最新高血压指南的几个问题+.ppt

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 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 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 120 80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 140 90亚组 临界收缩期高血压140 149 90 1 DistributionofNHANESIEpldemiologicFollow upStudyParticipantswithaHigh NormalBPorHypertensionatBaselineAccordingtoBPLovelandRiskCategorization Valuesaren 2 EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber Needed to TreattoPreventaCardiovascularDiseaseEventAmongNHANESIEpidemiologicFollow UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRisk SeetestorTable1fordeflnitionofriskgroups Correctedforregressiondilutionbiasusingareliabilitycoefficientor0 53tocorrectforImprecisioninthemeasurementofSBP 3 EstimatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber Needed to TreattoPreventaCardiovascularDiseaseDeathAmongNHANESIEpidemiologicFollow UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRisk SeetestorTable1fordeflnitionofriskgroups Correctedforregressiondilutionbiasusingareliabilitycoefficientor0 53tocorrectforImprecisioninthemeasurementofSBP 4 EstlmatedEffectofa12mmHgReductioninSBPOver10yearsontheNumber Needed to TreattoPreventAnAI CauseDeathAmongNHANESIEpidemiologicFollow UpStudyParticipantsAccordingtoBaselineBPLevelandCategoryofPresumedCardiovascularRisk SeetestorTable1fordefinitionofriskgroups 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 P 0 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 yearabsoluteCVDriskstrategyConsequencesofthe10 yearabsolute riskstrategyPossibleage relatedmodificationsofthe10 yearabsolute riskstrategyProblemsraisedbyinclusionofotherriskfactorsinthecalculationsProblemsincalculationoftheexpectedgainsfromantihypertensivetherapyProblemsincalculationsofCVDriskfromraisedbloodpressure Article1 Cardiovascularriskevaluation aninexactscience 1 Failuretoconsiderthefullriskofthe metabolicsyndrome incurrentguidelinesFailuretoappreciatethetotalbenefitofantihypertensivetherapyExcessiveweightingofadvancedageintheassessmentofcardiovascularriskHowaccurateiscurrentriskassessmentforuncomplicatedmildhypertension Althoughtheabsoluteriskassessmentmethodsmaylacksufficientsensitivity theystillrepresentanimprovementoverthatonlythelevelofbloodpressureandpriorcardiovasculardiseasewererelevanttotherapeutic decisionmaking Todate cardiovascularriskevaluationisaninexactscience Cardiovascularriskevaluation aninexactscience 2 Enhancingriskstratificationinhypertensivesubjects Howfarshouldwegoinroutinescreeningfortargetorgandamage First itappearstimelytoincludethesearchformicroalbuminuriaasaroutinecomponentofthework upofallhypertensivepatientsworldwide Second itseemsreasonabletorecommendthatthesearchfortargetorgandamageshouldextendtocardiacandcarotidultrasoundforhighriskandveryhighriskhypertensivesubjects PharmacologicalTreatmentofHypertensionJDSwales TheLancetVol344 Aug 6 1994 BenefitsoftreatmentTreatmentofseverehypertensionMildtomoderatehypertensionDefiningthehigh riskpatientValueofrepeatedmeasurementsSystolichypertensionTargetbloodpressureSelectionoftherapy Article2 血压水平为正常高值 SBP130 139或DBP85 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 ISH 2003 血压水平为I II级高血压 SBP140 179或DBP90 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 BP 140 90BP 140 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 SBP 140 159BP 140 90DBP 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 Interventionsevaluated Non personalinterventionsN1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N4N2 N3的综合干预P