高血压的分级、分期、分型管理-血管与心、脑、肾等器官结

高血压的分级、分期、分型管理

-血管与心、脑、肾等器官结构与功能检测-上海交通大学医学院附属瑞金医院上海市高血压研究所王继光jiguangw@0306090120150198519901995200020052010(year)StrokeCHDStandardizedrate(1/100,000)DeathsattributedtostrokeandCHD《ChinaCVDreport2005》100120140160180200无血管或靶器官损害有血管或靶器官损害血管或靶器官并发症分级(stageorgrade)高血压分级、分期、分型的基本理念708090100110120舒张压，mmHg收缩压，mmHg分型(phenotypingorpathophysiology)分期(stratificationorseverity)继发性高血压有可测量异常的高血压动脉硬化性高血压高血压分级--准确测量血压，使用普遍有效的降压药物高血压分期--测量血管与靶器官的结构与功能，选择强适应症药物高血压分型--筛查病因以及影响血压的主要因素，采取病因治疗措施坐位袖带血压计24-hambulatoryBPmonitoring

1501401301201101009080706050812161014182024422268HourofthedayBP(mmHg)135120857024-hmeanDaytimemeanNight-timemeanWhitecoathypertensionMaskedhypertensionJingNing:Prevalenceofwhite-coat,masked,andsustainedhypertension806040200Prevalence(%)Normotension46.4%(n=322)7.8%(n=54)10.8%(n=75)35.0%(n=243)White-coatHTMaskedHTSustainedHTWangGL,etal.JHypertens2007;25:2398–2405.n=694NICE2011:DefinitionsStage1hypertension:ClinicBPis140/90

mmHgorhigherandABPMorHBPMaverageis135/85

mmHgorhigher.Stage2hypertension:

ClinicBPis160/100

mmHgorhigherandABPMorHBPMdaytimeaverageis150/95

mmHgorhigher.Severehypertension:

ClinicsystolicBPis180

mmHgorhigherorClinicdiastolicBPis110

mmHgorhigher.KrauseT,etal.BMJ2011;343:d4891.A：ACEI

orARB；B：β-blockers；C：DihydropyridineCCBs；D：Thiazides；α：α-blockers；F：FixeddosecombinationDefinitivehypertensionMonotherapyCombinationBP<160/100mmHg；orlowriskpatientsBP≥160/100mmHg；orhighriskpatientswithaBP>20/10mmHgfromthegoalCADBC+AA+DC+DC+BFStep1FC+AA+DC+BC+DC+D+AC+A+BA+D+αStep2C+A+DC+A+BA+D+αOtherantihypertensivedrugs,suchasclonidipine,etc.Step3Chinesehypertensionguidelines:

ChoiceofantihypertensivedrugsChinJCardiol2011;39:579-616.Step4NICE2011:SummaryofantihypertensivedrugtreatmentAged

55yorblackpersonofAfricanorCaribbeanfamilyoriginofanyageAgedunder

55yearsCAA+CA+C+DResistanthypertensionA+C+D+considerfurtherdiuretic

oralpha-orbeta-blocker5ConsiderseekingexpertadviceStep1Step2Step3KeyA–ACEinhibitororlow-costangiotensin

IIreceptorblocker(ARB)1

C–Calcium-channelblocker(CCB)D–Thiazide-likediureticKrauseT,etal.BMJ2011;343:d4891.ASCOT-BPLA:Primaryandsecondaryendpoints0.500.701.001.45Primaryendpoint

NonfatalMI(includingsilentMI)+fatalCHD

Secondaryendpoint

NonfatalMI(excludingsilentMI)+fatalCHDAllcoronaryevents

AllCVeventsandprocedures

Totalmortality

CVmortalityFatalandnonfatalstroke

Fatalandnonfatalheartfailure2.00UnadjustedHazard

ratio(95%CI)0.90(0.79-1.02)0.87(0.76-1.00)0.87(0.79-0.96)0.84(0.78-0.90)0.89(0.81-0.99)0.76(0.65-0.90)0.77(0.66-0.89)0.84(0.66-1.05)DahlöfBetal.Lancet2005:366;895-906.Amlodipine

PerindoprilbetterAtenolol

Bendrofluathiazidebetter0.51.02.0ACCOMPLISH:

PrimaryendpointandcomponentsCompositeCVmortality/morbidityCardiovascularmortalityNon-fatalMINon-fatalstrokeHospitalizationforunstableanginaCoronaryrevascularizationprocedureResuscitatedsuddendeathRiskRatio

(95%)FavorsCCB/ACEIFavorsACEI/HCTZ0.80(0.72–0.90)0.81(0.62-1.06)0.81(0.63-1.05)0.87(0.67-1.13)0.74(0.49-1.11)0.85(0.74-0.99)1.75(0.73-4.17)JamersonKetal.NEnglJMed2008;359:2417-28.高血压分级--准确测量血压，使用普遍有效的降压药物高血压分期--测量血管与靶器官的结构与功能，选择强适应症药物高血压分型--筛查病因以及影响血压的主要因素，采取病因治疗措施Pulsediagnostics中国高血压指南：危险分层其他危险因素和病史血压(mmHg)1级高血压SBP140-159或DBP90-992级高血压SBP160-179或DBP100-1093级高血压SBP≥180或DBP≥110无低危中危高危1-2个其他危险因素中危中危很高危≥3个其他危险因素，或靶器官损害高危高危很高危临床并发症或合并糖尿病很高危很高危很高危中华心血管病杂志2011;39:579-616.ART.LAB

TheArterialAnalyserBloodvesselwallthicknessRFQIMTNormalthicknessDiameter:7.04mmIMT:536mBrightnessmodescanning(B-mode)Framerate30frames/sAssessmentof:ZhangY,etal.Submitted.ConcentricRemodelingN=107(12.7%)ConcentricHypertrophyN=16(1.9%)NormalGeometry