最新高血壓國(guó)際指南問題解讀

1、最新高血壓指南的幾個(gè)問題最新高血壓指南的幾個(gè)問題解放軍總醫(yī)院急診科解放軍總醫(yī)院急診科沈沈 洪洪 （教授）（教授）內(nèi)容提要 關(guān)于血壓水平的定義和分類關(guān)于血壓水平的定義和分類 關(guān)于危險(xiǎn)度分層關(guān)于危險(xiǎn)度分層 關(guān)于衛(wèi)生經(jīng)濟(jì)學(xué)關(guān)于衛(wèi)生經(jīng)濟(jì)學(xué) 關(guān)于用藥問題關(guān)于用藥問題高血壓患者危險(xiǎn)分層高血壓患者危險(xiǎn)分層-WHO/ISH 1999血壓血壓( (mmHg)mmHg)其他危險(xiǎn)因素和病史其他危險(xiǎn)因素和病史1 1級(jí)級(jí)SBP 140SBP 140159159或或DBP90-99DBP90-992 2級(jí)級(jí)SBP 160-179 SBP 160-179 或或DBP 100-109DBP 100-1093 3級(jí)級(jí)SBP S

2、BP 180 180 或或DBP DBP 110110I I 無其他危險(xiǎn)因素?zé)o其他危險(xiǎn)因素II 1-2II 1-2個(gè)危險(xiǎn)因素個(gè)危險(xiǎn)因素III III 3 3個(gè)危險(xiǎn)因素或個(gè)危險(xiǎn)因素或 器官損害或糖尿病器官損害或糖尿病IV IV 并存臨床情況并存臨床情況低危低危中危中危高危高危很高危很高危中危中危中危中危高危高危很高危很高危高危高危很高危很高危很高危很高危很高危很高危注：注：1999年中國(guó)高血壓防治指南年中國(guó)高血壓防治指南的危險(xiǎn)分層參考的是的危險(xiǎn)分層參考的是 1999年年WHO/ISH指南指南影響高血壓患者預(yù)后的因素影響高血壓患者預(yù)后的因素心血管危險(xiǎn)因素心血管危險(xiǎn)因素靶器官損害靶器官損害糖尿病糖尿

3、病關(guān)聯(lián)臨床狀況關(guān)聯(lián)臨床狀況 血壓水平血壓水平 男性男性55歲歲 女性女性65歲歲 吸煙吸煙 血脂紊亂血脂紊亂（TC6.5mmol/L, LDL-C4.0 mmol/L, HDL-C男男1.0，女，女1.2mmol/L） 早發(fā)心血管疾早發(fā)心血管疾病家族史病家族史(男男55, 女女102, 女女88cm) CRP 1 mg/dl 左心室肥厚左心室肥厚（心電圖：（心電圖：Sokolow-lyons38mm; Cornell2440mm*ms; 超聲超聲心動(dòng)圖：心動(dòng)圖：LVMI 男男 125，女女 110g/m2） 超聲證實(shí)動(dòng)脈壁增超聲證實(shí)動(dòng)脈壁增厚厚（頸動(dòng)脈（頸動(dòng)脈IMT 0.9mm）或粥樣硬化斑塊

4、或粥樣硬化斑塊 血清肌酐輕微升高血清肌酐輕微升高（男（男115-133，女，女107-124 mol/L） 微白蛋白尿癥微白蛋白尿癥（30-300mg/24H; 白蛋白白蛋白/肌酐比肌酐比值男值男 22，女，女 31） 空腹血漿葡空腹血漿葡萄糖萄糖7.0mmol/L 餐后血漿葡餐后血漿葡萄糖萄糖11.0mmol/L 腦血管疾?。耗X血管疾?。喝比毖阅X卒中；腦出血；血性腦卒中；腦出血；一過性腦缺血發(fā)作一過性腦缺血發(fā)作 心血管疾?。盒难芗膊。盒男募」Ｋ?；心絞痛；冠肌梗死；心絞痛；冠脈血運(yùn)重建；心力衰脈血運(yùn)重建；心力衰竭竭 腎臟病變：腎臟病變：糖尿糖尿病性腎臟病變；腎損病性腎臟病變；腎損害（肌酐升

