最新高血压指南的几个问题

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/ISH1999血压(mmHg)其他危险因素和病史1级SBP140—159或DBP90-992级SBP160-179或DBP100-1093级SBP180或DBP110I无其他危险因素II1-2个危险因素III3个危险因素或器官损害或糖尿病IV并存临床情况低危中危高危很高危中危中危高危很高危高危很高危很高危很高危注：《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心血管危险因素靶器官损害糖尿病关联临床状况血压水平男性55岁女性65岁吸烟血脂紊乱（TC6.5mmol/L,LDL-C4.0mmol/L,HDL-C男1.0，女1.2mmol/L）早发心血管疾病家族史(男55,女65)腹型肥胖(腹围男102,女88cm)CRP1mg/dl左心室肥厚（心电图：Sokolow-lyons38mm;Cornell2440mm*ms;超声心动图：LVMI男125，女110g/m2）超声证实动脉壁增厚（颈动脉IMT0.9mm）或粥样硬化斑块血清肌酐轻微升高（男115-133，女107-124mol/L）微白蛋白尿症（30-300mg/24H;白蛋白/肌酐比值男22，女31）空腹血浆葡萄糖7.0mmol/L餐后血浆葡萄糖11.0mmol/L脑血管疾病：缺血性脑卒中；脑出血；一过性脑缺血发作心血管疾病：心肌梗死；心绞痛；冠脉血运重建；心力衰竭肾脏病变：糖尿病性肾脏病变；肾损害（肌酐升高男133,女124mol/L）；蛋白尿（300mg/24H）周围血管疾病高度眼底病变：出血；或渗出，乳头水肿高血压患者危险分层--2003欧洲高血压指南III级高血压II级高血压I级高血压正常血压高值正常血压其他危险因素和疾病＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋关联临床状况＋＋＋＋＋＋＋＋＋＋＋＋＋＋＋3危险因素或糖尿病或靶器官损害＋＋＋＋＋＋＋＋＋＋1－2危险因素＋＋＋＋＋＋±±0危险因素±：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Riskfactorsimilaras1999guidelinesexcept:1.abdominalobesity2.Diabetesasaseparatecriterion3.CRPisadded血压分类--JNC-VI(1997)---------------------------------------------------------类别收缩压（mmHg)舒张压（mmHg)---------------------------------------------------------理想血压12080正常血压120-12980-84正常高值130-13985-891级高血压140–15990–99亚组：临界高血压140-14990-942级高血压160-179100-1093级高血压180110单纯收缩期高血压14090亚组：临界收缩期高血压140-14990---------------------------------------------------------------1.DistributionofNHANESIEpldemiologicFollow-upStudyParticipantswithaHigh-NormalBPorHypertensionatBaselineAccordingtoBPLovelandRiskCategorization640(9.0)107(1.5)257(3.6)276(3.9)RiskGroupA1366(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)130-139/85-89RiskGroupCRiskGroupBSBP/DBP,mmHgValuesaren(%)2.EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventaCardiovascularDiseaseEventAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA8167131016≥160/≥10091711192033140-159/90-99101913232541130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordeflnitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP,3.EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventaCardiovascularDiseaseDeathAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA112012213449≥160/≥10018312744273394140-159/90-9921373660486701130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordeflnitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP,4.EstlmatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber-Needed-to-TreattoPreventAnAI-CauseDeathAmongNHANESIEpidemiologicFollow-UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRiskRiskGroupCRiskGroupBRiskGroupA9169172337≥160/≥100122216276097140-159/90-991425193381130130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSeetestorTable1fordefinitionofriskgroups.*Correctedforregressiondilutionbiasusingareliabilitycoefficientor0.53tocorrectforImprecisioninthemeasurementofSBP不同危险程度高血压患者的血压水平(mmHg,xs)男女危险度SBPDBPSBPDBP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（CVDRisk）,而不仅是降低血压（RFs)，所以对心血管危险的估算是不可或缺的•血压升高是CVDRR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JNCVI，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.ProblemsWithaStrategyBasedonAbsoluteCardiovascularRiskF.OlafSimpson/JournalofHypertension1996,Vol14No6•TheproposedNewZealandguidelines:the10-yearabsoluteCVDriskstrategy•Consequencesofthe10-yearabsolute-riskstrategy•Possibleage-relatedmodificationsofthe10-yearabsolute-riskstrategy•Problemsraisedbyinclusionofotherriskfactorsinthecalculations•Problemsincalculationoftheexpectedgainsfromantihypertensivetherapy•ProblemsincalculationsofCVDriskfromraisedbloodpressureArticle1Cardiovascularriskevaluation：aninexactscience（1）•Failuretoconsiderthefullriskofthe‘metabolicsyndrome’incurrentguidelines•Failuretoappreciatethetotalbenefitofantihypertensivetherapy•Excessiveweightingofadvancedageintheassessmentofcardiovascularrisk•Howaccurateiscurrentriskassessmentforuncomplicatedmildhypertension?•Althoughtheabsoluteriskassessmentmethodsmaylacksufficientsensitivity,theystillrepresentanimprovementoverthatonlythelevelofbloodpressureandpriorcardiovasculardiseasewererelevanttotherapeutic-decisionmaking.Todate,cardio