高血压指南的几个问题专家讲座.pptx

最新高血压指南几个问题最新高血压指南几个问题高血压指南的几个问题第1页内容提要关于血压水平定义和分类关于血压水平定义和分类关于危险度分层关于危险度分层关于卫生经济学关于卫生经济学关于用药问题关于用药问题高血压指南的几个问题第2页高血压患者危险分层高血压患者危险分层-WHO/ISH 1999注：注：1999年中国高血压防治指南危险分层参考是年中国高血压防治指南危险分层参考是 1999年年WHO/ISH指南指南高血压指南的几个问题第3页影响高血压患者预后原因影响高血压患者预后原因心血管危险原因靶器官损害靶器官损害糖尿病糖尿病关联临床情况 血压水平血压水平 男性男性55岁岁 女性女性65岁岁 吸烟吸烟 血脂紊乱血脂紊乱（TC6.5mmol/L,LDL-C4.0 mmol/L,HDL-C男男1.0，女，女1.2mmol/L）早发心血管疾病早发心血管疾病家族史家族史(男男55,女女102,女女88cm)CRP 1 mg/dl 左心室肥厚左心室肥厚（心电图：（心电图：Sokolow-lyons38mm;Cornell2440mm*ms;超声超声心动图：心动图：LVMI 男男 125，女女 110g/m2）超声证实动脉壁增超声证实动脉壁增厚厚（颈动脉（颈动脉IMT 0.9mm）或粥样硬化斑或粥样硬化斑块块 血清肌酐轻微升高血清肌酐轻微升高（男（男115-133，女，女107-124 mol/L）微白蛋白尿症微白蛋白尿症（30-300mg/24H;白蛋白白蛋白/肌酐比肌酐比值男值男 22，女，女 31）空腹血浆葡空腹血浆葡萄糖萄糖7.0mmol/L 餐后血浆葡餐后血浆葡萄糖萄糖11.0mmol/L 脑血管疾病：脑血管疾病：缺缺血性脑卒中；脑出血；血性脑卒中；脑出血；一过性脑缺血发作一过性脑缺血发作 心血管疾病：心血管疾病：心心肌梗死；心绞痛；冠肌梗死；心绞痛；冠脉血运重建；心力衰脉血运重建；心力衰竭竭 肾脏病变：肾脏病变：糖尿糖尿病性肾脏病变；肾损病性肾脏病变；肾损害（肌酐升高男害（肌酐升高男133,女女124 mol/L）；蛋）；蛋白尿（白尿（300mg/24H）周围血管疾病周围血管疾病 高度眼底病变：高度眼底病变：出血；或渗出，乳头出血；或渗出，乳头水肿水肿高血压指南的几个问题第4页高血压患者危险分层高血压患者危险分层-欧洲高血压指南欧洲高血压指南III级级 高血压高血压II级级 高血压高血压I级级 高血压高血压正常血压高值正常血压高值正常血压正常血压其它危险原其它危险原因和疾病因和疾病关联临床情关联临床情况况 3危险原因危险原因或糖尿病或或糖尿病或靶器官损害靶器官损害12 危险危险原因原因0 危险原因危险原因：平均危险；：低度危险增加；：中度危险增加；：平均危险；：低度危险增加；：中度危险增加；：高度危险增加；：极高度危险增加：高度危险增加；：极高度危险增加Risk factor similar as 1999 guidelines except:1.abdominal obesity 2.Diabetes as a separate criterion 3.CRP is added 高血压指南的几个问题第5页血压分类血压分类-JNC-VI(1997)-JNC-VI(1997)-类类 别别 收缩压（收缩压（mm Hg)舒张压（舒张压（mm Hg)-理想血压理想血压 120 80 120 80正常血压正常血压 120-129 80-84 120-129 80-84正常高值正常高值 130-139 85-89 130-139 85-891 1级高血压级高血压 140 159 90 99 140 159 90 99 亚组：临界高血压亚组：临界高血压 140-149 90-94 140-149 90-942 2级高血压级高血压 160 -179 100-109 160 -179 100-109 3 3级高血压级高血压 180180 110110 单纯收缩期高血压单纯收缩期高血压 140140 90 90亚组：临界收缩期高血压亚组：临界收缩期高血压 140-149 90 140-149 90-高血压指南的几个问题第6页1.Distribution 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)130-139/85-89Risk Group CRisk Group BSBP/DBP,mmHgValues are n(%)高血压指南的几个问题第7页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 of 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 using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,高血压指南的几个问题第8页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 Baseline 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.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,高血压指南的几个问题第9页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 Participants 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 of risk groups.