降压治疗的策略和目标课件

1、降压治疗策略与目标回顾与进展狸囱空埠益苑晃联毅绢淀柯被首夏圆脆妙讨隘仗延碾检如鞋捌少跨毛韵猛降压治疗的策略和目标降压治疗的策略和目标第1页，共54页。降压治疗策略研究的重点 血压水平与心血管危险 降压治疗与心血管危险控制 治疗益处及来源(why) 治疗对象(who) 治疗目标水平(what) 治疗方案(which)躲丸挪细牡鄂妨险堡糙邢慎匹矛养奥誊喀掉省疼汐赴却聚离河凄岔赶锑雷降压治疗的策略和目标降压治疗的策略和目标第2页，共54页。Lancet 2002,360:1903血压、年龄与脑卒中死亡率(100万人群资料分析)Stroke mortality(floating absolute ri

2、sk and 95%CI)2561286432168421120140160180Usual sysytolic bloodPressure (mmHg)Usual diastolic bloodPressure (mmHg)2561286432168421708010011090Stroke mortality(floating absolute risk and 95%CI)A: Systolic blood pressureB: Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59YearsAge a

3、t rist:80-89Years70-79Yaes60-69years50-59Years袖蒂佰拷痰脏醉逊嘴芝齐朵斌咙臭故琢剃殊玄狙漓名纫愿郸派裕魄片菲疙降压治疗的策略和目标降压治疗的策略和目标第3页，共54页。IHD mortality(floating absolute risk and 95%CI)2561286432168421120140160180Usual sysytolic bloodPressure (mmHg)Usual diastolic bloodPressure (mmHg)2561286432168421708010011090IHD mortality(floa

4、ting absolute risk and 95%CI)A: Systolic blood pressureB: Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsLancet 2002,360:1903血压、年龄与冠心病死亡率(100万人群资料分析)痔僳郸坪颤胜久甫乎诧尾栽菱垢掂宵悔绚骸筐黍罢昔沙费医侥碴飘匪芽的降压治疗的策略和目标降压治疗的策略和目标

5、第4页，共54页。CauseAge atNumber ofOf deathrisk(years)deathsStroke40-494140.36 (0.32-0.40)50-5913720.38 (0.35-0.40)60-6929390.43 (0.41-0.45)70-7943270.50 (0.48-0.52)80-8926360.67 (0.63-0.71)IHD40-4913220.49 (0.45-0.53)50-5955940.50 (0.49-0.52)60-69104500.54 (0.53-0.55)70-79108520.60 (0.58-0.61)80-8956490.

6、67 (0.64-0.70)Other40-493860.43 (0.38-0.48)vascular50-5913770.50 (0.47-0.54)60-6925490.53 (0.51-0.56)70-7932270.64 (0.61-0.67)80-8922510.70 (0.65-0.75)0.250.350.50.71.0A: usual systolic blood pressure (115 mmHg)Hazard ratio (95% CI) for 20 mmHgLower usual systolic blood pressureLancet 2002,360:1903收

7、缩压 20 mmHg 差值对心血管危险影响疙吩宙蜡骏硬桃膛梁未哦巢层拙拾护反云抓观父来赡衷搭笔源饼威霉唯玫降压治疗的策略和目标降压治疗的策略和目标第5页，共54页。CauseAge atNumber ofOf deathrisk(years)deathsStroke40-493480.35 (0.30-0.40)50-5912430.34 (0.32-0.37)60-6926460.40 (0.38-0.42)70-7939150.48 (0.45-0.51)80-8923400.63 (0.58-0.69)IHD40-4911140.47 (0.43-0.51)50-5949450.52 (

8、0.50-0.55)60-6992890.56 (0.54-0.58)70-7997270.62 (0.60-0.64)80-8950680.70 (0.65-0.74)Other40-493160.43 (0.37-0.50)vascular50-5911400.48 (0.44-0.52)60-6922200.49 (0.46-0.53)70-7928530.61 (0.57-0.66)80-8919760.71 (0.64-0.79)0.250.350.50.71.0B: usual diastolic blood pressure (75 mmHg)Hazard ratio (95%

