【医脉通】2020+ISH全球高血压实践指南.pdf

1Table of ContentsSection 1.Introduction.1334Section 2.Definition of Hypertension.1336Section 3.Blood Pressure Measurement and Diagnosis of Hypertension.1336Section 4.Diagnostic and Clinical Tests.1337Section 5.Cardiovascular Risk Factors.1339Section 6.Hypertension-Mediated Organ Damage.1340Section 7.Exacerbators and Inducers of Hypertension.1341Section 8.Treatment of Hypertension.1341 8.1 Lifestyle Modification.1341 8.2 Pharmacological Treatment.1341 8.3 Adherence to Antihypertensive Treatment.1341Section 9.Common and Other Comorbidities of Hypertension.1342Section 10.Specific Circumstances.134610.1 Resistant Hypertension.134610.2 Secondary Hypertension.134610.3 Hypertension in Pregnancy.134710.4 Hypertensive Emergencies.134810.5 Ethnicity,Race and Hypertension.1350Section 11.Resources.1350Section 12.Hypertension Management at a Glance.1352Acknowledgments.1354References.1354Section 1:IntroductionContext and Purpose of This GuidelineStatement of RemitTo align with its mission to reduce the global burden of raised blood pressure(BP),the International Society of Hypertension(ISH)has developed worldwide practice guidelines for the management of hypertension in adults,aged 18 years and older.The ISH Guidelines Committee extracted evidence-based content presented in recently published extensively reviewed guidelines and tailored and standards of care in a practical format that is easy-to-use particularly in low,but also in high resource settings by clinicians,but also nurses and community health workers,as appropriate.Although distinction between low and high resource settings often refers to high(HIC)and low-and middle-income coun-tries(LMIC),it is well established that in HIC there are areas with low resource settings,and vice versa.Herein optimal care refers to evidence-based standard of care articulated in recent guidelines1,2 and summarized here,whereas standards recognize that standards would not always be possible.Hence essential stan-dards refer to minimum standards of care.To allow specifica-tion of essential standards of care for low resource settings,the Committee was often confronted with the limitation or absence in clinical evidence,and thus applied expert opinion.Received March 6,2020;first decision March 16,2020;revision accepted March 27,2020.From the CARIM School for Cardiovascular Diseases,Maastricht University,the Netherlands(T.U.);Department of Medical and Surgical Sciences,University of Bologna,Italy(C.B.);Federation University Australia,School of Health and Life Sciences,Ballarat,Australia(F.C.);University of Melbourne,Department of Physiology,Melbourne,Australia(F.C.);University of Leicester,Department of Cardiovascular Sciences,United Kingdom(F.C.);University of British Columbia,Vancouver,Canada(N.A.K.);Center for Health Evaluation and Outcomes Sciences,Vancouver,Canada(N.A.K.);Imperial Clinical Trials Unit,Imperial College London,United Kingdom(N.R.P.);Public Health Foundation of India,New Delhi,India(D.P.);Centre for Chronic Disease Control,New Delhi,India(D.P.);London School of Hygiene and Tropical Medicine,United Kingdom(D.P.);Hypertension and Metabolic Unit,University Hospital,Favaloro Foundation,Buenos Aires,Argentina(A.R.);Dobney Hypertension Centre,School of Medicine,Royal Perth Hospital Unit,University of Western Australia,Perth(M.S.);Neurovascular Hypertension&Kidney Disease Laboratory,Baker Heart and Diabetes Institute,Melbourne,Victoria,Australia(M.N.);Hypertension Center STRIDE7,School of Medicine,Third Department of Medicine,Sotiria Hospital,National and Kapodistrian University of Athens,Greece(G.S.S.);Division of Cardiovascular Sciences,Faculty of Medicine,Biology and Health,University of Manchester,United Kingdom(M.T.);Division of Medicine and Manchester Academic Health Science Centre,Manchester University NHS Foundation Trust Manchester,United Kingdom(M.T.);Department of Pharmacology and Experimental Therapeutics,Boston University School of Medicine,MA(R.D.W.);The Whitaker Cardiovascular Institute,Boston University,MA(R.D.W.);Department of Health Sciences,Boston University Sargent College,MA(R.D.W.);University College London,NIHR University College London,Hospitals Biomedical Research Centre,London,United Kingdom(B.W.);Faculty of Medicine,University of New South Wales,Sydney,Australia(A.E.S.);The George Institute for Global Health,Sydney,Australia(A.E.S.);and Hypertension in Africa Research Team(A.E.S.)and South African MRC Unit for Hypertension and Cardiovascular Disease(A.E.S.),North-West University,Potchefstroom,South Africa.This article has been copublished in the Journal of Hypertension.Correspondence to Thomas Unger,CARIM-Maastricht University,P.O.Box 616,6200 MD Maastricht,the Netherlands.Email thomas.ungermaastrichtuniversity.nl(Hypertension.2020;75:00-00.DOI:10.1161/HYPERTENSIONAHA.120.15026.)2020 International Society of Hypertension Global Hypertension Practice GuidelinesThomas Unger,Claudio Borghi,Fadi Charchar,Nadia A.Khan,Neil R.Poulter,Dorairaj