rifampin . Meningococcal o
ceftriaxone Gonococcal o
clotrimazole ,nystatin o

Approach to the Patient with Anxiety - 226

Neurotransmitters: norepinephrine (from the locus ceruleus), GABA is implicated
as serving an anxiolytic function within the limbic system.
The components of anxiety:
1. Affective component- the experience of dread, foreboding, or panic.
Normally, it is countered by cognitions that make sense. In the pathologic
form, other components of the clinical presentation may be exacerbated by
cognitions, such as catastrophizing.
2. Psychological presentations- complaints of apprehension, motor tension or
agitation (restlessness, edginess, jitteriness), and heightened arousal (including
hypervigilance, distractibility, impaired concentration, and insomnia).
Types of anxiety disorders:
1. Adjustment Disorder with Anxious Mood
When a patient's capacity for coping is overwhelmed, excessive anxiety may
transiently emerge until the patient is able to adjust. This typically resolves in less
than 6 months.
2. Generalized Anxiety Disorder
Anxiety lasting longer than 6 months and worry extending beyond a specific subject.
Rumination with worries over a variety of concerns for several years. Also an array of
physical concomitants, including restlessness, fatigability, poor concentration,
irritability, muscle tension, and insomnia.
3. Panic Disorder
Recurrent unexpected panic attacks, with at least one attack followed by no less than
1 month of persistent concern about having additional attacks, worry about the
implications of the attack or its consequences (e.g., losing control, having a heart
attack), or a significant change in behavior related to the attacks. Many patients
become disabled by anticipatory fear of subsequent panic attacks and by phobic
avoidant behavior patterns. The paroxysmal nature of panic attacks and the
prominence of autonomic symptoms may mimic cardiac or neurologic disease.
4. Phobias
A phobia is an irrational fear related to a specific stimulus. This includes Social
Anxiety Disorder (Social Phobia).
5. Obsessive Compulsive Disorder
Obsessions are unwanted intrusive thoughts of a bizarre, senseless, or extreme nature.
The recurrent and persistent thoughts, impulses, or images themselves become a
source of anxiety. Compulsions are repetitive behaviors that are performed in a
stereotypical or ritualized fashion, usually in response to obsessions, sometimes in an
effort to neutralize them.
6. Posttraumatic Stress Disorder
Is characterized by persistent reexperiencing of the traumatic event, via intrusive
thoughts, vivid dreams, or flashbacks. Other requisite characteristics include
avoidance of stimuli associated with the trauma, hyperarousal (e.g., increased startle
response), and persistence of symptoms for more than 1 month. PTSD may develop as
a consequence of medical illness or procedures (e.g., amputation or cardiac
defibrillation). Medical settings may serve to trigger reexperiencing phenomena.
Substance Abuse
Anxiety is often poorly tolerated, leading some patients to seek relief through use or
abuse of anxiolytic substances. Chronic use of sedating substances can lead to neural
irritability and can cause or exacerbate anxiety after withdrawal. Patients with anxiety

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

leads to receptor adaptation (tolerance) and the development of physical dependence.

Withdrawal is usually accompanied by only mild symptoms but may include rebound
anxiety, involuntary movements, insomnia, psychomotor restlessness, and perceptual
changes. Severe withdrawal symptoms are unlikely unless high doses or a highpotency preparation (especially a short-acting one) has been used daily for a
prolonged time period and then halted abruptly. In such cases, a delirium tremens-like
syndrome may develop.
B. Antidepressants- SSRIs are first-line agents in the treatment of anxiety. TCAs and
MAOIs are generally used in the treatment of refractory patients.
Therapy is often initiated with BZDs to offer some immediate relief. Concurrently, or
after anxiety symptoms are attenuated, antidepressant medication may be added. Once
the antidepressant agent has become effective, the BZD may be tapered down and
even discontinued.
C. Buspirone- is a non-BZD anxiolytic that acts as a partial serotonergic agonist and
has mild anxiolytic and antidepressant effects. Because of its benign side-effect
profile (nonaddicting and no withdrawal), buspirone is a reasonable alternative to
BZDs in cases where chronic anxiolysis is required, especially when substance abuse
or noncompliance is a concern. Its anxiolytic effects are modest compared with those
of the BZDs, and onset of action may take weeks, rendering the drug ineffective for
single-dose use and of little help to patients with severe symptoms.
D. Beta-Blockers- blunt the peripheral catecholamine-mediated manifestations of
anxiety. As such, they are very useful on a short-term as-needed basis for
performance anxiety and stage fright.
Anxiolytic Pharmacotherapy in the Elderly
Because drug metabolism is slowed in the elderly, excessive sedation is a risk with
anxiolytic therapy, especially with use of long-acting agents.
Benzodiazepines - nighttime use of a short-acting agent that has no active metabolites
and in patients whose metabolism is relatively unaffected by aging is preferred.
Elimination of active drug metabolites lengthens with age, markedly prolonging drug
half-life. Accumulation of active metabolites can cause diminished alertness and
impair memory acquisition, mimicking dementia. Excessive sedation may cause a fall
with serious injury.
Antipsychotics- anxiety accompanied by agitation or specific psychotic
manifestations may require short-term antipsychotic therapy. The atypical
antipsychotics have become first-line agents for this indication.
Antidepressants- SSRIs are the best tolerated. Of the TCAs with anxiolytic activity,
those with low anticholinergic and antiadrenergic side effects (e.g., nortriptyline) are
preferred. Because antidepressant metabolism slows with age, one should start with
half the usual dose and titrate up slowly.
Beta-Blockers- require particular caution, given the prevalence of congestive heart
failure, heart block, and obstructive lung disease in the elderly and their susceptibility
to such side effects as cognitive blunting, nightmares, and depression.

