最新高血压指南几个问题规范

内容提要(nèirónɡtíyào)关于(guānyú)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第二页，共二十五页。高血压患者(huànzhě)危险分层--WHO/ISH1999注：《1999年中国高血压防治(fángzhì)指南》的危险分层参考的是1999年WHO/ISH指南第三页，共二十五页。影响(yǐngxiǎng)高血压患者预后的因素心血管危险因素靶器官损害糖尿病关联临床状况血压水平男性>55岁女性>65岁吸烟血脂紊乱（TC>6.5mmol/L,LDL-C>4.0mmol/L,HDL-C男<1.0，女<1.2mmol/L）早发心血管疾病家族史(男<55,女<65)腹型肥胖(腹围男>102,女>88cm)CRP1mg/dl左心室肥厚（心电图：Sokolow-lyons>38mm;Cornell>2440mm*ms;超声心动图：LVMI男

125，女

110g/m2）超声证实动脉壁增厚（颈动脉IMT

0.9mm）或粥样硬化斑块血清肌酐轻微升高（男115-133，女107-124mol/L）微白蛋白尿症（30-300mg/24H;白蛋白/肌酐比值男

22，女

31）空腹血浆葡萄糖>7.0mmol/L餐后血浆葡萄糖>11.0mmol/L脑血管疾病：缺血性脑卒中；脑出血；一过性脑缺血发作心血管疾病：心肌梗死；心绞痛；冠脉血运重建；心力衰竭肾脏病变：糖尿病性肾脏病变；肾损害（肌酐升高男>133,女>124mol/L）；蛋白尿（>300mg/24H）周围血管疾病高度眼底病变：出血；或渗出，乳头水肿第四页，共二十五页。高血压患者危险(wēixiǎn)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(píngjūn)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第五页，共二十五页。

血压(xuèyā)分类--JNC-VI(1997)

---------------------------------------------------------类别收缩压（mmHg)舒张压（mmHg)---------------------------------------------------------理想(lǐxiǎng)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---------------------------------------------------------------

第六页，共二十五页。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(%)第七页，共二十五页。2.EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventaCardiovascularDiseaseEventAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA8167131016≥160/≥10091711192033140-159/90-99101913232541130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordeflnitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP,第八页，共二十五页。3.EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventaCardiovascularDiseaseDeathAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA112012213449≥160/≥10018312744273394140-159/90-9921373660486701130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordeflnitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP,第九页，共二十五页。4.EstlmatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventAnAI-CauseDeathAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA9169172337≥160/≥100122216276097140-159/90-991425193381130130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordefinitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP第十页，共二十五页。不同危险程度(chéngdù)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(ɡāowēi) 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第十一页，共二十五页。心血管危险度分层的重要性（一）高血压常常伴随其它危险因素降压治疗的目的是减少(jiǎnshǎo)心血管发病与死亡（CVDRisk）,而不仅是降低血压（RFs)，所以对心血管危险的估算是不可或缺的血压升高是CVDRR的重要指标，故以往只看血压水平决定治疗策略。此法对中重度高血压行之有效，对轻度高血压则否第十二页，共二十五页。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(huànzhě)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.第十三页，共二十五页。ProblemsWithaStrategyBasedonAbsoluteCardiovascularRisk

F.OlafSimpson/JournalofHypertension1996,Vol14No6TheproposedNewZealandguidelines:the10-yearabsoluteCVDriskstrategyConsequencesofthe10-yearabsolute-riskstrategyPossibleage-relatedmodificationsofthe10-yearabsolute-riskstrategyProblemsraisedbyinclusionofotherriskfactorsinthecalculationsProblemsincalculationoftheexpectedgainsfromantihypertensivetherapyProblemsincalculationsofCVDriskfromraisedbloodpressureArticle1第十四页，共二十五页。Cardiovascularriskevaluation：

aninexactscience（1）Failuretoconsiderthefullriskofthe‘metabolicsyndrome’incurrentguidelinesFailuretoappreciatethetotalbenefitofantihypertensivetherapyExcessiveweightingofadvancedageintheassessmentofcardiovascularriskHowaccurateiscurrentriskassessmentforuncomplicatedmildhypertension?第十五页，共二十五页。Althoughtheabsoluteriskassessmentmethodsmaylacksufficientsensitivity,theystillrepresentanimprovementoverthatonlythelevelofbloodpressureandpriorcardiovasculardiseasewererelevanttotherapeutic-decisionmaking.Todate,cardiovascularriskevaluationisaninexactscience.Cardiovascularriskevaluation：

aninexactscience（2）第十六页，共二十五页。Enhancingriskstratificationinhypertensivesubjects:Howfarshouldwegoinroutinescreeningfortargetorgandamage?First,itappearstimelytoincludethesearchformicroalbuminuriaasaroutinecomponentofthework-upofallhypertensivepatientsworldwide;Second,itseemsreasonabletorecommendthatthesearchfortargetorgandamageshouldextendtocardiacandcarotidultrasoundforhighriskandveryhighriskhypertensivesubjects.第十七页，共二十五页。PharmacologicalTreatmentofHypertension

JDSwales/TheLancetVol344.Aug.6,1994BenefitsoftreatmentTreatmentofseverehypertensionMildtomoderatehypertensionDefiningthehigh-riskpatientValueofrepeatedmeasurementsSystolichypertensionTargetbloodpressureSelectionoftherapyArticle2第十八页，共二十五页。血压(xuèyā)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(juéduì)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）第十九页，共二十五页。血压(xuèyā)水平为I-II级高血压(xuèyā)SBP140-179或DBP90-109mmHg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(gǎibiàn)、纠正其它危险因素或疾病危险分层

极高危高危中危低危BP140/90BP<140/90药物(yàowù)治疗继续监测及时药物治疗及时药物治疗监测（BP/RF)至少3个月监测(BP/RF)3-12个月SBP140-159BP<140/90DBP90-99考虑