Prabhakaran,Agustin Ramirez,Markus Schlaich,George S.Stergiou,Maciej Tomaszewski,Richard D.Wainford,Bryan Williams,Aletta E.Schutte 2020 American Heart Association,Inc.DOI:10.1161/HYPERTENSIONAHA.120.15026Hypertension is available at https:/www.ahajournals.org/journal/hypClinical Practice GuidelinesDownloaded from http:/ahajournals.org by on May 6,20202 Hypertension June 2020In the Guidelines,differentiation between optimal and es-sential standards were not always possible,and were made in sections where it was most practical and sensible.The Guidelines Committee is also aware that some recommended essential standards may not be feasible in low resource set-tings,for example,out-of-office BP measurements,the requirement of multiple visits for the diagnosis of hyperten-sion,or advising the use of single pill combination therapy.Although challenging to implement,these guidelines may aid in local initiatives to motivate policy changes and serve as an instrument to drive local improvements in standards of care.Every effort should be made to achieve essential standards of care to reduce hypertension-induced cardiovascular morbidity and mortality.MotivationRaised BP remains the leading cause of death globally,accounting for 10.4 million deaths per year.3 When reviewing global figures,an estimated 1.39 billion people had hyperten-sion in 2010.4 However,BP trends show a clear shift of the highest BPs from high-income to low-income regions,5 with an estimated 349 million with hypertension in HIC and 1.04 billion in LMICs.4The large disparities in the regional burden of hyperten-sion are accompanied by low levels of awareness,treatment and control rates in LMIC,when compared to HIC.In re-sponse to poor global awareness for hypertension(estimated 67%in HIC and 38%in LMIC),4 the ISH launched a global campaign to increase awareness of raised BP,namely the May Measurement Month initiative.6,7Despite several initiatives,the prevalence of raised BP and adverse impact on cardiovascular morbidity and mor-tality are increasing globally,irrespective of income.4,5 It is therefore critical that population-based initiatives are applied to reduce the global burden of raised BP,such as salt-reduction activities and improving the availability of fresh fruit and vegetables.To improve the management of hyper-tension,the ISH has published in 2014 with the American Society of Hypertension,Clinical Practice Guidelines for the Management of Hypertension in the Community(See Section 11:Resources).Recently,we have observed a recent flurry of updated evidence-based guidelines arising mainly from high-income regions and countries,including the United States of America,2 Europe,1 United Kingdom,8 Canada9 and Japan.10 New developments include redefining hypertension,2 initiating treatment with a single pill combination therapy,1 AbbreviationsABI ankle-brachial indexABPM ambulatory blood pressure monitoringACE angiotensin converting enzymeARB angiotensin AT-1 receptor blockerARNI angiotensin receptor-neprilysin inhibitorsBMI body mass indexBP blood pressureCAD coronary artery diseaseCCBs calcium channel blockersCKD chronic kidney diseaseCOPD chronic obstructive pulmonary diseaseCVD cardiovascular diseaseDBP diastolic blood pressureDHP-CCB dihydropyridine calcium channel blockerDM diabetes mellitusDRI direct renin inhibitorECG electrocardiogrameGFR estimated glomerular filtration rateESC-ESH European Society of Cardiology,European Society of HypertensionHBPM home blood pressure measurementHDL high density lipoproteinHELLP hemolysis,elevated liver enzymes and low plateletsHF heart failureHFpEF heart failure with preserved ejection fractionHFrEF heart failure with reduced ejection fractionHIC high-income countriesHIIT high intensity interval trainingHIV human immunodeficiency virusHMOD hypertension-mediated organ damageIMT intima media thicknessIRD inflammatory rheumatic diseaseISH International Society of HypertensionLDH lactate dehydrogenaseLDL-C low-density lipoprotein cholesterolLMIC low-and middle-income countriesLV left ventricularLVH left ventricular hypertrophyMAP mean arterial pressureMRI magnetic resonance imagingMS metabolic syndromeNSAIDs nonsteroidal anti-inflammatory drugsPWV pulse wave velocityRAAS renin angiotensin aldosterone systemRAS renin-angiotensin systemRCT randomized control trialsSBP systolic blood pressureSNRI selective norepinephrine and serotonin reuptake inhibitorsSPC single pill combination therapySRI serotonin reuptake inhibitorsSSRI selective serotonin reuptake inhibitorss-UA serum uric acidT4 thyroxin 4TIA transient ischemic attackTMA thrombotic microangiopathyTSH thyroid stimulating hormoneTTE two-dimensional transthoracic echocardiogramUACR urinary albumin creatinine ratioDownloaded from http:/ahajournals.org by on May 6,2020Unger et al 2020 ISH Global Hypertension Practice Guidelines 3advising wider out-of-office BP measurement,2,10 and lower BP targets.1,2,8,11,12Low-and middle-income regions often follow the