2013年ESH ESC高血压指南启迪和要点

2013ESH/ESC高血压指南更新要点和启迪2013ESH/ESCHypertensionGuidelineClassesofrecommendationsClassesofrecommendationsDefinitionSuggestedwordingtouseClassIEvidenceand/orgeneralagreementthatagiventreatmentorprocedureisbeneficial,useful,effective.Isrecommended/isindicatedClassIIConflictingevidenceand/oradivergenceofopinionabouttheusefulness/efficacyofthegiventreatmentorprocedureClassIIaWeightofevidence/opinionisinfavourofusefulness/efficacyShouldbeconsideredClassIIbUsefulness/efficacyislesswellestablishedbyevidence/opinionMaybeconsideredClassIIIEvidenceorgeneralagreementthatthegiventreatmentorprocedureisnotuseful/effective,andinsomecasesmaybeharmfulIsnotrecommended2013ESH/ESCHypertensionGuidelineLevelofevidenceADataderivedfrommultiplerandomizedclinicaltrialsormeta-analyses.LevelofevidenceBDataderivedfromasinglerandomizedclinicaltrialorlargenon-randomizedstudiesLevelofevidenceCConsensusofopinionoftheexpertsand/orsmallstudies,retrospectivestudies,registriesLevelsofEvidence更新要点(一):心血管风险分层★细化了分层标准，将RFs、TOD和DM、CKD不同阶段分属于不同的层面。★将隐蔽性高血压或白大衣性高血压列入心血管风险分层，分别提高或降低一个风险层次。★以患者心血管风险程度作为高血压患者启动治疗和治疗路径的主要决定因素。2013ESH/ESCHypertensionGuidelineOtherriskfactors(RF),asymptomaticorgandamage(OD)ordiseaseBloodPressure(mmHg)HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NOotherRFLowriskModerateriskHighrisk1-2RFLowriskModerateriskModeratetoHighriskHighrisk≥3RFLowtoModerateriskModeratetoHighriskHighriskHighriskOD,CKDstage3ordiabetesModeratetoHighriskHighriskHighriskHightoVeryhighriskSymptomaticCVD,CKDstage≥4ordiabeteswithOD/RFsVeryhighriskVeryhighriskVeryhighriskVeryhighriskStratificationoftotalCVriskDefinitionsaccordingtoofficeBPandout-of-officeBP(daytimeambulatoryorhomeBP)OfficeBP(mmHg)SBP140andDBP90SBP≥140orDBP≥90DaytimeABPorhomeBP(mmHg)SBP135andDBP85Truenormotension(NT)White-coathypertension(WCHT)SBP≥135orDBP≥85Maskedhypertension(MHT)Sustainedhypertension(SHT)TheprognosisofmaskedhypertensionChronicetal,JAmCollCardiong,2005;46:508-515Prevalenceisapproximately10%ingeneralpopulationCVeventsper1000patientsyear35251530201050CVEventsNormal23/685Whitecoat24/656masked236/3125Uncontrolled41/462诊室血压有时升高；有高血压家族史；未能解释的静息心率增快；阻塞性睡眠呼吸暂停；有多种心血管危险因素，肥胖或糖尿病；左心室肥厚或微量白蛋白尿。诊室血压水平正常高值的以下人群应怀疑并寻找隐蔽性高血压更新要点(二):启动药物治疗★将2-3级和1级高危患者列为药物治疗强指征推荐。★将老年人高血压患者SBP≥160mmHg列为药物治疗强指征推荐。★对血压水平在正常高值，即使高危或很高危患者，不推荐实施降压干预治疗。InitiationofantihypertensivedrugtreatmentGrade2-3Recommended(Promptly)IAGrade1/HighCVriskRecommendedIBGrade1/LowCVriskShouldbeconsideredIIaBElderlyRecommendedifSBP≥160mmHgIA(also80ysofage)MaybeconsideredifSBP140-159IIbCmmHgHighnormalBPNodrugtreatmentrecommendedIIIA2013ESH/ESCHypertensionGuideline2013ESH/ESCHypertensionGuidelineOtherriskfactors(RF),asymptomaticorgandamage(OD)ordiseaseBloodPressure(mmHg)HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NOotherRFNoBPInterventionLifestylechangesforseveralmonthsThenaddBPdrugstargeting140/90LifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/901-2RFLifestylechangesNoBPInterventionLifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90≥3RFLifestylechangesNoBPInterventionLifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90OD,CKDstage3ordiabetesLifestylechangesNoBPInterventionLifestylechangesBPdrugstargeting140/90LifestylechangesBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90SymptomaticCVD,CKDstage≥4ordiabeteswithOD/RFsLifestylechangesNoBPInterventionLifestylechangesBPdrugstargeting140/90LifestylechangesBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90Initiationoflifestylechangesandantihypertensivedrugtreatment更新要点(三):治疗目标★调整很高危患者的血压控制目标值。★调整老年人高血压的血压控制目标值。★确定舒张压80-85mmHg是合适安全的控制目标范围。2013ESH/ESCHypertensionGuidelineRecommendationsClassLevelASBPgoal140mmHga)isrecommendedinpatientsatlow-moderateCVrisk;IBb)isrecommendedinpatientswithdiabetes;IAc)shouldbeconsideredinpatientswithpreviousstrokeorTIA;IIaBd)shouldbeconsideredinpatientswithCHD;IIaBd)shouldbeconsideredinpatientswithdiabeticornon-diabeticCKD;IIaBInelderlyhypertensivelessthan80yearsoldwithSBP≥160mmHgthereissolidevidencetorecommendreducingSBPtobetween150and140mmHgIAInfitelderlypatientslessthan80yearsoldSBPvalues140mmHgmaybeconsidered,whereasinthefragileelderlypopulationSBPgoalsshouldbeadaptedtoindividualtolerability.IIbCInindivdualsolderthan80yearsandwithinitialSBP≥160mmHgitisrecommendedtoreduceSBPtobetween150and140mmHgprovidedtheyareingoodphysicalandmentalconditions.IBADBPtargetof90mmHgisalwaysrecommended,exceptinpatientswithdiabetes,inwhomvalves85mmHgarerecommended.ItshouldneverthelessbeconsideredthatDBPvaluesbetween80and85mmHgaresafeandwilltolerated.IABloodpressuregoalsinhypertensivepatientsSBPsachievedbytreatmentinplacebo-c