2004年中国高血压防治指南

重点内容血压分类和定义心血管危险分层血压控制目标值联合治疗方案血压水平的分类和定义

分类 收缩压(mmHg)舒张压(mmHg)正常血压<120和<80正常高值120-139或80-89高血压140或

901级140-159或90-992级160-179或100-1093级180或

110单纯收缩期高血压140和<90

SystolicBloodPressure

150mmHg160mmHg140mmHg130mmHg120mmHg100806040200020406080100False-positiveerrorrate(%)SensitivityPaterC.CurrentControlledTrialsinCardiovascularMedicine.2005,6:5中国高血压患病率1959197919912002患病率(%)5.117.7311.88患病人数(亿)0.9High-normal130-139Stage1140-159Stage2+160+High-normal85-89Stage190-99Stage2+100+JNC6StageAverageDBPAverageSBPUpstagedbasedonSBPCongruentUpstagedbasedonDBP85％7％9％高血压分级FranklinSS,etal.Hypertens.2001;37:869100%80%60%40%20%0%<4040-4950-5960-6970-7980+17%16%16%20%20%11%Age(y)Frequencyofhypertensionsubtypesinalluntreatedsubjects(%)Frequencydistributionofuntreatedhypertensiveindividualsbyageandhypertensionsubtype.Numbersatthetopsofbarsrepresenttheoverallpercentagedistributionofuntreatedhypertensioninthatagegroup.■,ISH(SBP≥140mmHgandDBP<90mmHg);■,SDH(SBP≥140mmHgandDBP≥90mmHg);■,IDH(SBP<140mmHgandDBP≥90mmHg).IDH,SDHandISHSubtypesinAmericanPatients

FranklinSS.Hypertension2001;37:869HuangJ,etal.JHypertens2004;17:955-962IDH,SDHandISHSubtypesinChinesePatients关于IDH的几点新认识80%IDH在10年内进展到SDH(Franklin,etal.Circulation2005;111:1121)约70%IDH是代谢综合征

(Franklin,etal.JACC2004;43:449A)Vasanetal.NEnglJMed.2001;345:1291-1297.High-NormalBPandCVDRisk

FraminghamStudyWomen1086420Time(years)02468101214P<.001MenCumulativeIncidence(%ime(years)02468101214P<.001Highnormal130-139/85-89mmHg

Normal120-129/80-84mmHg

Optimal<120/80mmHgPrehypertensionResidualLifetimeRiskofHypertensioninWomenandMenAged65Years10080604020002468101214161820YearsofFollow-upRiskofHypertension,%WomenAged65Years1967-19981952-1975A10080604020002468101214161820YearsofFollow-upMenAged65YearsBVasanRS.JAMA2002;287:1003-1010心血管危险水平分层 血压(mmHg) 1级 2级 3级

SBP140~159或 SBP160~179或 SBP≥180或 DBP90~99 DBP100~109 DBP≥110I 无其它危险因素 低危 中危 高危II 1~2个危险因素 中危 中危 很高危III ≥3个危险因素 高危 高危 很高危 或靶器官损害或糖尿病IV 并存临床情况 很高危 很高危 很高危其它危险因素和病史用于危险性分层的危险因素收缩压和舒张压水平(1-3级)男性>55岁女性>65岁吸烟血脂异常:TC

5.7mmol/L(220mg/dl)

或mmol/L(130mg/dl)

或HDL-C<1.0mmol/L(40mg/dl)早发心血管病家族史(一级亲属发病年龄<50岁)腹型肥胖(腰围:男性85cm,女性80cm)或肥胖(BMI28kg/m2)C反应蛋白1mg/dl

靶器官损害左心室肥厚心电图Sokolow-Lyons>38mv,Cornel>2440mm·mms

超声心动图LVMI或X线颈动脉超声IMT或动脉粥样斑块血请肌酐轻度升高男性115-133

mol/L或mg/dl

女性107-124

mol/L或mg/dl微量白蛋白尿

30-300mg/24h

白蛋白/肌酐:男性22mmol)

女性31mmol)Assessmentof

Total(Global)CVRiskJNC7NoYesEuropeanTaskForceESH/ESCWHO/ISHContinuous/ColorimetricscalesDiscontinuousriskcategoriesManciaG.etal.,JHypertens2004;22:51-57454035302520151050None1234Additionalriskfactors13.7%39.8%32.4%12.1%2.0%5221518123546176高血压常与其它心血管危险因素合并存在%Microalbuminuria6543210RelativeriskofIHDSBP<140SBP140-160SBP>160Normoalbuminuria2.5(1.2-5.3)5.3(2.2-13.0)3.3(1.6-6.9)2.2(1.3-3.7)1.01.5(0.9-2.7)收缩压、微量蛋白尿与心血管危险Borch-JohnsenK,etal.ArteiosclerThrombVascBiol1999;19:1992HOT心血管危险因素研究血压水平以外的各项因素对CVD发生率的影响Riskfactor CV/1000pt.y RR Cl(95%)

