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1、2004年中国高血压防治指南 重点内容解释,重点内容,血压分类和定义 心血管危险分层 血压控制目标值 联合治疗方案,血压水平的分类和定义,分类 收缩压(mmHg) 舒张压(mmHg) 正常血压 120 和 80 正常高值 120-139 或 80-89 高血压 140 或 90 1级 140-159 或 90-99 2级 160-179 或 100-109 3级 180 或 110 单纯收缩期高血压 140 和 90,Systolic Blood Pressure,150 mmHg,160 mmHg,140 mmHg,130 mmHg,120 mmHg,100,80,60,40,20,0,0,
2、20,40,60,80,100,False-positive error rate (%),Sensitivity,Pater C. Current Controlled Trials in Cardiovascular Medicine. 2005,6 : 5,Vasan et al. N Engl J Med. 2001;345:1291-1297.,High-Normal BP and CVD Risk Framingham Study,Residual Lifetime Risk of Hypertension in Women and Men Aged 65 Years,Vasan
3、RS. JAMA 2002;287:1003-1010,心血管危险水平分层,用于危险性分层的危险因素,收缩压和舒张压水平(1-3级) 男性55岁 女性65岁 吸烟 血脂异常: TC5.7mmol/L(220mg/dl) 或LDL-C3.3mmol/L(130mg/dl) 或HDL-C1.0mmol/L(40mg/dl) 早发心血管病家族史(一级亲属发病年龄50岁) 腹型肥胖(腰围:男性85cm,女性80cm)或肥胖(BMI28kg/m2) C反应蛋白1mg/dl,靶器官损害,左心室肥厚 心电图Sokolow-Lyons38mv, Cornel2440mmmms 超声心动图LVMI或X线 颈动脉
4、超声IMT0.9mm或动脉粥样斑块 血请肌酐轻度升高 男性 115-133mol/L或1.3-1.5mg/dl 女性 107-124mol/L或1.2-1.4mg/dl 微量白蛋白尿 30-300mg/24h 白蛋白/肌酐:男性22mg/g(2.5mg/mmol) 女性31mg/g(3.5mg/mmol),Mancia G. et al., J Hypertens 2004; 22:51-57,45,40,35,30,25,20,15,10,5,0,None,1,2,3,4,Additional risk factors,13.7%,39.8%,32.4%,12.1%,2.0%,522,151
5、8,1235,461,76,高血压常与其它心血管危险因素合并存在,%,收缩压、微量蛋白尿与心血管危险,Borch-Johnsen K, et al. Arteioscler Thromb Vasc Biol 1999; 19:1992,HOT 心血管危险因素研究 血压水平以外的各项因素对CVD发生率的影响,Risk factor CV/1000 pt.y RR Cl(95%) Yes No Gender(M vs F) 12.0 7.2 1.62 (1.421.94) Age(65 vs 65 yrs) 15.0 7.3 2.06 (1.772.39) Smoking 14.0 8.9 1.5
6、7 (1.311.88) S-Cholesterol(6.8 vs 6.8 mmol/l) 11.6 9.0 1.29 (1.091.53) S-Creatinine(1.3 vs 1.3 mg/dl) 21.8 8.7 2.50 (2.033.07) Diabetes 18.3 9.0 2.03 (1.652.51) Ischemic Heart Disease 18.4 8.1 2.27 (1.932.68),HOT：心血管危险分层与CVD事件,BMJ 2002, 324:71,RR： 1.58 1.38 1.60 1.79 1.51 Cl: 1.45-1.72 1.18-1.61 1.4
7、1-1.82 1.56-2.05 1.38-1.66 P: 0.0001 0.0001 0.0001 0.0001 0.0001,Major cardiovascular events,All myocardial infarction,All stroke,Cardiovascular mortality,Total mortality,Risk:,Medium,High,Very High,20,15,10,5,0,Events per 1000 patient years,Risk Reclassification in APROS Study,Cuspidi et al., J Hyp
