高血压指南的几个问题课件

最新高血压指南的几个问题内容提要关于血压水平的定义和分类关于危险度分层关于卫生经济学关于用药问题高血压患者危险分层--WHO/ISH1999注：《1999年中国高血压防治指南》的危险分层参考的是1999年WHO/ISH指南高血压患者危险分层--2003欧洲高血压指南III级高血压II级高血压I级高血压正常血压高值正常血压其他危险因素和疾病＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋关联临床状况＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋3危险因素或糖尿病或靶器官损害＋＋＋＋＋＋＋＋＋＋1－2危险因素＋＋＋＋＋＋±±0危险因素±：平均危险；＋：低度危险增加；＋＋：中度危险增加；＋＋＋：高度危险增加；＋＋＋＋：极高度危险增加Riskfactorsimilaras1999guidelinesexcept:1.abdominalobesity2.Diabetesasaseparatecriterion3.CRPisadded

血压分类--JNC-VI(1997)

---------------------------------------------------------类别收缩压（mmHg)舒张压（mmHg)---------------------------------------------------------理想血压<120<80正常血压120-12980-84正常高值130-13985-891级高血压140–15990–99

亚组：临界高血压140-14990-942级高血压160-179100-109

3级高血压180

110

单纯收缩期高血压140<90亚组：临界收缩期高血压140-149<90---------------------------------------------------------------

1.DistributionofNHANESIEpldemiologicFollow-upStudyParticipantswithaHigh-NormalBPorHypertensionat

BaselineAccordingtoBPLovelandRiskCategorization640(9.0)107(1.5)257(3.6)276(3.9)RiskGroupA1366(19.2)5084(71.7)Total483(6.5)1505(21.2)≥160/≥100609(8.5)2208(31.1)140-159/90-99300(4.2)1371(19.3)130-139/85-89RiskGroupCRiskGroupBSBP/DBP,mmHgValuesaren(%)3.EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventaCardiovascularDiseaseDeathAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA112012213449≥160/≥10018312744273394140-159/90-9921373660486701130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordeflnitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP,4.EstlmatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventAnAI-CauseDeathAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA9169172337≥160/≥100122216276097140-159/90-991425193381130130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordefinitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP不同危险程度高血压患者的血压水平(mmHg,xs)

男 女危险度

SBP DBP SBP DBP低危 141.3(12.0) 88.7(7.9) 141.7(10.8) 88.4(10.1)中危 144.7(15.6) 89.3(9.7) 144.1(26.7) 86.4(10.6)高危 144.0(17.7) 88.8(11.5) 139.6(18.6) 85.6(14.5)极高危 148.4(21.5)* 88.8(12.8) 145.9(22.6)* 87.6(34.2)

*P<0.05心血管危险度分层的重要性（二）

NHANES-I根据JNCVI，对7,090NHEFS队列20年随访说明临床决策不仅依靠平均血压水平，并需考虑其他危险因素1999年医院门诊人群高血压抽样调查报告表明,对门诊高血压患者的危险度评估中,如果只注意血压水平,是很不够的,会明显低估危险度,必须全面评估其他危险因素,才能作出正确的判断.ProblemsWithaStrategyBasedonAbsoluteCardiovascularRisk

F.OlafSimpson/JournalofHypertension1996,Vol14No6TheproposedNewZealandguidelines:the10-yearabsoluteCVDriskstrategyConsequencesofthe10-yearabsolute-riskstrategyPossibleage-relatedmodificationsofthe10-yearabsolute-riskstrategyProblemsraisedbyinclusionofotherriskfactorsinthecalculationsProblemsincalculationoftheexpectedgainsfromantihypertensivetherapyProblemsincalculationsofCVDriskfromraisedbloodpressureArticle1Cardiovascularriskevaluation：

aninexactscience（1）Failuretoconsiderthefullriskofthe‘metabolicsyndrome’incurrentguidelinesFailuretoappreciatethetotalbenefitofantihypertensivetherapyExcessiveweightingofadvancedageintheassessmentofcardiovascularriskHowaccurateiscurrentriskassessmentforuncomplicatedmildhypertension?Enhancingriskstratificationinhypertensivesubjects:Howfarshouldwegoinroutinescreeningfortargetorgandamage?First,itappearstimelytoincludethesearchformicroalbuminuriaasaroutinecomponentofthework-upofallhypertensivepatientsworldwide;Second,itseemsreasonabletorecommendthatthesearchfortargetorgandamageshouldextendtocardiacandcarotidultrasoundforhighriskandveryhighriskhypertensivesubjects.PharmacologicalTreatmentofHypertension

JDSwales/TheLancetVol344.Aug.6,1994BenefitsoftreatmentTreatmentofseverehypertensionMildtomoderatehypertensionDefiningthehigh-riskpatientValueofrepeatedmeasurementsSystolichypertensionTargetbloodpressureSelectionoftherapyArticle2血压水平为正常高值SBP130-139或DBP85-89mmHg（多次测量）其它危险因素、靶器官损害（肾）糖尿病、高血压关联临床状况生活方式改变、纠正其它危险因素或疾病绝对危险分层

药物治疗药物治疗经常监测无需干预BP极高危高危中危低危(ESH/ESC/ISH--2003）内容提要关于血压水平的定义和分类关于危险度分层关于卫生经济学关于联合用药问题InterventionsevaluatedNon-personalinterventions N1 通过强制性合同使企业限盐 N2 全民限盐条例 N3 大众传媒的健康宣传 N4 N2&N3的综合干预Personalinterventions P1&P2基于抗高血压的个体治疗和教育 (P1