高血压指南几个问题规范课件

1、最新高血压指南(zhnn)的几个问题刘力生第一页，共二十五页。高血压指南几个问题规范内容提要(ni rn t yo)关于(guny)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第二页，共二十五页。高血压指南几个问题规范高血压患者(hunzh)危险分层-WHO/ISH 1999注：1999年中国高血压防治(fngzh)指南的危险分层参考的是 1999年WHO/ISH指南第三页，共二十五页。高血压指南几个问题规范影响(yngxing)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-C

2、4.0 mmol/L, HDL-C男1.0，女1.2mmol/L） 早发心血管疾病家族史(男55, 女102, 女88cm) CRP1 mg/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107-124mol/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

3、；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124mol/L）；蛋白尿（300mg/24H） 周围血管疾病 高度眼底病变：出血；或渗出，乳头水肿第四页，共二十五页。高血压指南几个问题规范高血压患者危险(wixin)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12 危险因素0 危险因素：平均(pngjn)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Risk factor s

4、imilar as 1999 guidelines except :1.abdominal obesity 2.Diabetes as a separate criterion 3.CRP is added 第五页，共二十五页。高血压指南几个问题规范血压(xuy)分类-JNC-VI(1997)-类 别 收缩压（mm Hg) 舒张压（mm Hg)-理想(lxing)血压 120 80正常血压 120 - 129 80 - 84正常高值 130 - 139 85 - 891级高血压 140 159 90 99 亚组：临界高血压 140 - 149 90 - 942级高血压 160 - 179 10

5、0 -109 3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- 第六页，共二十五页。高血压指南几个问题规范1. Distribution of NHANES I Epldemiologic Follow-up Study Participants with a High-Normal BP or Hypertension at Baseline According to BP Lovel and Risk Categorization640(9.0)107(1.5)257(3.6)276(3.9)Risk Group A1366(19

6、.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)130-139/85-89Risk Group CRisk Group BSBP/DBP, mmHgValues are n (%)第七页，共二十五页。高血压指南几个问题规范2. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular

7、 Disease Event Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A8167131016160/ 10091711192033140-159/90-99101913232541130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrect

8、ed*UncorrectedSBP/DBP, mmHgSee test or Table 1 for deflnition of risk groups.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,第八页，共二十五页。高血压指南几个问题规范3. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the

9、 Number-Needed-to-Treat to Prevent a Cardiovascular Disease Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A112012213449160/ 10018312744273394140-159/90-9921373660486701130-

10、139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP, mmHgSee test or Table 1 for deflnition of risk groups.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,第九页，共二十五页。高血压指南几个问题规范4. Estlmate

11、d Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent An AI-Cause Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A9169172337160/ 10012

12、2216276097140-159/90-991425193381130130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP, mmHgSee test or Table 1 for definition of risk groups.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement

13、 of SBP第十页，共二十五页。高血压指南几个问题规范不同危险程度(chngd)高血压患者的血压水平(mmHg, xs) 男 女危险度 SBP DBP SBP DBP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(o wi) 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第十一页，共二十五页。高血压指南几个问题规

14、范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(jinsho)心血管发病与死亡（CVD Risk）,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CVD RR 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 第十二页，共二十五页。高血压指南几个问题规范心血管危险度分层的重要性（二）NHANES-I根据 JNC VI，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(hunzh)的危险度评估中

15、,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.第十三页，共二十五页。高血压指南几个问题规范Problems With a Strategy Based on Absolute Cardiovascular RiskF. Olaf Simpson/Journal of Hypertension 1996, Vol 14 No 6The proposed New Zealand guidelines: the 10-year absolute CVD risk strategyConsequences of the 10-year absolut

16、e-risk strategyPossible age-related modifications of the 10-year absolute-risk strategyProblems raised by inclusion of other risk factors in the calculationsProblems in calculation of the expected gains from antihypertensive therapyProblems in calculations of CVD risk from raised blood pressureArtic

17、le 1第十四页，共二十五页。高血压指南几个问题规范Cardiovascular risk evaluation：an inexact science （1）Failure to consider the full risk of the metabolic syndrome in current guidelinesFailure to appreciate the total benefit of antihypertensive therapyExcessive weighting of advanced age in the assessment of cardiovascular r

18、iskHow accurate is current risk assessment for uncomplicated mild hypertension?第十五页，共二十五页。高血压指南几个问题规范Although the absolute risk assessment methods may lack sufficient sensitivity, they still represent an improvement over that only the level of blood pressure and prior cardiovascular disease were rel

19、evant to therapeutic-decision making. To date, cardiovascular risk evaluation is an inexact science.Cardiovascular risk evaluation： an inexact science （2）第十六页，共二十五页。高血压指南几个问题规范Enhancing risk stratification in hypertensive subjects: How far should we go in routine screening for target organ damage? F

20、irst, it appears timely to include the search for microalbuminuria as a routine component of the work-up of all hypertensive patients worldwide;Second, it seems reasonable to recommend that the search for target organ damage should extend to cardiac and carotid ultrasound for high risk and very high

21、 risk hypertensive subjects.第十七页，共二十五页。高血压指南几个问题规范Pharmacological Treatment of HypertensionJ D Swales / The Lancet Vol 344. Aug. 6, 1994Benefits of treatmentTreatment of severe hypertensionMild to moderate hypertensionDefining the high-risk patientValue of repeated measurementsSystolic hypertensionTarget blood pressureSelection of therapyArticle 2第十八页，共二十五页。高血压指南几个问题规范血压(xuy)水平为正常高值SBP 130-139或DBP 85-89mmHg（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(judu)危险分层 药物治疗 药物治疗 经常监测 无需干预BP极高危高危中