5、高男害（肌酐升高男133,女女124 mol/L）；蛋）；蛋白尿（白尿（300mg/24H） 周圍血管疾病周圍血管疾病 高度眼底病變：高度眼底病變：出血；或滲出，乳頭出血；或滲出，乳頭水腫水腫高血壓患者危險(xiǎn)分層高血壓患者危險(xiǎn)分層-2003歐洲高血壓指南歐洲高血壓指南III級(jí)級(jí) 高血壓高血壓II級(jí)級(jí) 高血壓高血壓I級(jí)級(jí) 高血壓高血壓正常血壓高值正常血壓高值正常血壓正常血壓其他危險(xiǎn)因其他危險(xiǎn)因素和疾病素和疾病關(guān)聯(lián)臨床狀關(guān)聯(lián)臨床狀況況 3危險(xiǎn)因素危險(xiǎn)因素或糖尿病或或糖尿病或靶器官損害靶器官損害12 危險(xiǎn)危險(xiǎn)因素因素0 危險(xiǎn)因素危險(xiǎn)因素：平均危險(xiǎn)；：低度危險(xiǎn)增加；：中度危險(xiǎn)增加；：平均危險(xiǎn)；：低度危險(xiǎn)

6、增加；：中度危險(xiǎn)增加；：高度危險(xiǎn)增加；：極高度危險(xiǎn)增加：高度危險(xiǎn)增加；：極高度危險(xiǎn)增加Risk factor similar as 1999 guidelines except :1.abdominal obesity 2.Diabetes as a separate criterion 3.CRP is added 血壓分類血壓分類-JNC-VI(1997)-JNC-VI(1997)-類類 別別 收縮壓（收縮壓（mm Hg) ) 舒張壓（舒張壓（mm Hg) )-理想血壓理想血壓 120 80120 80正常血壓正常血壓 120 - 129 80 - 84120 - 129 80 - 84正

7、常高值正常高值 130 - 139 85 - 89130 - 139 85 - 891 1級(jí)高血壓級(jí)高血壓 140 140 159 90 159 90 99 99 亞組：臨界高血壓亞組：臨界高血壓 140 - 149 90 - 94140 - 149 90 - 942 2級(jí)高血壓級(jí)高血壓 160 - 179 100 -109160 - 179 100 -109 3 3級(jí)高血壓級(jí)高血壓 180180 110110 單純收縮期高血壓?jiǎn)渭兪湛s期高血壓 140140 90 90亞組：臨界收縮期高血壓亞組：臨界收縮期高血壓 140 - 149 90140 - 149 90- 1. Distributio

8、n of NHANES I Epldemiologic Follow-up Study Participants with a High-Normal BP or Hypertension at Baseline According to BP Lovel and Risk Categorization640(9.0)107(1.5)257(3.6)276(3.9)Risk Group A1366(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-

9、139/85-89Risk Group CRisk Group BSBP/DBP, mmHgValues are n (%)2. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Event Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category o

10、f Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A8167131016160/ 10091711192033140-159/90-99101913232541130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP, mmHgSee test or Table 1 for deflnition of risk groups.*Corrected for regression dilution bias u

11、sing a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,3. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Ba

12、seline BP Level and Category of Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A112012213449160/ 10018312744273394140-159/90-9921373660486701130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP, mmHgSee test or Table 1 for deflnition of risk groups.*Cor

13、rected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,4. Estlmated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent An AI-Cause Death Among NHANES I Epidemiologic Follow-Up Study Part

14、icipants According to Baseline BP Level and Category of Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A9169172337160/ 100122216276097140-159/90-991425193381130130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP, mmHgSee test or Table 1 for definition

15、of risk groups.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP不同危險(xiǎn)程度高血壓患者的血壓水平不同危險(xiǎn)程度高血壓患者的血壓水平(mmHg, x s) 男男 女女危險(xiǎn)度危險(xiǎn)度 SBP DBP SBP DBP低危低危 141.3(12.0)88.7(7.9)141.7(10.8)88.4(10.1)中危中危 144.7(15.6)89.3(9.7)144.1(26.7)