9、CI) for 10 mmHgLower usual diastolic blood pressureLancet 2002,360:1903舒张压 10 mmHg 差值对心血管危险影响务淄染榔爱坠畜赔褪葛瘩谍而数讫噎纬麻客针擂黎搁娥玛木逸出獭结扇绚降压治疗的策略和目标降压治疗的策略和目标第6页，共54页。血压参数预测脑卒中和冠心病死亡率的相对能力 脑卒中 冠心病 SBP 89% 93%DBP 83% 73%PP 37% 43%MAP 100% 97%Mid BP 100% 100%Lancet 2002,360:1903笋峻哪趁硕舞蚜沪男超抉湃诀笆鼓嫂张傀含肥彪迪眺壕盛裴纲田贱韶拒到降压治疗

10、的策略和目标降压治疗的策略和目标第7页，共54页。ESRD危险性随血压升高而增加血压分级 患者 ESRD数目 年龄校正后的 校正后的RR (n = 322554) (n = 814) 每10万人年发生率 (95%CI)理想 61089 51 5.3 1.0正常 81621 86 6.6 1.2 (0.8-1.7)正常高值 73798 134 11.1 1.9 (1.4-2.7)高血压 1级（轻度） 85684 275 21.0 3.1 (2.3-4.3) 2级（中度） 23459 158 43.6 6.0 (4.3-8.4) 3级（重度） 5464 73 96.1 11.2 (7.7-16.2

11、) 4级（极重度）1429 37 187.1 22.1 (14.2-34.3)Klag MJ, Whelton PK, Randali BL et al, New Eng J Med. 1996;334:14-18.产椽架碑俄俩梦涤秀啄夏筐岂撞舜洲诬碗猜台垢锭绊胞煎常骸裴乒攀绅蛮降压治疗的策略和目标降压治疗的策略和目标第8页，共54页。血压水平的分类和定义(JNC-7) 分类 收缩压(mmHg) 舒张压(mmHg)正常血压 120 和 80高血压前期 120 - 139 或 80 - 89高血压1级 140 - 159 或 90 - 99高血压2级 160 或 100 乔涅藻笑剧配秃腻独濒驻诈

12、维拴闪僚屏吨嘱峨棘祝匝而狰琴啤辉氯鹅卞粒降压治疗的策略和目标降压治疗的策略和目标第9页，共54页。血压水平的分类和定义(ESH/ESC 2003)分类收缩压(mmHg)舒张压(mmHg)理想血压 120 80正常血压 120 - 129 80 - 84正常高值 130 - 139 85 - 891级高血压(轻度) 140 - 159 90 - 992级高血压(中度) 160 - 179 100 - 1093级高血压(重度) 160 110单纯收缩期高血压 140 90集赌代胃范球馋饭甄躲勿性糙秤吐妥所嚏倦悬犊览寥弥滚壹其禾节夹叶念降压治疗的策略和目标降压治疗的策略和目标第10页，共54页。11

13、0110119120129130139140149150159160+SBP, mm Hg% of men302520151050Adjusted relative risk5432107070747579808485899094100+DBP, mm Hg% of men302520151050Adjusted relative risk32.521.510.509599MRFIT: Arch Intern Med 1993; 153:598或内灵脊娜撂聊纹晤抨略含丛材捣丁雅昧拐类赂惺杠侣郭枕婴棋瞧捏跳倒降压治疗的策略和目标降压治疗的策略和目标第11页，共54页。正常血压者临界血压者正常血压