Yes NoGender(MvsF) 12.0 7.2 1.62 (1.42~1.94)Age(≥65vs65yrs) 15.0 7.3 2.06 (1.77~2.39)Smoking 14.0 8.9 1.57 (1.31~1.88)S-Cholesterol(>6.8vs ≤6.8mmol/l) 11.6 9.0 1.29 (1.09~1.53)S-Creatinine(>1.3vs≤1.3mg/dl) 21.8 8.7 2.50 (2.03~3.07)Diabetes 18.3 9.0 2.03 (1.65~2.51)IschemicHeartDisease 18.4 8.1 2.27 (1.93~2.68)HOT：心血管危险分层与CVD事件BMJ2002,324:71MajorcardiovasculareventsAllmyocardialinfarctionAllstrokeCardiovascularmortalityTotalmortalityRisk:MediumHighVeryHigh20151050Eventsper1000patientyearsManciaG.etal,.JHypertens2004;22:51-5750403020100LowMediumHighVeryhighPercentageofpatients18.1%4.8%46.0%38.8%28.8%41.3%7.0%15.2%PerceivedglobalriskCalculatedglobalriskRiskReclassificationinAPROSStudyCuspidietal.,JHypertens2002;20:1307-1315100806040200%InitialFinal*HighMediumLowRisk:* Afterecocardiogram+ carotidultrasonography81.3%18.7%53.2%35.7%11.1%降压治疗的实施过程对高血压患者临床评价后，首先进行心血管危险水平 分层(低危、中危、高危、很高危)所有患者都应采用非药物治疗措施制定降压治疗计划，确定血压控制目标值很高危、高危患者：立即开始药物治疗中危：随访观测数周，然后决定是否开始药物治疗低危：随访观测数月，然后决定是否开始药物治疗治疗随访，调整治疗方案血压控制目标值中青年高血压患者<140/90mmHg老年高血压患者<150/90mmHg

糖尿病或肾病患者 <130/80

mmHgRelativeRisk

RR(95%CI)BPDifference

(mmHg)Favors

FirstListedFavors

SecondListedMajorCVeventsCVmortalityTotalmortality1.02(0.98,1.07)2/0ACEIvsD/BB1.03(0.95,1.11)2/0ACEIvsD/BB1.00(0.95,1.05)2/0ACEIvsD/BB1.04(0.99,1.08)1/0CAvsD/BB1.05(0.97,1.13)1/0CAvsD/BB0.99(0.95,1.04)1/0CAvsD/BB0.97(0.92,1.03)1/1ACEIvsCA1.03(0.94,1.13)1/1ACEIvsCA1.04(0.98,1.10)1/1ACEIvsCABloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.BP-LoweringTreatmentTrialists

ComparisonsofDifferentActiveTreatmentsFatal/Non-fatalcardiaceventsFatal/Non-fatalstrokeAll-causedeathMyocardialinfarctionHeartfailurehospitalisationsControlledpatients*(n=10755)Non-controlledpatients(n=4490)HazardRatio95%CI*SBP<140mmHgat6months.Pooled

Treatment

Groups**********P<0.01.0.75(0.67–0.83)0.55(0.46–0.64)0.79(0.71–0.88)0.86(0.73–1.01)0.64(0.55–0.74)OddsRatioWeberMAetal.Lancet.2004;363:2047–49.VALUE:根据6个月时血压控制情况的结果分析Benetosetal.JHypertens.2003;21:1635-1640.Follow-up(Years)Survival(%)1135791113151719212325P=.03P<.0001P=.001TreatedBPnotatgoal140/90mmHgUntreatedBP<140/90mmHgUntreatedBP140/90mmHgTreatedBPatgoal<140/90mmHgCVDSurvivalinTreatedHypertensives

atGoalandNotatGoal1210864208090100110120130Diastolicbloodpressure(mmHg)CVeventsElderlypatientsPatientsWithDiabetesandotherCVriskFactorsHypertensivesWithaverageriskHypertensivesWithlowerthanaverageriskRelationshipbetweendiastolic(inprinciple,similarforsystolic)bloodpressuresandcardiovascular(CV)events(arbitrayscale)inhypertensivepatientswithdifferentlevelsofcardiovascularriskMajorcardiovascularevents(per100patients-years)inalltreatedhypertensiveandinhypertensivepatientswithdiabetesinrelationtotargetbloodpressuresof90.85,and80mmHg.302520151050808590908580P=0.50fortrendP=0.005fortrendAllhypertensivepatients(n=18790)Hypertensivewithdiabetes(n=1501)TargetbloodpressuregroupsMajorcardiovascularevents/1000patients-yearsHOT:糖尿病与非糖尿病患者的CV事件发生率老年高血压患者血压控制目标值调整的原因老年ISH临床试验(SHEP,SYST-EURO,SYST-CHINA)

SBP目标：<150mmHg大多数降压治疗临床试验结果：

SBP目标<140mmHg较难达到200mmHgSBP190180170160150140130200mmHg110100908070DBPHOPEPROGRESSCAPPPINSIGHTNORDILHOTSTONESTOP-2ALLHAT1LIFEALLHAT2ANBP2INVESTSCOPETreatedDiabeticPatientsofFORLIFEwithBPControlledandNotControlled≥140mmHgSBP≥90mmHg<90mmHg<140mmHg<130mmHg<80mmHgDBP80.6%19.4%4.4%64.8%35.2%10.6%Awareness,TreatmentandControlofHypertensioninChina

Awareness(%) Treatment(%) Control(%)6050403020100NorthSouthPrevalence(%)(a)50.231.57.910.733.246.5Aware