2004年中國高血壓防治指南

重點內(nèi)容血壓分類和定義心血管危險分層血壓控制目標值聯(lián)合治療方案血壓水平的分類和定義

分類 收縮壓(mmHg)舒張壓(mmHg)正常血壓<120和<80正常高值120-139或80-89高血壓140或

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

110單純收縮期高血壓140和<90

SystolicBloodPressure

150mmHg160mmHg140mmHg130mmHg120mmHg100806040200020406080100False-positiveerrorrate(%)SensitivityPaterC.CurrentControlledTrialsinCardiovascularMedicine.2005,6:5中國高血壓患病率1959197919912002患病率(%)5.117.7311.88患病人數(shù)(億)0.9High-normal130-139Stage1140-159Stage2+160+High-normal85-89Stage190-99Stage2+100+JNC6StageAverageDBPAverageSBPUpstagedbasedonSBPCongruentUpstagedbasedonDBP85％7％9％高血壓分級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關(guān)于IDH的幾點新認識80%IDH在10年內(nèi)進展到SDH(Franklin,etal.Circulation2005;111:1121)約70%IDH是代謝綜合征

(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心血管危險水平分層 血壓(mmHg) 1級 2級 3級

SBP140~159或 SBP160~179或 SBP≥180或 DBP90~99 DBP100~109 DBP≥110I 無其它危險因素 低危 中危 高危II 1~2個危險因素 中危 中危 很高危III ≥3個危險因素 高危 高危 很高危 或靶器官損害或糖尿病IV 并存臨床情況 很高危 很高危 很高危其它危險因素和病史用于危險性分層的危險因素收縮壓和舒張壓水平(1-3級)男性>55歲女性>65歲吸煙血脂異常:TC

5.7mmol/L(220mg/dl)

或mmol/L(130mg/dl)

或HDL-C<1.0mmol/L(40mg/dl)早發(fā)心血管病家族史(一級親屬發(fā)病年齡<50歲)腹型肥胖(腰圍:男性85cm,女性80cm)或肥胖(BMI28kg/m2)C反應蛋白1mg/dl

靶器官損害左心室肥厚心電圖Sokolow-Lyons>38mv,Cornel>2440mm·mms

超聲心動圖LVMI或X線頸動脈超聲IMT或動脈粥樣斑塊血請肌酐輕度升高男性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高血壓常與其它心血管危險因素合并存在%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)收縮壓、微量蛋白尿與心血管危險Borch-JohnsenK,etal.ArteiosclerThrombVascBiol1999;19:1992HOT心血管危險因素研究血壓水平以外的各項因素對CVD發(fā)生率的影響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：心血管危險分層與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%降壓治療的實施過程對高血壓患者臨床評價后，首先進行心血管危險水平 分層(低危、中危、高危、很高危)所有患者都應采用非藥物治療措施制定降壓治療計劃，確定血壓控制目標值很高危、高?；颊撸毫⒓撮_始藥物治療中危：隨訪觀測數(shù)周，然后決定是否開始藥物治療低危：隨訪觀測數(shù)月，然后決定是否開始藥物治療治療隨訪，調(diào)整治療方案血壓控制目標值中青年高血壓患者<140/90mmHg老年高血壓患者<150/90mmHg

糖尿病或腎病患者 <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:根據(jù)6個月時血壓控制情況的結(jié)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:糖尿病與非糖尿病患者的CV事件發(fā)生率老年高血壓患者血壓控制目標值調(diào)整的原因老年ISH臨床試驗(SHEP,SYST-EURO,SYST-CHINA)

SBP目標：<150mmHg大多數(shù)降壓治療臨床試驗結(jié)果：

SBP目標<140mmHg較難達到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