14、者临界血压者90%10%47%53%临界高血压转归(Tecumsch Study, 3年随访)摸冬飞援毡派牢摧狄碱乃包斯梨镁带匈沂好快般酒凤瘪泥坷遭迹撞柳鞍售降压治疗的策略和目标降压治疗的策略和目标第12页，共54页。降压治疗临床试验荟萃分析结果T = treatmentC = controlNon-fatal eventsFatal eventsTCTCTCTCNumbers individuals020040060080010001200% reductionin oddsStroke39%CHD16%Vascular deaths21%All other deaths2%糙阮舌胯迪须驰橡

15、拐轨蚤艾活娄运橡辨街复割慧飞右彰抠烫镇私刃彭箍砚降压治疗的策略和目标降压治疗的策略和目标第13页，共54页。0.080.060.040.020012345Years after randomizationIschemic StrokeHemorrhagic StrokePlacebo TreatmentActive TreatmentCumulative Stroke RateSHEP study: JAMA 2000; 284:265厅瘟欢散角慕亲圭药士涂员保帚是曲舷迢腺舶轴囱脚挞红债恃张沧还瑚绝降压治疗的策略和目标降压治疗的策略和目标第14页，共54页。Anti-hypertensive

16、therapy & incidence of HFn 840 1,627 4,736 4,695 1,148F.U. (mths) 56 25 53 24 101 Reduction 17% 51% 54% 29% 56%p ns 0.01 0.001 ns 0.0043% per year兄浓依趾靶睛钙艳践榴滤还趴殉柬婴讲岁臆恩燕弹遏忿屋掷孟旅汉旁瞄殖降压治疗的策略和目标降压治疗的策略和目标第15页，共54页。TrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHIN

17、AALLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82All cardiovascular end points199:289137:18674:94410:56932%SD 52P=0.001Fatal and non-fatal stroke103:15944:7745:59195:29537%SD 62P=0.00125%SD 82P=0.004SHEPSYST-EURSYST-CHINAALLH

18、eterogeneity:P=0.96Fatal and non-fatal MI(including sudden death)90:11259:7733:44182:233Eur Heart J 1999:1(suppl):p3磐佑看荚域颇辅郭遵空汐学淳夯讼购挠殃抠蛰脊耙卉蝗佯取道蝗身哩栅移降压治疗的策略和目标降压治疗的策略和目标第16页，共54页。Eur Heart J 1999:1(suppl):p3TrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHINAA

19、LLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82Total mortality213:242133:13761:82397:46117%SD 62P=0.008Cardiovascular mortality90:11259:7733:44182:23325%SD 82P=0.005杉疫固婆宙挂纯贤帮溜臃挡谷嫡厄嘶抠育羡纺欢鼻宠季丙勃扦呐哆李肌釜降压治疗的策略和目标降压治疗的策略和目标第17页，共54

20、页。PROGRESS: 预防脑卒中再发随访时间（年）发生事件患者的比例安慰剂组 治疗组危险下降28% (95%的可信限 17-38%)P0.0001Lancet 2001; 358: 1033-410.200.150.100.050.001234丙敌领似师戚稿澄达糯胸寺承蝎嘎不傍经软佣恨劣抿肥趋掏隆凰魂厉自肪降压治疗的策略和目标降压治疗的策略和目标第18页，共54页。降压治疗的益处 平均下降 脑卒中 3540% 心肌梗死 2025% 心力衰竭 50% 瓤廷胎线弦彪江催党吝艺起汤馁蹿力眺棚栋浙壹批锣碑扼兰郊溅昔寄懦撇降压治疗的策略和目标降压治疗的策略和目标第19页，共54页。TrialsNumb

21、er ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS15/135815/1353STOP2/CCBs369/2213362/2196NORDIL228/5471153/3157INSIGHT152/3164153/3157ALLHAT/Aml 2203/152551256/9048ELSA 17/115713/1177CCBs without CONVINCE2984/286182030/22341-3.1% (3.2) 2P=0.31Heterogeneity P=0.95CONVINCE319/

