2004年中國(guó)高血壓防治指南

重點(diǎn)內(nèi)容血壓分類和定義心血管危險(xiǎn)分層血壓控制目標(biāo)值聯(lián)合治療方案血壓水平的分類和定義

分類 收縮壓(mmHg)舒張壓(mmHg)正常血壓<120和<80正常高值120-139或80-89高血壓140或

901級(jí)140-159或90-992級(jí)160-179或100-1093級(jí)180或

110單純收縮期高血壓140和<90

SystolicBloodPressure

150mmHg160mmHg140mmHg130mmHg120mmHg100806040200020406080100False-positiveerrorrate(%)SensitivityPaterC.CurrentControlledTrialsinCardiovascularMedicine.2005,6:5中國(guó)高血壓患病率1959197919912002患病率(%)5.117.7311.88患病人數(shù)(億)0.9High-normal130-139Stage1140-159Stage2+160+High-normal85-89Stage190-99Stage2+100+JNC6StageAverageDBPAverageSBPUpstagedbasedonSBPCongruentUpstagedbasedonDBP85％7％9％高血壓分級(jí)FranklinSS,etal.Hypertens.2001;37:869100%80%60%40%20%0%<4040-4950-5960-6970-7980+17%16%16%20%20%11%Age(y)Frequencyofhypertensionsubtypesinalluntreatedsubjects(%)Frequencydistributionofuntreatedhypertensiveindividualsbyageandhypertensionsubtype.Numbersatthetopsofbarsrepresenttheoverallpercentagedistributionofuntreatedhypertensioninthatagegroup.■,ISH(SBP≥140mmHgandDBP<90mmHg);■,SDH(SBP≥140mmHgandDBP≥90mmHg);■,IDH(SBP<140mmHgandDBP≥90mmHg).IDH,SDHandISHSubtypesinAmericanPatients

FranklinSS.Hypertension2001;37:869HuangJ,etal.JHypertens2004;17:955-962IDH,SDHandISHSubtypesinChinesePatients關(guān)于IDH的幾點(diǎn)新認(rèn)識(shí)80%IDH在10年內(nèi)進(jìn)展到SDH(Franklin,etal.Circulation2005;111:1121)約70%IDH是代謝綜合征

(Franklin,etal.JACC2004;43:449A)Vasanetal.NEnglJMed.2001;345:1291-1297.High-NormalBPandCVDRisk

FraminghamStudyWomen1086420Time(years)02468101214P<.001MenCumulativeIncidence(%ime(years)02468101214P<.001Highnormal130-139/85-89mmHg

Normal120-129/80-84mmHg

Optimal<120/80mmHgPrehypertensionResidualLifetimeRiskofHypertensioninWomenandMenAged65Years10080604020002468101214161820YearsofFollow-upRiskofHypertension,%WomenAged65Years1967-19981952-1975A10080604020002468101214161820YearsofFollow-upMenAged65YearsBVasanRS.JAMA2002;287:1003-1010心血管危險(xiǎn)水平分層 血壓(mmHg) 1級(jí) 2級(jí) 3級(jí)

SBP140~159或 SBP160~179或 SBP≥180或 DBP90~99 DBP100~109 DBP≥110I 無(wú)其它危險(xiǎn)因素 低危 中危 高危II 1~2個(gè)危險(xiǎn)因素 中危 中危 很高危III ≥3個(gè)危險(xiǎn)因素 高危 高危 很高危 或靶器官損害或糖尿病IV 并存臨床情況 很高危 很高危 很高危其它危險(xiǎn)因素和病史用于危險(xiǎn)性分層的危險(xiǎn)因素收縮壓和舒張壓水平(1-3級(jí))男性>55歲女性>65歲吸煙血脂異常:TC

5.7mmol/L(220mg/dl)

或mmol/L(130mg/dl)

