高血壓指南的幾個(gè)問(wèn)題

1、最新高血壓指南的幾個(gè)問(wèn)題,劉力生,內(nèi)容提要,關(guān)于血壓水平的定義和分類關(guān)于危險(xiǎn)度分層關(guān)于衛(wèi)生經(jīng)濟(jì)學(xué)關(guān)于用藥問(wèn)題,高血壓患者危險(xiǎn)分層--WHO/ISH 1999,,注：《1999年中國(guó)高血壓防治指南》的危險(xiǎn)分層參考的是 1999年WHO/ISH指南,影響高血壓患者預(yù)后的因素,高血壓患者危險(xiǎn)分層--2003歐洲高血壓指南,,±：平均危險(xiǎn)；＋：低度危險(xiǎn)增加；＋＋：中度危險(xiǎn)增加；＋＋＋：高度危險(xiǎn)增加；＋＋＋＋：

2、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--JNC-VI(1997),---------------------------------------------------------類 別

3、收縮壓（mm Hg) 舒張壓（mm Hg)---------------------------------------------------------理想血壓 <120 <80正常血壓 120 - 129 80 - 84正常高值 130 - 139

4、 85 - 891級(jí)高血壓 140 – 159 90 – 99 亞組：臨界高血壓 140 - 149 90 - 942級(jí)高血壓 160 - 179 100 -109 3級(jí)高血壓 ?180 ?110 單純收縮期高

5、血壓 ?140 <90亞組：臨界收縮期高血壓 140 - 149 <90---------------------------------------------------------------,1. Distribution of NHANES I Epldemiologic Follow-up Study Partici

6、pants with a High-Normal BP or Hypertension at Baseline According to BP Lovel and Risk Categorization,Values are n (%),2. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Pre

7、vent a Cardiovascular Disease Event Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk,See test or Table 1 for deflnition of risk groups.

8、*Corrected for regression dilution bias using 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-

9、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 Risk,See test or Table 1 for deflnition

10、of risk groups.*Corrected 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

11、 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 Risk,See test or Table 1 for definitio

12、n 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(mmHg, x?s),男 女危險(xiǎn)度 SBP DBP SBP

13、 DBP低危 141.3(12.0)88.7(7.9)141.7(10.8)88.4(10.1)中危 144.7(15.6)89.3(9.7)144.1(26.7)86.4(10.6)高危 144.0(17.7)88.8(11.5)139.6(18.6)85.6(14.5)極高危 148.4(21.5)*88.8(12.8)145.9(22.6)*87.6(34.2) * P<0

14、.05,,,,,,心血管危險(xiǎn)度分層的重要性（一）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（CVD Risk）,而不僅是降低血壓（RFs)，所以對(duì)心血管危險(xiǎn)的估算是不可或缺的血壓升高是CVD RR 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）,NHANES-I根據(jù) JNC VI，對(duì)7,090NHEFS隊(duì)列20年隨訪說(shuō)明臨床決策不僅依靠

15、平均血壓水平，并需考慮其他危險(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,對(duì)門診高血壓患者的危險(xiǎn)度評(píng)估中,如果只注意血壓水平,是很不夠的,會(huì)明顯低估危險(xiǎn)度,必須全面評(píng)估其他危險(xiǎn)因素,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

16、14 No 6,The 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 rai

17、sed 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 pressure,Article 1,Cardiovascu

18、lar 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 a

19、dvanced age in the assessment of cardiovascular riskHow accurate is current risk assessment for uncomplicated mild hypertension?,Although the absolute risk assessment methods may lack sufficient sensitivity, they still

20、 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.,Cardiovas

21、cular 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

22、 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 ultras

23、ound for high risk and very high risk hypertensive subjects.,Pharmacological Treatment of HypertensionJ D Swales / The Lancet Vol 344. Aug. 6, 1994,Benefits of treatmentTreatment of severe hypertensionMild to moderate

24、 hypertensionDefining the high-risk patientValue of repeated measurementsSystolic hypertensionTarget blood pressureSelection of therapy,Article 2,血壓水平為正常高值,SBP 130-139或DBP 85-89mmHg（多次測(cè)量）其它危險(xiǎn)因素、靶器官損害（腎）糖尿病、高血壓關(guān)聯(lián)臨

25、床狀況生活方式改變、糾正其它危險(xiǎn)因素或疾病絕對(duì)危險(xiǎn)分層 藥物治療 藥物治療 經(jīng)常監(jiān)測(cè) 無(wú)需干預(yù)BP,,,,,,,,,,,,,(ESH/ESC/ISH--2003）,血壓水平為I-II級(jí)高血壓,SBP 140-179 或 DBP 90-109mmHg其它危險(xiǎn)因素、靶器官損害（腎）糖尿病、高血壓關(guān)聯(lián)臨床狀況生活方式改變、糾正其它危險(xiǎn)因素或疾病

26、危險(xiǎn)分層,,,,,,,,,,,,,,,,BP?140/90 BP<140/90藥物治療 繼續(xù)監(jiān)測(cè),,及時(shí)藥物治療 及時(shí)藥物治療 監(jiān)測(cè)（BP/RF)至少3個(gè)月 監(jiān)測(cè)(BP/RF)3-12個(gè)月,,,,,,SBP?140-159 BP<140/90DBP ? 90-99考慮藥物治療 繼續(xù)監(jiān)測(cè),(ESH/ESC/ISH--2003）

27、,內(nèi)容提要,關(guān)于血壓水平的定義和分類關(guān)于危險(xiǎn)度分層關(guān)于衛(wèi)生經(jīng)濟(jì)學(xué)關(guān)于聯(lián)合用藥問(wèn)題,Interventions evaluated,Non-personal interventionsN1通過(guò)強(qiáng)制性合同使企業(yè)限鹽N2全民限鹽條例N3大眾傳媒的健康宣傳N4N2 & N3 的綜合干預(yù)Personal interventionsP1 & P2 基于抗高血壓的個(gè)體治療和教育

28、 (P1: SBP >160 mmHg 或 P2: SBP > 140 mmHg)P3 & P4 高膽固醇的個(gè)體治療和教育 (P3: TC >6.2 mmol/L 或 P4: TC > 5.7mmol/L) P5 收縮期高血壓和膽固醇個(gè)體治療和健康教育 (P2+P3)P6 to P9 高危人群管理 (35%, 25%, 15%, 5