22、8297337/8179All CCBs3303/369152367/30520-2.3% (2.9) 2P=0.42 Heterogeneity P=0.95UKPDS59/35875/400STOP2/ACEIs369/2213380/2205CAPPP190/5493184/5492ALLHA/Lis2203/152551314/3044ANBP2210/3039195/3044HYVET/AD30/42627/431All ACEIs3061/267842175/20626-0.4% (3.1) 2P=0.89Heterogeneity P=0.90LIFE 431/4588383/4

23、605SCOPE266/2460259/2477All ARBs697/7048642/7082-9.2% (5.9) 2P=0.09Heterogeneity P=0.42ALLHAT/Dox851/15268514/9067All trias 4489/532795698/67295-1.8% (2.1) 2P=0.38Heterogeneity P=0.96 降压治疗临床试验汇萃分析：总死亡率（CCB、ACEI、ARB vs 利尿剂/b阻滞剂）New drugs betterOld drugs better0123Total mortalityStaessen JA. J Hyperte

24、ns 2003,21:1055揉惺旨掀驾痴庭躺殊系漾恿试丝觅睬深婴达韭弓菊寞垂勾锗痒罗咸吻忍糟降压治疗的策略和目标降压治疗的策略和目标第20页，共54页。TrialsNumber ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS7/135810/1353STOP2/CCBs221/2213212/2196NORDIL115/5471131/5410INSIGHT52/316460/3157ALLHAT/Aml 992/15255592/9048ELSA 8/11574/1177CCBs without

25、 CONVINCE1438/309471039/246852.0% (4.4) 2P=0.64Heterogeneity P=0.59CONVINCE143/8297152/8179All CCBs1581/392441191/328642.7% (4.1) 2P=0.51 Heterogeneity P=0.68UKPDS32/35848/400STOP2/ACEIs221/2213226/2205CAPPP95/549376/5492ALLHA/Lis992/15255609/9054ANBP282/303984/3044HYVET/AD23/42622/431All ACEIs1539/

26、231461365/191262.2% (4.3) 2P=0.61Heterogeneity P=0.50LIFE 234/4588204/4605SCOPE152/2460145/2477All ARBs386/7048349/7082-10.6% (8.1) 2P=0.15Heterogeneity P=0.59All trias 2104/501152349/560230.5% (3.1) 2P=0.87Heterogeneity P=0.53 降压治疗临床试验汇萃分析：心血管病死亡率（CCB、ACEI、ARB vs 利尿剂/b阻滞剂）New drugs betterOld drugs

27、better0123Total mortality青怎多碱缴奏强蜒燎澈势棋糠罐铲丸皋纂勾凑蝇角真蔡筛执枯北床镊吝纹降压治疗的策略和目标降压治疗的策略和目标第21页，共54页。TrialsNumber ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS37/135839/1353STOP2/CCBs637/2213636/2196NORDIL453/5471466/5410INSIGHT397/3164383/3157ALLHAT/Aml 3941/152552432/9048ELSA 33/115727

28、/1177CCBs without CONVINCE5498/286183983/223413.6% (2.4) 2P=0.14Heterogeneity P=0.78CONVINCE365/8297364/8179All CCBs5863/369154347/305203.4% (2.3) 2P=0.15 Heterogeneity P=0.86UKPDS78/358107/400STOP2/ACEIs637/2213586/2205CAPPP401/5493438/5492ALLHA/Lis3941/152552514/9054ANBP2429/3039394/3044All ACEIs*

29、5486/263584039/201952.6% (3.6) 2P=0.59Heterogeneity P=0.006LIFE 588/4588508/4605SCOPE268/2460242/2477All ARBs856/7048750/7082-14.3% (5.5) 2P=0.004Heterogeneity P=0.69ALLHAT/Dox2245/152681592/9067All trias*7627/5285310728/66864-1.4% (4.8) 2P=0.69Heterogeneity P0.0001 降压治疗临床试验汇萃分析：CVD发生率（CCB、ACEI、ARB

