高血壓的分級(jí)、分期、分型管理-血管與心、腦、腎等器官結(jié)

高血壓的分級(jí)、分期、分型管理

-血管與心、腦、腎等器官結(jié)構(gòu)與功能檢測(cè)-上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院上海市高血壓研究所王繼光jiguangw@0306090120150198519901995200020052010(year)StrokeCHDStandardizedrate(1/100,000)DeathsattributedtostrokeandCHD《ChinaCVDreport2005》100120140160180200無(wú)血管或靶器官損害有血管或靶器官損害血管或靶器官并發(fā)癥分級(jí)(stageorgrade)高血壓分級(jí)、分期、分型的基本理念708090100110120舒張壓，mmHg收縮壓，mmHg分型(phenotypingorpathophysiology)分期(stratificationorseverity)繼發(fā)性高血壓有可測(cè)量異常的高血壓動(dòng)脈硬化性高血壓高血壓分級(jí)--準(zhǔn)確測(cè)量血壓，使用普遍有效的降壓藥物高血壓分期--測(cè)量血管與靶器官的結(jié)構(gòu)與功能，選擇強(qiáng)適應(yīng)癥藥物高血壓分型--篩查病因以及影響血壓的主要因素，采取病因治療措施坐位袖帶血壓計(jì)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)Dahl?fBetal.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.高血壓分級(jí)--準(zhǔn)確測(cè)量血壓，使用普遍有效的降壓藥物高血壓分期--測(cè)量血管與靶器官的結(jié)構(gòu)與功能，選擇強(qiáng)適應(yīng)癥藥物高血壓分型--篩查病因以及影響血壓的主要因素，采取病因治療措施Pulsediagnostics中國(guó)高血壓指南：危險(xiǎn)分層其他危險(xiǎn)因素和病史血壓(mmHg)1級(jí)高血壓SBP140-159或DBP90-992級(jí)高血壓SBP160-179或DBP100-1093級(jí)高血壓SBP≥180或DBP≥110無(wú)低危中危高危1-2個(gè)其他危險(xiǎn)因素中危中危很高危≥3個(gè)其他危險(xiǎn)因素，或靶器官損害高危高危很高危臨床并發(fā)癥或合并糖尿病很高危很高危很高危中華心血管病雜志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