中国高血压防治指南重点内容解释

2004年中国 高血压 防治指南 重点内容解释 重点内容 q 血压分类和定义 q 心血管危险分层 q 血压控制目标值 q 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 55岁 q 女性 65岁 q 吸烟 q 血脂异常 : TC5.7mmol/L(220mg/dl) 或 LDL-C3.3mmol/L(130mg/dl) 或 HDL-C38mv, Cornel2440mmmms 超 声心动 图 LVMI或 X线 q 颈动脉超声 IMT0.9mm或动脉粥样斑块 q 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 q 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 1518 1235 461 76 高血压常与其它心血管危险因素合并存在 % Microalbuminuria 6 5 4 3 2 1 0 Relative risk of IHD SBP 160 Normoalbuminuria 2.5 (1.2-5.3) 5.3 (2.2-13.0) 3.3 (1.6-6.9) 2.2 (1.3-3.7) 1.0 1.5 (0.9-2.7) 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心血管危险因素研究 血压水平以外的各项因素对血压水平以外的各项因素对 CVD发生率的影响发生率的影响 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 1.57 (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 1.41-1.82 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 Hypertens 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 q 中青年高血压患者 140/90 mmHg q 老年 高血压 患者 150/90 mmHg q 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 First 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)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-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 (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 Treated BP not at goal 140/90 mm Hg Untreated BP 140/90 mm Hg Untreated BP 140/90 mm Hg Treated BP at goal 140/90 mm Hg CVD Survival in Treated Hypertensives at Goal and Not at Goal 12 10 8 6 4 2 0 80 90 100 110 120 130 Diastolic blood pressure (mm Hg) CV events Elderly patients Patients With Diabetes and other CV risk Factors Hypertensives With average risk Hypertensives With lower than average risk 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 hypertensive and in hypertensive patients with diabetes in relation to target blood pressures of 90. 85, and 80 mm Hg. 30 25 20 15 10 5 0 80 85 90 90 85 80 P=0.50 for trend P=0.005 for trend All hypertensive patients (n=18790) Hypertensive with diabetes (n=1501) Target blood pressure groups Major cardiovascular events/ 1000 patients-years 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 q 老年 ISH临床试验 (SHEP, SYST-EURO, SYST-CHINA) SBP目标： 150 mmHg q 大多数降压治疗临床试验结果： SBP目标 140 mmHg 较难达到 常用降压常用降压 药物药物 q 利尿剂 -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 q 固定 剂量复方降