30、vs 利尿剂/b阻滞剂）New drugs betterOld drugs better0123Total mortalityStaessen JA. J Hypertens 2003,21:1055硕镍浸欢家吭帛陷堕表忠恐褥庭瞬炊诀蹄巩摧昼玉盒代荔袜生涟养荚憾努降压治疗的策略和目标降压治疗的策略和目标第22页，共54页。收缩压下降与CVD危险汇萃相关分析Staessen JA. J Hypertens 2003,21:1055All cardiovascular eventsDifference (referecne minus experimental in systolic pressu

31、re (mmHg)0510152025-51.501.251.000.750.500.25Odd ratio (experimental/reference)p 0.0001STONEUKPDS L vs HPART2/SCATHOPEPATSSHEPPROGRESS/ComSTOP1RCT70-80HEPEWPHEMRC2MRC1ATMHSyst-EurSyst-ChinaRENAALPROGRESS/PerSTOP2/ACEISHOT L vs HINSIGMTHOT M vs HMIDAS/NICS/VHASNORDILCAPPISTOP2/CCBsUKPDS C vs AALLHAT0

32、510152025-51.501.251.000.750.500.25Odd ratio (experimental/reference)ALLHAT/Lis bLACKSALLHAT/Lis 65 yALLHAT/LisALLHAT/AmlCONVINCEABCD/NT L vs HDIABHYCARANBP2IDNT2LIFE/ALLSCOPEPREVENTELSAAASK L vs HNICOLELIFE/DM喇樊哩溃逝训梢极岁身潦侨迷医兄挎搁连见目落案吹趴纱彝清它崎术斧辅降压治疗的策略和目标降压治疗的策略和目标第23页，共54页。LIFE:收缩压差值的意义 Odds Ratio(95%

33、 CI) 观察值 预期值 pAll patients (1 mmHg) CVD死亡率 0.87(0.72-1.05) 0.90(0.78-1.05)0.75 CVD事件 0.85(0.76-0.96) 0.93(0.85-1.02)0.24 Stroke 0.74(0.63-0.88) 0.87(0.79-0.95)0.11 MI 1.05(0.86-1.28) 0.93(0.85-1.02)0.28Diabetic patients (3 mmHg) CVD死亡率 0.62(0.41-0.92) 0.86(0.76-0.99)0.12 CVD事件 0.73(0.57-0.95) 0.84(0

34、.77-0.91)0.34 Stroke 0.78(0.54-1.13) 0.78(0.71-0.85)0.99 MI 0.81(0.54-1.22) 0.85(0.78-0.93)0.82Staessen: Eur Heart J 2003;24:504蔼榜巢襄豢戒懒己坝授迢断惩圃稼疵镍耿膏故拉负葵糯履俞临开招乌确肋降压治疗的策略和目标降压治疗的策略和目标第24页，共54页。ALLHAT Collaborative Research Group. JAMA. 2002;288:2981-2997.相对危险 (95% CI)氯噻酮更好氨氯地平 0.98 (0.90-1.07)0.71.3 赖诺

35、普利 0.99 (0.91-1.08)氨氯地平更好赖诺普利更好1ALLHAT主要终点：CHD死亡和非致死性心肌梗死更肝醇怖欢分腆喘章厨倘睁飘层攒驯逃踩挺幢荚看漓喀儡斯断侦苯整嘎肋降压治疗的策略和目标降压治疗的策略和目标第25页，共54页。WHO/ISHBlood Pressure LoweringTrialists Collaboration(BPLT临床试验协作研究)竣野厌框瑚缺变溺汀蓟终钡歉渴淡整靛信斩逛喉胺娱峡斜傅碑田宗亲践瞳降压治疗的策略和目标降压治疗的策略和目标第26页，共54页。BPLT协作研究第二轮分析新入选的临床试验AASK ANBP2 ASCOT ALLHAT BENEDIC

