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1、高血压治疗指南和研究进展 中国高血压防治指南解读 血压水平的分类和定义 分类 收缩压 mmHg 舒张压 mmHg 正常血压 120 和 80 正常高值 120 139 或 80 89 高血压 140 或 90 1级 140 159 或 90 99 2级 160 179 或 100 109 3级 180 或 110 单纯收缩期高血压 140 或 90 Systolic Blood Pressure 150 mmHg 160 mmHg 140 mmHg 130 mmHg 120 mmHg 100 80 60 40 20 0 020406080100 False positive error rat
2、e Sensitivity Pater C Current Controlled Trials in Cardiovascular Medicine 2005 6 5 Vasan et al Vasan et al N Engl J Med N Engl J Med 2001 345 1291 1297 2001 345 1291 1297 WomenWomen 1010 8 8 6 6 4 4 2 2 0 0 Time years Time years 0 0 2 2 4 4 6 6 8 8 101012121414 P P 001 001 MenMen Cumulative Inciden
3、ce Cumulative Incidence 1414 1212 1010 8 8 6 6 4 4 2 2 0 0 Time years Time years 0 0 2 2 4 4 6 6 8 8 101012121414 P P 001 001 High normal 130 139 85 89 mm HgHigh normal 130 139 85 89 mm Hg Normal 120 129 80 84 mm HgNormal 120 129 80 84 mm Hg Optimal 120 80 mm HgOptimal 120 80 mm Hg PrehypertensionPr
4、ehypertension High Normal BP and CVD Risk Framingham Study High normalHigh normal 130 139130 139 Stage 1Stage 1 140 159140 159 Stage 2 Stage 2 160 160 High normalHigh normal 85 8985 89 Stage 1Stage 1 90 9990 99 Stage 2 Stage 2 100 100 JNC 6 StageJNC 6 Stage Average DBPAverage DBP Average SBPAverage
5、SBP Upstaged based on SBPUpstaged based on SBPCongruentCongruentUpstaged based on DBPUpstaged based on DBP 85 7 9 高血压分级 Franklin SS et al Hypertens 2001 37 869 100 80 60 40 20 0 4040 4950 5960 6970 7980 17 16 16 20 20 11 Age y Frequency of hypertension subtypes in all untreated subjects Frequency di
6、stribution of untreated hypertensive individuals by age and hypertension subtype Numbers at the tops of bars represent the overall percentage distribution of untreated hypertension in that age group ISH SBP 140 mm Hg and DBP 90 mm Hg SDH SBP 140 mm Hg and DBP 90 mm Hg IDH SBP55岁 q女性 65岁 q吸烟 q血脂异常 TC
7、 5 7mmol L 220mg dl 或LDL C 3 3mmol L 130mg dl 或HDL C 1 0mmol L 40mg dl q早发心血管病家族史 一级亲属发病年龄38mv Cornel 2440mm mms 超声心动图LVMI或X线 q颈动脉超声IMT 0 9mm或动脉粥样斑块 q血请肌酐轻度升高 男性 115 133 mol L或1 3 1 5mg dl 女性 107 124 mol 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 并存的临床情况并存的临
8、床情况 脑血管病脑血管病 q缺血性卒中史 q脑出血史 q短暂性脑缺血发作史 心脏疾病心脏疾病 q心肌梗死史 q心绞痛 q冠状动脉血运重建 q充血性心力衰竭 肾脏疾病肾脏疾病 q糖尿病肾病 q蛋白尿 300mg 24h q肾功能衰竭 血清肌酐 177 mol L或2 0mg dl q肾功能受损 血清肌酐 男性 133 mol L或1 5mg dl 女性 124 mol L或1 4mg dl 外周血管疾病外周血管疾病 糖尿病糖尿病 q空腹血糖 7 0mmol L 126mg dl q餐后血糖 11 1mmol L 200mg dl 视网膜病变视网膜病变 q出血或渗出 q视乳头水肿 Microalb
9、uminuria 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 Risk Reclassification in APROS Study Cuspidi et al J Hypertens 2002 20 1307 1315 100 8
10、0 60 40 20 0 InitialFinal High Medium Low Risk After ecocardiogram carotid ultrasonography 81 3 18 7 53 2 35 7 11 1 降压治疗策略的核心 血压控制达标和联合治疗 60 50 40 30 20 10 0 52 38 21 16 Risk Reduction Fatal nonfatal strokes Heart failure CVD deaths Fatal nonfatal CHD events 降压治疗的益处 收缩压降低10 12mmHg或舒张压降低5 6mmHg Achie
11、ved DBP mm Hg HOT Study Risk of a major cardiovascular event reduced by 30 0 5 10 15 20 25 30 10510095908580 risk reduction Optimal DBP reduction in the HOT Study Fatal Non fatal cardiac events Fatal Non fatal stroke All cause death Myocardial infarction Heart failure hospitalisations 0 40 60 81 01
12、21 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 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 Odds Ratio Weber MA et al Lancet 2004 363 2047 49 VALUE 根据6个月时血压控制情况的结果分析 SBP differen
13、ce between randomized groups mmHg SBP difference between randomized groups mmHg Relative risk of outcome eventRelative risk of outcome event 1 501 50 1 251 25 1 001 00 0 750 75 0 500 50 0 250 25 1 501 50 1 251 25 1 001 00 0 750 75 0 500 50 0 250 25 1 501 50 1 251 25 1 001 00 0 750 75 0 500 50 0 250
14、25 1 501 50 1 251 25 1 001 00 0 750 75 0 500 50 0 250 25 1 501 50 1 251 25 1 001 00 0 750 75 0 500 50 0 250 25 StrokeStrokeMajor CVDMajor CVDCHDCHD CVD deathCVD deathTotal mortalityTotal mortality 10 10 8 8 6 6 4 4 2 2 0 0 2 2 4 4 10 10 8 8 6 6 4 4 2 2 0 0 2 2 4 4 10 10 8 8 6 6 4 4 2 2 0 0 2 2 4 4 1
15、0 10 8 8 6 6 4 4 2 2 0 0 2 2 4 4 10 10 8 8 6 6 4 4 2 2 0 0 2 2 4 4 0 51 02 0 Relative Risk RR 95 CI RR 95 CI BP DifferenceBP Difference mm Hg mm Hg FavorsFavors First ListedFirst Listed FavorsFavors Second ListedSecond Listed Major CV eventsMajor CV events CV mortalityCV mortality Total mortalityTot
16、al mortality 1 02 0 98 1 07 1 02 0 98 1 07 2 02 0 ACEI vs D BB ACEI vs D BB 1 03 0 95 1 11 1 03 0 95 1 11 2 02 0 ACEI vs D BB ACEI vs D BB 1 00 0 95 1 05 1 00 0 95 1 05 2 02 0 ACEI vs D BB ACEI vs D BB 1 04 0 99 1 08 1 04 0 99 1 08 1 01 0 CA vs D BB CA vs D BB 1 05 0 97 1 13 1 05 0 97 1 13 1 01 0 CA vs D BB CA vs D BB 0 99 0 95 1 04 0 99 0 95 1 04 1 01 0 CA vs D BB CA vs D BB 0 97 0 92 1 03 0 97 0 92 1 03 1 11 1 ACEI vs CA ACEI vs CA 1 03 0 94 1 13 1 03 0 94 1 13 1 11 1 ACEI vs CA ACEI vs CA 1 0