或HDL-C<1.0mmol/L(40mg/dl)早發(fā)心血管病家族史(一級(jí)親屬發(fā)病年齡<50歲)腹型肥胖(腰圍:男性85cm,女性80cm)或肥胖(BMI28kg/m2)C反應(yīng)蛋白1mg/dl

靶器官損害左心室肥厚心電圖Sokolow-Lyons>38mv,Cornel>2440mm·mms

超聲心動(dòng)圖LVMI或X線頸動(dòng)脈超聲IMT或動(dòng)脈粥樣斑塊血請(qǐng)肌酐輕度升高男性115-133

mol/L或mg/dl

女性107-124

mol/L或mg/dl微量白蛋白尿

30-300mg/24h

白蛋白/肌酐:男性22mmol)

女性31mmol)Assessmentof

Total(Global)CVRiskJNC7NoYesEuropeanTaskForceESH/ESCWHO/ISHContinuous/ColorimetricscalesDiscontinuousriskcategoriesManciaG.etal.,JHypertens2004;22:51-57454035302520151050None1234Additionalriskfactors13.7%39.8%32.4%12.1%2.0%5221518123546176高血壓常與其它心血管危險(xiǎn)因素合并存在%Microalbuminuria6543210RelativeriskofIHDSBP<140SBP140-160SBP>160Normoalbuminuria2.5(1.2-5.3)5.3(2.2-13.0)3.3(1.6-6.9)2.2(1.3-3.7)1.01.5(0.9-2.7)收縮壓、微量蛋白尿與心血管危險(xiǎn)Borch-JohnsenK,etal.ArteiosclerThrombVascBiol1999;19:1992HOT心血管危險(xiǎn)因素研究血壓水平以外的各項(xiàng)因素對(duì)CVD發(fā)生率的影響Riskfactor CV/1000pt.y RR Cl(95%)

Yes NoGender(MvsF) 12.0 7.2 1.62 (1.42~1.94)Age(≥65vs65yrs) 15.0 7.3 2.06 (1.77~2.39)Smoking 14.0 8.9 1.57 (1.31~1.88)S-Cholesterol(>6.8vs ≤6.8mmol/l) 11.6 9.0 1.29 (1.09~1.53)S-Creatinine(>1.3vs≤1.3mg/dl) 21.8 8.7 2.50 (2.03~3.07)Diabetes 18.3 9.0 2.03 (1.65~2.51)IschemicHeartDisease 18.4 8.1 2.27 (1.93~2.68)HOT：心血管危險(xiǎn)分層與CVD事件BMJ2002,324:71MajorcardiovasculareventsAllmyocardialinfarctionAllstrokeCardiovascularmortalityTotalmortalityRisk:MediumHighVeryHigh20151050Eventsper1000patientyearsManciaG.etal,.JHypertens2004;22:51-5750403020100LowMediumHighVeryhighPercentageofpatients18.1%4.8%46.0%38.8%28.8%41.3%7.0%15.2%PerceivedglobalriskCalculatedglobalriskRiskReclassificationinAPROSStudyCuspidietal.,JHypertens2002;20:1307-1315100806040200%InitialFinal*HighMediumLowRisk:* Afterecocardiogram+ carotidultrasonography81.3%18.7%53.2%35.7%11.1%降壓治療的實(shí)施過(guò)程對(duì)高血壓患者臨床評(píng)價(jià)后，首先進(jìn)行心血管危險(xiǎn)水平 分層(低危、中危、高危、很高危)所有患者都應(yīng)采用非藥物治療措施制定降壓治療計(jì)劃，確定血壓控制目標(biāo)值很高危、高?；颊撸毫⒓撮_(kāi)始藥物治療中危：隨訪觀測(cè)數(shù)周，然后決定是否開(kāi)始藥物治療低危：隨訪觀測(cè)數(shù)月，然后決定是否開(kāi)始藥物治療治療隨訪，調(diào)整治療方案血壓控制目標(biāo)值中青年高血壓患者<140/90mmHg老年高血壓患者<150/90mmHg