16、86.4(10.6)高危高危 144.0(17.7)88.8(11.5)139.6(18.6)85.6(14.5)極高危極高危 148.4(21.5)*88.8(12.8)145.9(22.6)*87.6(34.2) * P0.05心血管危險(xiǎn)度分層的重要性心血管危險(xiǎn)度分層的重要性（一）（一）高血壓常常伴隨其它危險(xiǎn)因素高血壓常常伴隨其它危險(xiǎn)因素降壓治療的目的是減少心血管發(fā)病與死亡降壓治療的目的是減少心血管發(fā)病與死亡（CVD Risk）,而不僅是降低血壓（而不僅是降低血壓（RFs)，所以，所以對(duì)心血管危險(xiǎn)的估算是不可或缺的對(duì)心血管危險(xiǎn)的估算是不可或缺的血壓升高是血壓升高是CVD RR 的重要指標(biāo)，

17、故以往只看的重要指標(biāo)，故以往只看血壓水平?jīng)Q定治療策略。此法對(duì)中重度高血壓行血壓水平?jīng)Q定治療策略。此法對(duì)中重度高血壓行之有效，對(duì)輕度高血壓則否之有效，對(duì)輕度高血壓則否 心血管危險(xiǎn)度分層的重要性（二）心血管危險(xiǎn)度分層的重要性（二） NHANES-I根據(jù)根據(jù) JNC VI，對(duì)，對(duì)7,090NHEFS隊(duì)列隊(duì)列20年隨訪說明臨床決策不僅依靠平均血壓水平，并年隨訪說明臨床決策不僅依靠平均血壓水平，并需考慮其他危險(xiǎn)因素需考慮其他危險(xiǎn)因素 1999年醫(yī)院門診人群高血壓抽樣調(diào)查報(bào)告表明年醫(yī)院門診人群高血壓抽樣調(diào)查報(bào)告表明,對(duì)對(duì)門診高血壓患者的危險(xiǎn)度評(píng)估中門診高血壓患者的危險(xiǎn)度評(píng)估中,如果只注意血壓如果只注意血壓

18、水平水平,是很不夠的是很不夠的,會(huì)明顯低估危險(xiǎn)度會(huì)明顯低估危險(xiǎn)度,必須全面評(píng)估必須全面評(píng)估其他危險(xiǎn)因素其他危險(xiǎn)因素,才能作出正確的判斷才能作出正確的判斷.Problems With a Strategy Based on Absolute Cardiovascular RiskF. Olaf Simpson/Journal of Hypertension 1996, Vol 14 No 6The proposed New Zealand guidelines: the 10-year absolute CVD risk strategy Consequences of the 10-year

19、absolute-risk strategy Possible age-related modifications of the 10-year absolute-risk strategyProblems raised by inclusion of other risk factors in the calculationsProblems in calculation of the expected gains from antihypertensive therapyProblems in calculations of CVD risk from raised blood press

20、ureArticle 1Cardiovascular risk evaluation：an inexact science （1） Failure to consider the full risk of the metabolic syndrome in current guidelines Failure to appreciate the total benefit of antihypertensive therapy Excessive weighting of advanced age in the assessment of cardiovascular risk How acc

21、urate is current risk assessment for uncomplicated mild hypertension?Although the absolute risk assessment methods may lack sufficient sensitivity, they still represent an improvement over that only the level of blood pressure and prior cardiovascular disease were relevant to therapeutic-decision ma

22、king. To date, cardiovascular risk evaluation is an inexact science.Cardiovascular risk evaluation： an inexact science （2）Enhancing risk stratification in hypertensive subjects: How far should we go in routine screening for target organ damage? First, it appears timely to include the search for micr

23、oalbuminuria as a routine component of the work-up of all hypertensive patients worldwide; Second, it seems reasonable to recommend that the search for target organ damage should extend to cardiac and carotid ultrasound for high risk and very high risk hypertensive subjects.Pharmacological Treatment

24、 of HypertensionJ D Swales / The Lancet Vol 344. Aug. 6, 1994Benefits of treatmentTreatment of severe hypertension Mild to moderate hypertension Defining the high-risk patient Value of repeated measurementsSystolic hypertensionTarget blood pressureSelection of therapyArticle 2血壓水平為正常高值血壓水平為正常高值SBP 130-139或或DBP 85-89mmHg（多次測(cè)量）（多次測(cè)量）其它危險(xiǎn)因素、靶器官損害（腎）其它危險(xiǎn)因素、靶器官損害（腎）糖尿病、高血壓關(guān)聯(lián)臨床狀況糖尿病、高血壓關(guān)聯(lián)臨床狀況生活方式改變、糾正其它危險(xiǎn)因素或疾病生活方式改變、糾