 - 227

, .

,
.

: ) , ,
( , ) , ( , )
, , ( ,
) ,CRH , ( ,.
.

MDD 3 ,
.

: , , , , '.

- : - . ,
, , , - .
- , .

: - , 75%
.

) MDD( : , 4 -
) , , / , ,
, / , , ( .
) ( .

MDD ' : , , , .

MDD : . 50.

: + MDD . :
+.

: . ,
- .MDD- / ,
, .' -
.MDD : ' -
.

MDD : MDD . MDD

.

: , / /
/MDD . . :
.

:Seasonal affective disorder 5 ,

" , .

:Adjustment disorder w/ depressed mood ,

,MDD- ,self-limited 6-
. ' ,MDD
!

:Post partum depression 10%- , .

: , - , . :
, , / .' MDD 4
. 3 .

' , 50% , -
MDD 1/4 1/8 , . .
, , .

: .
:- ,- ,Bz , , ,CNS
,B , , , ,H2.

Lyme disease, -
.chronic fatigue syndrome, fibromyalgia, rheumatoid disease, endocrinopathy
MDD- ) ,
(.

: ,- , ,
, , , , ,DM ,Subdural ,
,hematoma , , , , , ,HIV ,
,AIDS , ,pellagra ,B12 ) ( , )
(.

: ) ,
6- , ' - ,
( , )
, ( , -
- , )
- . ,
' (.

:' - , , , .
, "
.

BB , .BBB
CNS- .BBB

.
.

: ) (

: , . digit span
, .
) ,( . ,
.organic brain syndrome-

: 15% .
' , .
, .
. - , ,
,
.

)( : , ,' )
( , , , ) 75 55-65 ,( , )
3-4 , 2-3( , ) , , ,,
( , ) , ( , ) 50%
, , ,
(.

) ( : , ,
, . .

, .
/ .
// ,
. 1-
.TCA

: , . -
Dexamethasone suppression .

MS .MRI- MRI
,
.

21 - Beck : 21 - Hamilton .self administered , , " .

, , .
= . ',90-95% :
.50-70% : .

: 10% , ,
." .
. 30%
.

96% ) 57% (:
.1 , ?
.2 ?
PPV ) (25-40% pre test probability .5-10%
FP .
,GAD , , , ,.

: ) (MDD .
, , ,
) (.
:MDD o ' .
o : ,
.
o : , .
o ) ( : ,
.
o : .' -
) (SSRI . 5
MDD.
- Adjustment disorder w/ depressed mood o
.
/.

: . .
.

-
,
. 1-2 .

- CBT ,
.
, . , .

.

/ - , .

SSRI - TCA , .SSRI-

MAO-i .

:SSRi 3-4 . : -
TCA , TCA- , .
SSRi .TCA TCA- . ,
" RCT .TCA SSRi-
, " . ,
. - ,
" " .
. ,
.

" :SSRi
o - , , , , .
o - , .
o )( 20%-
o ) TCA- , ( "
, , , .
o - , ,
." . ,30-70%-
,
. : , , ,,
, .drug holiday , - -
RCT 50%
. .
.
o , .TCA-
o , ,.

SSRi ,MAO-i SSRi 5-

.

, , - CytP450
, '.

SSRi , -
.

- withdrawal syndrome , .SSRi , ,,

, . 0.1%- .

: : 20-" 10-20- 4 , 20 40
.80 ) 2-3( ,
20-" . : , .
100-250".

SSRi- , .

:TCA .SSRi .
, " ,
. .
reuptake NA / . -
TCA . 3-4 .
" . . "
" .

:TCA
o ..
o .
o - BPH - ,.
o - orthostatic hypotension.TCA-
o - .SSRi

+ TCA - Bz / .
TCA .
,
.

" :TCA
o
. 1-
.
o " - , .
o , , , -
, , . .

 o - " .TCA
o , , - ,
. " 40 . /
.
o . BBB, AVB
SN- ."
.
o - , , , .
. :
)( , , , ,
OTC .
- withdrawal syndrome o , , , , , -
,SSRi- , ,25-50%- "
.

: , ,
,
. . 10%-
TCA . " . -
50%.

: SSRi- :
o - ,SNRI - ,
.
o - SNRI - , .
o - SSRI - , SSRi-
o - .
. .
o - ,TCA- . . " ,
, , . , , .
o - - .NA-.

:MAO-I " , ." : ",

. " .
. " .
.

.MAO-i , .
. ) OTC ,( ,SSRi ,,

 . : ,
.

- - , ,
. .MDD- - ,
" , . .MDD-
.

- St. John's wart , MDD- ,

. ) . (Goroll

: , , , , "
, ,.
o ,BPH " , SSRi - .
o " - , .
o - ,SSRi - ,.
o ' - -.

: 4 )6-
( .
) ( .
.

) ( . /
.

" ,
.

, 6-9- . -
, .
. 70%- 36- .

- , 4 , .
- 6-9 30% .
80% , . 2-3
3-5- .
.

: .
: ,-
. .

: .
.ECT ".

 o- , SSRi - . , , -
- ,
'.
TCA o . ,".
, .
o - , .
o ) 10" ( , 5-7 ,
, , , " .
2 , 8-10 ,
.
, MAO-i .ECT
:MAO-i o , ,
, . ,
.
:ECT o , ,
.
. . : ,
" ,
. .
.
ECT . " ,
.

:Seasonal affective dis. , SSRi ,

.

- ,10% ,IUGR- )
( . SSRi- TCA-
, , ' .
.3 .
,
, 30-50%- .

- ,
. .
. , .SSRi
SSRi .
, 6-9 .
50-85% .

MDD : , , , ,
, 1-2.

: , ,
, .

- ,
" , ,
.