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1、最新高血压指南的几个问题,刘力生,内容提要,关于血压水平的定义和分类 关于危险度分层 关于卫生经济学 关于用药问题,高血压患者危险分层-WHO/ISH 1999,注：1999年中国高血压防治指南的危险分层参考的是 1999年WHO/ISH指南,影响高血压患者预后的因素,高血压患者危险分层-2003欧洲高血压指南,：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,Risk factor similar as 1999 guidelines except : 1.abdominal obesity 2.Diabetes as a separate criterion 3
2、.CRP is added,血压分类-JNC-VI(1997),- 类 别 收缩压（mm Hg) 舒张压（mm Hg) - 理想血压 120 80 正常血压 120 - 129 80 - 84 正常高值 130 - 139 85 - 89 1级高血压 140 159 90 99 亚组：临界高血压 140 - 149 90 - 94 2级高血压 160 - 179 100 -109 3级高血压 180 110 单纯收缩期高血压 140 90 亚组：临界收缩期高血压 140 - 149 90 -,1. Distribution of NHANES I Epldemiologic Follow-up
3、 Study Participants 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 Prevent a Cardiovascular Disease Event Among NHANES I Epidemiologic Fol
4、low-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk,See 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,3. Estimated E
5、ffect 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 Risk,See test or Table 1 for deflnition of risk gr
6、oups. *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 Number-Needed-to-Treat to Prevent An AI-Cause Death Among NHANES I Epidemiologic Follow-Up
7、Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk,See 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,不同危险程度高血压患者的血压水平(mmHg
8、, xs),男 女 危险度 SBP DBP SBP 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) 极高危 148.4(21.5)* 88.8(12.8) 145.9(22.6)* 87.6(34.2) * P0.05,心血管危险度分层的重要性（一） 高血压常常伴随其它危险因素 降压治疗的目的是减少心血管发病与死亡（CVD Risk）,而不仅是降低
9、血压（RFs)，所以对心血管危险的估算是不可或缺的 血压升高是CVD RR 的重要指标，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效，对轻度高血压则否,心血管危险度分层的重要性（二）,NHANES-I根据 JNC VI，对7,090NHEFS队列20年随访说明临床决策不仅依靠平均血压水平，并需考虑其他危险因素 1999年医院门诊人群高血压抽样调查报告表明,对门诊高血压患者的危险度评估中,如果只注意血压水平,是很不够的,会明显低估危险度,必须全面评估其他危险因素,才能作出正确的判断.,Problems With a Strategy Based on Absolute Cardio
10、vascular Risk F. Olaf Simpson/Journal of Hypertension 1996, Vol 14 No 6,The proposed New Zealand guidelines: the 10-year absolute CVD risk strategy Consequences of the 10-year absolute-risk strategy Possible age-related modifications of the 10-year absolute-risk strategy Problems raised by inclusion
11、 of other risk factors in the calculations Problems in calculation of the expected gains from antihypertensive therapy Problems in calculations of CVD risk from raised blood pressure,Article 1,Cardiovascular risk evaluation： an inexact science （1）,Failure to consider the full risk of the metabolic s
12、yndrome in current guidelines Failure to appreciate the total benefit of antihypertensive therapy Excessive weighting of advanced age in the assessment of cardiovascular risk How accurate is current risk assessment for uncomplicated mild hypertension?,Although the absolute risk assessment methods ma
13、y 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 scien
14、ce （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 microalbuminuria as a routine component of the work-up of all hypertensive patients worldwide; Second, it seems reasona
15、ble 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.,Pharmacological Treatment of Hypertension J D Swales / The Lancet Vol 344. Aug. 6, 1994,Benefits of treatment Treatment of severe hypertens
16、ion Mild to moderate hypertension Defining the high-risk patient Value of repeated measurements Systolic hypertension Target blood pressure Selection of therapy,Article 2,血压水平为正常高值,SBP 130-139或DBP 85-89mmHg（多次测量） 其它危险因素、靶器官损害（肾） 糖尿病、高血压关联临床状况 生活方式改变、纠正其它危险因素或疾病 绝对危险分层 药物治疗 药物治疗 经常监测 无需干预BP,(ESH/ESC/
17、ISH-2003）,血压水平为I-II级高血压,SBP 140-179 或 DBP 90-109mmHg 其它危险因素、靶器官损害（肾） 糖尿病、高血压关联临床状况 生活方式改变、纠正其它危险因素或疾病 危险分层,BP140/90 BP140/90 药物治疗 继续监测,及时药物治疗 及时药物治疗 监测（BP/RF)至少3个月 监测(BP/RF)3-12个月,SBP140-159 BP140/90 DBP 90-99 考虑药物治疗 继续监测,(ESH/ESC/ISH-2003）,内容提要,关于血压水平的定义和分类 关于危险度分层 关于卫生经济学 关于联合用药问题,Interventions ev
18、aluated,Non-personal interventions N1 通过强制性合同使企业限盐 N2 全民限盐条例 N3 大众传媒的健康宣传 N4 N2 & N3 的综合干预 Personal interventions P1 & P2 基于抗高血压的个体治疗和教育 (P1: SBP 160 mmHg 或 P2: SBP 140 mmHg) P3 & P4 高胆固醇的个体治疗和教育 (P3: TC 6.2 mmol/L 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 (P2+P3) P6 to P9 高危人群管理 (35%, 25%, 15%, 5%) Combined personal and non-personal intervention (C1 to C4) P6 to P9 + N4,谢谢大家,