8、ertens 2002; 20:1307-1315,100,80,60,40,20,0,%,Initial,Final *,High,Medium,Low,Risk:,* After ecocardiogram + carotid ultrasonography,81.3%,18.7%,53.2%,35.7%,11.1%,血压控制目标值,中青年高血压患者 140/90 mmHg 老年高血压患者 150/90 mmHg 糖尿病或肾病患者 130/80 mmHg,0.5,1.0,2.0,Relative Risk,RR (95% CI),BP Difference (mm Hg),Favors F
9、irst Listed,Favors Second Listed,Major CV events,CV mortality,Total mortality,1.02 (0.98, 1.07),2/0,ACEI vs D/BB,1.03 (0.95, 1.11),2/0,ACEI vs D/BB,1.00 (0.95, 1.05),2/0,ACEI vs D/BB,1.04 (0.99, 1.08),1/0,CA vs D/BB,1.05 (0.97, 1.13),1/0,CA vs D/BB,0.99 (0.95, 1.04),1/0,CA vs D/BB,0.97 (0.92, 1.03),
10、1/1,ACEI vs CA,1.03 (0.94, 1.13),1/1,ACEI vs CA,1.04 (0.98, 1.10),1/1,ACEI vs CA,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,BP-Lowering Treatment Trialists Comparisons of Different Active Treatments,Fatal/Non-fatal cardiac events,Fatal/Non-fatal stroke,All
11、-cause death,Myocardial infarction,Heart failure hospitalisations,0.4,0.6,0.8,1.0,1.2,1.4,Controlled patients* (n = 10755),Non-controlled patients (n = 4490),Hazard Ratio 95% CI,*SBP 140 mmHg at 6 months.,Pooled Treatment Groups,*,*,*,*,*P 0.01.,0.75 (0.670.83),0.55 (0.460.64),0.79 (0.710.88),0.86 (
12、0.731.01),0.64 (0.550.74),Odds Ratio,Weber MA et al. Lancet. 2004;363:204749.,VALUE:根据6个月时血压控制情况的结果分析,Benetos et al. J Hypertens. 2003;21:1635-1640.,Follow-up (Years),Survival (%),1,0.96,0.92,0.88,0.84,0.8,1,3,5,7,9,11,13,15,17,19,21,23,25,P=.03,P.0001,P=.001,CVD Survival in Treated Hypertensives at
13、 Goal and Not at Goal,Relationship between diastolic (in principle, similar for systolic) blood pressures and cardiovascular (CV) events (arbitray scale) in hypertensive patients with different levels of cardiovascular risk,Major cardiovascular events (per 100 patients-years) in all treated hyperten
14、sive and in hypertensive patients with diabetes in relation to target blood pressures of 90. 85, and 80 mm Hg.,HOT: 糖尿病与非糖尿病患者的CV事件发生率,老年高血压患者血压控制目标值调整的原因,老年ISH临床试验(SHEP, SYST-EURO, SYST-CHINA) SBP目标： 150 mmHg 大多数降压治疗临床试验结果： SBP目标 140 mmHg 较难达到,常用降压药物,利尿剂 b-阻滞剂 -阻滞剂 钙拮抗剂 ACE抑制剂 血管紧张素II受体拮抗剂 固定剂量复方降压制剂,推荐的降压联合治疗方案,利尿剂b-阻滞剂 利尿剂ACE抑制剂或ARB 二氢吡啶类钙拮抗剂b-阻滞剂 钙拮抗剂ACE抑制剂或ARB 钙拮抗剂利尿剂 -阻滞剂-阻滞剂,长期治疗随访实施过程,继续治疗 血压控制1年以上 可减少剂量,治疗3个月后， 达到降压目标值,治疗3个月后，未 达到降压目标值,有明显副作用,增加剂量 改用另一类降压药 联合治疗,改用另一类降压药 减少剂量,