re-lease of guidelines from high-income regions closely,as their resources and health systems to develop and imple-ment local guidelines remain challenging.In Africa only 25%of countries have hypertension guidelines13 and in many instances these guidelines are adopted from those of high-income regions.However,the adoption of guide-lines from high-income regions are sometimes impractical as low resource settings are confronted with a substantial number of obstacles including severe lack of trained health-care professionals,unreliable electricity in rural clinics,low access to basic office BP devices and limited ability to con-duct basic recommended diagnostic procedures and poor access to affordable high-quality medications.In both low and high-income regions,the ambiguities of latest guide-lines are often met with confusion among healthcare pro-viders,anxiety among patients,14 and they resulted in a call for global harmonization.15 Guidelines from high-income regions may thus not fit global purpose.16Guideline Development ProcessThe 2020 ISH Global Hypertension Practice Guidelines were developed by the ISH Hypertension Guidelines Committee based on evidence criteria,(1)to be used globally;(2)to be fit for application in low and high resource settings by advis-ing on essential and optimal standards;and(3)to be concise,simplified,and easy to use.They were critically reviewed and evaluated by numerous external hypertension experts from HIC and LMIC with expertize in the optimal management of hypertension and management in resource-constraint settings.These Guidelines were developed without any support from industry or other sources.Composition of the ISH Hypertension Guidelines Committee and Selection of External ReviewersThe ISH Hypertension Guidelines Committee was composed of members of the ISH Council;they were included on the basis of(1)specific expertize in different areas of hyperten-sion;(2)previous experience with the generation of hyper-tension guidelines,as well as(3)representation of different regions of the world.A similar strategy was followed con-cerning the selection of external reviewers with particular consideration of representatives from LMICs.Section 2:Definition of Hypertension In accordance with most major guidelines it is rec-ommended that hypertension be diagnosed when a persons systolic blood pressure(SBP)in the office or clinic is 140 mm Hg and/or their diastolic blood pressure(DBP)is 90 mm Hg following repeated examination(see below,Section 3).Table 1 provides a classification of BP based on office BP measure-ment,Table 2 provides ambulatory and home BP values used to define hypertension;these definitions apply to all adults(18 year old).These BP cate-gories are designed to align therapeutic approaches with BP levels.High-normal BP is intended to identify individuals who could benefit from lifestyle interventions and who would receive pharmacological treatment if compelling indications are present(see Section 9).Isolated systolic hypertension defined as elevated SBP(140 mm Hg)and low DBP(90 mm Hg)is common in young and in elderly people.In young individuals,including children,adolescents and young adults,iso-lated systolic hypertension is the most common form of essential hypertension.However,it is also particularly common in the elderly,in whom it reflects stiffening of the large arteries with an increase in pulse pressure(dif-ference between SBP and DBP).Individuals identified with confirmed hypertension(grade 1 and grade 2)should receive appropriate phar-macological treatment.Details of home-,office-and ambulatory BP measure-ment techniques are addressed in Section 3.Section 3:Blood Pressure Measurement and Diagnosis of HypertensionHypertension Diagnosis Office BP Measurement The measurement of BP in the office or clinic is most commonly the basis for hypertension diagno-sis and follow-up.Office BP should be measured ac-cording to recommendations shown in Table 3 and Figure 1.1,2,17,18 Whenever possible,the diagnosis should not be made on a single office visit.Usually 23 office visits at 14-week intervals(depending on the BP level)are required to confirm the diagnosis of hypertension.The diagnosis might be made on a single visit,if BP is 180/110 mm Hg and there is evidence of cardio-vascular disease(CVD).1,2,17,18 The recommended patient management according to office BP levels is presented in Table 4.If possible and available,the diagnosis of hyperten-sion should be confirmed by out-of-office BP meas-urement(see below).1,2,1921Table 1.Classification of Hypertension Based on Office Blood Pressure(BP)MeasurementCategorySystolic(mm Hg)Diastolic(mm Hg)Normal BP130and10 mm Hg in repeated measurements,use the arm with the higher BP.If the difference is 20 mm Hg consider further investigation.Standing blood pressure:Measure in treated hyper-tensives after 1 min and again after 3 min when there are symptoms suggesting postural hypotension and at the first visit in the elderly and people with diabete