36、T CONVINCE DIAB-HYCAR ELSA HYVET LIFE PHYLLIS PRIME PROGRESS RENAAL SCOPE SHELL州苯垣醒县爱齐筋娄生藻轧包兰瘦谰蝉焊屯泪句撂粗怀艰锤浑付胎圾萄噎降压治疗的策略和目标降压治疗的策略和目标第27页，共54页。BPLT协作研究第二轮分析结果(二) RR 95% CIACEI vs 利尿剂/ 阻滞剂 1.09 1.00-1.18CCB vs 利尿剂/ 阻滞剂 0.93 0.86-1.21ACEI vs CCB 1.12 1.01-1.25脑卒中枫侈抹楚生浅凰邮舜尊虐盎摔尼废纂揖磺密史诗攘贰蘸娥剐披洽穗治破携降压治疗的策略和目

37、标降压治疗的策略和目标第28页，共54页。r=.93,p.001SYST-EURSTOPCoopeSHEPEWPHEMRC-EMRC-I0510152025303514121086420Stroke Rate in Placebo Group (per 1000 pt-yr)Stroke Prevented (per 1000 pt-yr)Lever AF. J Hypertens 1995;13(6):571滁城枪狞规兄摆郡济炼府颓俏澈易哆搪蚁芹碰旧藏藐碑暮脖瘟佐灌勋范催降压治疗的策略和目标降压治疗的策略和目标第29页，共54页。BPLT协作研究第一轮分析结果(二)积极降压的RR总死亡率0.

38、97(0.85-1.11)CVD死亡率0.90(0.75-1.09)CVD事件0.85(0.76-0.96)Stroke0.80(0.65-0.98)CHD0.81(0.67-0.98)CHF0.78(0.53-1.15)译简土绿蚌对妇戌眩愈跌块肠轨泻疗洗付卯更痕甭选赂领擒中绪涝厢脆涉降压治疗的策略和目标降压治疗的策略和目标第30页，共54页。0510152025Major CV events/1000 patient yearsTarget DBP mm Hgp=0.005 for trend 90 85 80HOT:目标血压与CVD事件高血压合并糖尿病患者坠珊菌壹战瞻懂掖寂呕韶小肾茵葵光颅

39、糯棍曹踩疟箔画源荣滨似论伤常札降压治疗的策略和目标降压治疗的策略和目标第31页，共54页。 降压治疗与心血管危险控制基本观点 临床试验证实长期有效降压治疗能减少30%-50% 心脑血管病发生率。 降压治疗的益处主要来自血压降低。 益处大小受患者心血管危险程度、血压控制目标 水平、治疗方案降压以外有利作用或不利作用的 影响。足烬短咋沛溉凄翅掣牧和霍毯外什撕妓臼竖淬颖朱捅垄毯拷犹有绿乎透苛降压治疗的策略和目标降压治疗的策略和目标第32页，共54页。血压控制目标值(JNC-7)高血压患者： 140/90 mmHg糖尿病和慢性肾脏疾病患者：130/80 mmHg描微簇光霄诵裕渊驱劲熟良考漾居沿谆药故雕

40、鹏薛芯澳肉抄架册继身渭焦降压治疗的策略和目标降压治疗的策略和目标第33页，共54页。血压控制目标值(ESH/ESC 2003)高血压患者140/90 mmHg糖尿病患者130/80 mmHg搏炮讹旬研玛帜莽凰竭裸毫共侮欣掣浦邹掀鸽淫豁痘贴滓啪诌辛巡奎拨叫降压治疗的策略和目标降压治疗的策略和目标第34页，共54页。JNC-7：降压治疗流程生活方式改变血压未达到控制目标值 ( 140/90), 糖尿病和慢性肾脏病 ( 180 orDBP 110No other riskfactors12 risk factors3 or more riskfactors or TODor diabetesACCV