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP高血压指南的几个问题第10页不一样危险程度高血压患者血压水平不一样危险程度高血压患者血压水平(mmHg,x s)男男 女女危险度危险度 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)86.4(10.6)高危高危 144.0(17.7)88.8(11.5)139.6(18.6)85.6(14.5)极高危极高危 148.4(21.5)*88.8(12.8)145.9(22.6)*87.6(34.2)*P0.05高血压指南的几个问题第11页心血管危险度分层主要性心血管危险度分层主要性（一）（一）高血压经常伴随其它危险原因高血压经常伴随其它危险原因降压治疗目标是降低心血管发病与死亡（降压治疗目标是降低心血管发病与死亡（CVD Risk）,而不但是降低血压（而不但是降低血压（RFs)，所以对心血，所以对心血管危险估算是不可或缺管危险估算是不可或缺血压升高是血压升高是CVD RR 主要指标，故以往只看血压主要指标，故以往只看血压水平决定治疗策略。此法对中重度高血压行之有水平决定治疗策略。此法对中重度高血压行之有效，对轻度高血压则否效，对轻度高血压则否 高血压指南的几个问题第12页心血管危险度分层主要性（二）心血管危险度分层主要性（二）NHANES-I依据依据 JNC VI，对，对7,090NHEFS队列队列20年随访说明临床决议不但依靠平均血压水平，并年随访说明临床决议不但依靠平均血压水平，并需考虑其它危险原因需考虑其它危险原因 1999年医院门诊人群高血压抽样调查汇报表明年医院门诊人群高血压抽样调查汇报表明,对对门诊高血压患者危险度评定中门诊高血压患者危险度评定中,假如只注意血压水假如只注意血压水平平,是很不够是很不够,会显著低估危险度会显著低估危险度,必须全方面评定必须全方面评定其它危险原因其它危险原因,才能作出正确判断才能作出正确判断.高血压指南的几个问题第13页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 strategyConsequences of the 10-year absolute-risk strategyPossible 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 pressureArticle 1高血压指南的几个问题第14页Cardiovascular risk evaluation：an inexact science（1）Failure to consider the full risk of the metabolic syndrome in current guidelinesFailure to appreciate the total benefit of antihypertensive therapyExcessive weighting of advanced age in the assessment of cardiovascular riskHow accurate is current risk assessment for uncomplicated mild hypertension?高血压指南的几个问题第15页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 making.To date,cardiovascular risk evaluation is an inexact science.Cardiovascular risk evaluation：an inexact science（2）高血压指南的几个问题第16页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 microalbuminuria 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.高血压指南的几个问题第17页Pharmacological Treatment of HypertensionJ D Swales/The Lancet Vol 344.Aug.6,1994Benefits of treatmentTreatment of severe hypertensionMild to moderate hypertensionDefining the high-risk patientValue of repeated measurementsSystolic hypertensionTarget blood pressureSelection of therapyArticle 2高血压指南的几个问题第18页血压水平为正常高值血压水平为正常高值SBP 130-139或或DBP 85-89mmHg（屡次测量）（屡次测量）其它危险原因、靶器官损害（肾）其它危险原因、靶器官损害（肾）糖尿病、高血压关联临床情况糖尿病、高血压关联临床情况生活方式改变、纠正其它危险原因或疾病生活方式改变、纠正其它危险原因或疾病绝对危险分层绝对危险分层 药品治疗药品治疗 药品治疗药品治疗 经常监测经常监测 无需干预无需干预BP极高危极高危高危高危中危中危低危低危(ESH/ESC/ISH-）高血压指南的几个问题第19页血压水平为I-II级高血压SBP 140-179 或或 DBP 90-109mmHg其它危险原因、靶器官损害（肾）其它危险原因、靶器官损害（肾）糖尿病、高血压关联临床情况糖尿病、高血压关联临床情况生活方式改变、纠正其它危险原因或疾病生活方式改变、纠正其它危险原因或疾病危险分层危险分层 极高危极高危高危高危中危中危低危低危BP 140/90 BP140/90药品治疗药品治疗 继续监测继续监测 及时药品治疗及时药品治疗 及时药品治疗及时药品治疗 监测（监测（BP/RF)最少最少3个月个月 监测监测(BP/RF)3-12个月个月SBP 140-159 BP160 mmHg 或或 P2:SBP 140 mmHg)P3&P4 高胆固醇个体治疗和教育高胆固醇个体治疗和教育 (P3:TC 6.2 mmol/L 或或 P4:TC 5.7mmol/L)P5 收缩期高血压和胆固醇个体治疗和健康教育收缩期高血压和胆固醇个体治疗和健康教育(P2+P3)P6 to P9 高危人群管理高危人群管理(35%,25%,15%,5%)Combined personal and non-personal intervention (C1 to C4)P6 to P9+N4高血压指南的几个问题第22页高血压指南的几个问题第23页谢谢大家高血压指南的几个问题第24页