糖尿病或腎病患者 <130/80

mmHgRelativeRisk

RR(95%CI)BPDifference

(mmHg)Favors

FirstListedFavors

SecondListedMajorCVeventsCVmortalityTotalmortality1.02(0.98,1.07)2/0ACEIvsD/BB1.03(0.95,1.11)2/0ACEIvsD/BB1.00(0.95,1.05)2/0ACEIvsD/BB1.04(0.99,1.08)1/0CAvsD/BB1.05(0.97,1.13)1/0CAvsD/BB0.99(0.95,1.04)1/0CAvsD/BB0.97(0.92,1.03)1/1ACEIvsCA1.03(0.94,1.13)1/1ACEIvsCA1.04(0.98,1.10)1/1ACEIvsCABloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.BP-LoweringTreatmentTrialists

ComparisonsofDifferentActiveTreatmentsFatal/Non-fatalcardiaceventsFatal/Non-fatalstrokeAll-causedeathMyocardialinfarctionHeartfailurehospitalisationsControlledpatients*(n=10755)Non-controlledpatients(n=4490)HazardRatio95%CI*SBP<140mmHgat6months.Pooled

Treatment

Groups**********P<0.01.0.75(0.67–0.83)0.55(0.46–0.64)0.79(0.71–0.88)0.86(0.73–1.01)0.64(0.55–0.74)OddsRatioWeberMAetal.Lancet.2004;363:2047–49.VALUE:根據(jù)6個(gè)月時(shí)血壓控制情況的結(jié)果分析Benetosetal.JHypertens.2003;21:1635-1640.Follow-up(Years)Survival(%)1135791113151719212325P=.03P<.0001P=.001TreatedBPnotatgoal140/90mmHgUntreatedBP<140/90mmHgUntreatedBP140/90mmHgTreatedBPatgoal<140/90mmHgCVDSurvivalinTreatedHypertensives

atGoalandNotatGoal1210864208090100110120130Diastolicbloodpressure(mmHg)CVeventsElderlypatientsPatientsWithDiabetesandotherCVriskFactorsHypertensivesWithaverageriskHypertensivesWithlowerthanaverageriskRelationshipbetweendiastolic(inprinciple,similarforsystolic)bloodpressuresandcardiovascular(CV)events(arbitrayscale)inhypertensivepatientswithdifferentlevelsofcardiovascularriskMajorcardiovascularevents(per100patients-years)inalltreatedhypertensiveandinhypertensivepatientswithdiabetesinrelationtotargetbloodpressuresof90.85,and80mmHg.302520151050808590908580P=0.50fortrendP=0.005fortrendAllhypertensivepatients(n=18790)Hypertensivewithdiabetes(n=1501)TargetbloodpressuregroupsMajorcardiovascularevents/1000patients-yearsHOT:糖尿病與非糖尿病患者的CV事件發(fā)生率老年高血壓患者血壓控制目標(biāo)值調(diào)整的原因老年ISH臨床試驗(yàn)(SHEP,SYST-EURO,SYST-CHINA)

SBP目標(biāo)：<150mmHg大多數(shù)降壓治療臨床試驗(yàn)結(jié)果：

SBP目標(biāo)<140mmHg較難達(dá)到200mmHgSBP190180170160150140130200mmHg110100908070DBPHOPEPROGRESSCAPPPINSIGHTNORDILHOTSTONESTOP-2ALLHAT1LIFEALLHAT2ANBP2INVESTSCOPETreatedDiabeticPatientsofFORLIFEwithBPControlledandNotControlled≥140mmHgSBP≥90mmHg<90mmHg<140mmHg<130mmHg<80mmHgDBP80.6%19.4%4.4%64.8%35.2%10.6%Awareness,TreatmentandControlofHypertensioninChina

Awareness(%) Treatment(%) Control(%)6050403020100NorthSouthPrevalence(%)(a)50.231.57.910.733.246.5Aware