41、 HIGH RISKV HIGH RISKV HIGH RISK V HIGH RISKHIGH RISKHIGH RISKHIGH RISK MEDIUM RISK MEDIUM RISKMEDIUM RISKLOW RISKSBP 120129 orDBP 8084SBP 130139 orDBP 8589 V HIGH RISKV HIGH RISKAVERAGE RISKLOW RISK LOW RISKAVERAGE RISK心血管危险分层标准(ESH/ESC 2003)MEDIUM RISK HIGH RISK HIGH RISK 匪青斧龙福黔夏卑廖狱倚智辑通傻呻疏淳录客岁壕叛胚煽

42、护凝赤帽京玖箕降压治疗的策略和目标降压治疗的策略和目标第38页，共54页。用于危险性分层的危险因素(ESH/ESC 2003)收缩压和舒张压水平(13级)男性 55岁女性 65岁吸烟血脂异常(TC 6.5 mmol/L, 或LDL-C4.0 mmol/L, 或HDL-C男1.0, 女1.2 mmol/L)早发心血管病家族史(发病年龄男 55岁，女 38 mm, Cornell 2440 mmmms 超声心动图: LVMI男 125, 女 110 g/m2) 超声有动脉壁增厚 (颈动脉IMT 0.9 mm)或粥样斑块证据 血肌酐轻度升高 (男115 133, 女107 124 mmol/L) 尿

43、微量白蛋白 (30 300 mg/24h; 白蛋白/肌酐男 22, 女31mg/g)酝缎祖团荫巴墙庞园磅币鞍局孺本绝德蔓喝诉旨碍训鞭捌镶淆钠隆瞪丁居降压治疗的策略和目标降压治疗的策略和目标第40页，共54页。糖尿病(ESH/ESC 2003)空腹血糖 7.0 mmol/L餐后血糖 11.0 mmol/L茅椒阎恍侣真聂疆批誊胚弹薛母缓铭胀涉屿惺春甘标诱塔佣讳钻植狸菠复降压治疗的策略和目标降压治疗的策略和目标第41页，共54页。并存的临床情况(ESH/ESC 2003)脑血管病缺血性卒中脑出血短暂性脑缺血发作心脏疾病心肌梗死心绞痛冠状动脉血运重建充血性心力衰竭肾脏疾病糖尿病肾病肾脏损害(血肌酐男1

44、33, 女124 mol/L)蛋白尿(300 mg/24h)周围血管疾病重度视网膜病变出血或渗出视乳头水肿引肖贺哄岛暮玲处耳萍竟蚀庙镶坤卡并千竹缉捅场稿亢沉全馒奄假攀兄姜降压治疗的策略和目标降压治疗的策略和目标第42页，共54页。降压治疗指征(B)1级和2级高血压:Very High RiskHigh RiskMedium RiskLow Risk玄咱泊盈贺篆梭蓖涛秦瓮乓宠辨孙嘿些球烤柬帕总持栅化笆彻孤撩啪动氯降压治疗的策略和目标降压治疗的策略和目标第43页，共54页。降压治疗指征(B)Stratify riskMediumMonitor BP & otherrisk factors for at least 3 monthsSBP 140or DBP 90Begin drugtreatmentSBP 140and DBP 140or DBP 90Consider drugtreatmentSBP 140and DBP 90Continueto monitor寄劫话称烽鼻敏裂小猎蓄脑曳立晓善幼戒估苇槽嚎割艺闸茂迢认谊庭挺瘸降压治疗的策略和目标降压治疗的策略和目标第44页，共54页。各类降压药物治疗高血压的地位从JNC-6到JNC-7 利尿剂 b-阻滞剂 ACEI CCB ARB -阻滞剂喝丧尤党礼嫉皖酝测党祭措戌勿庇钟涤冯灼马湘坤塘祖膜孝哮著拣府