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1、高血压抗动脉粥样硬化治疗策略江苏省人民医院 黄峻高血压压从 “无需治疗疗”时时代穿越“The treatment of hypertension itself is a difficult and almost hopeless task in the present state of knowledge, and in fact for aught we know . the hypertension may be an important compensation mechanism which should not be tampered with, even were it certa
2、in that we could control it.“ 高血压可能是一种重要的代偿机 制，我们不应该干预它 Paul Dudley White, 1937年Paul Dudley White (1886-1973)：近代著名的世界级心脏病学家，AHA创始人之一，预激综合征的最早发 现者之一，世界最早的专著的作者 罗斯福总统最后一个任期时的文件詳細记载了他的健康Franklin D. Roosevelt （FDR） was referred to Dr. Howard Bruenn, a cardiologist at Bethesda Naval Hospital who, on Marc
3、h 27, 1944 found him cyanotic, breathless, with an enlarged left ventricle and a blood pressure of 186/108. Bruenn diagnosed hypertensive heart disease and wanted to give digitalis, but was prohibited by Dr. Ross McIntire, the presidents personal physician and then surgeon-general of the U.S. Navy.
4、The next day, FDR developed moist rales at the base of the right lung. During a press conference that day, FDR was asked about his physical condition and answered, “I got bronchitis.“ By March 30 crackles were present at the base of both lungs. Bruenn diagnosed congestive heart failure, but it was n
5、ot until the next day, after FDR was examined by civilian consultants, that digitalis was begun. FDR would continue the digitalis for the rest of his life. By April 3, FDR was better. His color was better, he could lie flat without dyspnea, and the crackles disappeared from both lungs. His blood pre
6、ssure, however, was 210/110. The nation was stunned when FDR died unexpectedly on April 12, 1945 - less than six months after being elected to a fourth term in office. The death was unexpected because the presidents personal physician, VADM Ross McIntire, whenever asked, had proclaimed that FDRs hea
7、lth was excellent.1944年3月27日：血压186/1081944年4月3日：血压210/110总统的医生宣称：罗斯福总统健康状况很好！1945年4月12日，罗斯福总统死於脑溢血。“Franklin D. Roosevelts health was excellent”！？ 1944年高血压压治疗发疗发 展史（20世纪纪初中期）The American Journal of Medicine(1972)一些基本问题有待回答： 什么是高血压？ 血压高于多少诊断为高血压？ 如何评估预后和治疗效果？分界值(mmHg)文献出处 120/80Robinson and Brucer (1
8、939) 130/70Browne (1947) 140/80Ayman (1934) 140/90Perera (1948) 150/90Thomas (1952) 160/100Bechgaard (1946) 180/100Burgess (1948) 180/110Evans (1956)血压诊断标准不断修正：百年高血压压治疗疗史：成绩绩斐然www.sma.org; Ann Intern Med 1970;72:579-591; Mourad et al. Journal of hypertension 2004,22:2379-2385; Journal of Hypertensio
9、n 2007, 25:11051187; Sever PS et al. European Heart Journal 2006;27:2982-2988不治疗限盐治疗序贯治疗阶梯治疗联合治疗优化联合治疗脑卒中冠心病下降% / DBP降低6 mm Hg流行病学资料随机试验流行病学资料随机试验0 10 20 30 40 50但是， 降压压治疗疗降低冠心病事件的幅度未达预预期Collins and Peto, 1994-60-50-40-30-20-100-52%-38%-21%-16%卒中心衰CVD死亡CHD事件收缩压降低10-12mmHg或舒张压降低5-6mmHg风险降低 (%)Collins
10、 and Peto, 1994荟荟萃分析： 单纯单纯 降压压治疗疗的冠心病获获益存在瓶颈颈治疗的高血压患者即使控制血压压， 高血压压患者的冠心病风险风险 仍显显著高于常人Andersson OK. Br Med J. 1998;317:167-171.686名高血压患者和6810名血压正常人群，平均随访22-23年冠心病生存185/114145/89mmHg146/93mmHg1.00.90.80.7 0 2 4 6 8 10 12 14 16 18 20 22无高血压患者P=0.0001高血压压患者的冠心病风险风险Andersson OK. Br Med J. 1998;317:167-17
11、1.参数偏回归系数HR (95% CI)P值血压0.011.01 (0.90-1.21)NS吸烟0.031.03 (0.92-1.19)NS胆固醇水平0.191.20 (1.08-1.32)20%（高危），当总胆固醇 3.5mmol/L(135mg/dl)时应接受他汀治疗。高血压患者虽无已发心血管疾病，但属于心血 管病高危患者，则不论其基线总胆固醇或LDL-C是 否升高，均应进行他汀治疗高血压的治疗目标不是降低血压本身，而是最大程度降低 心脑血管疾病的总体风险！欧洲高血压防治指南(2007)Mancia G. et al. Eur Heart J. 2007;28(12):1462-1536未
12、来之路www.sma.org; Ann Intern Med 1970;72:579-591; Mourad et al. Journal of hypertension 2004,22:2379-2385; Journal of Hypertension 2007, 25:11051187; Sever PS et al. European Heart Journal 2006;27:2982-2988不治疗限盐治疗序贯治疗阶梯治疗联合治疗优化联合治疗以抗动脉粥样硬化为核 心的高血压治疗策略回归临床，对高血压抗AS治疗策略付诸实践的几点思考WhenWhom How（1）When高血压患者的动
13、脉血管脂纹/中间病变粥样硬化纤维斑块复杂病变/破裂朝鲜战鲜战 争阵阵亡美国士兵的尸检报检报 告： 动动脉粥样样硬化已经经普遍存在ENOS JAMA 1953300例尸检报告（平均年龄22.1岁） 77.3%冠状动脉粥样硬化，39%狭窄性斑块Collaboration group.Chinese J Pathology 1983, 12(2):81中国人冠脉粥样样硬化检检出率高(岁)(%)587487909510010213743504002040608010040-50-60-70-80-90-动脉粥样硬化狭窄中国人冠脉粥样硬化发生率（1983年）阵线阵线 前移：从“亡羊补补牢”推进进到“未雨
14、稠繆”高血压患者的动脉血管冠心病 二级预防冠心病 一级预防无论一级预防，还是二级预防，高血压患者治疗的主要目的都是为了延缓或逆转潜在的动脉粥样硬化过程。AHA防治缺血性心脏病高血压治疗指南(2007)Circulation 2007;115:2761-2788(2)Whom合并冠心病（二级预防）30%全部高血压患者一级预防已被广泛关注从谁开始？TC 200-239mg/dl LDL-C 130-159mg/dlTC240mg/dl LDL-C 160mg/dl无高血压且其他危险因 素数20%为冠心病等危症。 * 急性冠脉综合征、冠心病合并糖尿病为极高危。.2007年 中国成人血脂异常防治指南高
15、血压患者中 危险因素越多，心血管病风险越高Hypertension. 2001;37:1256-1261.前瞻性队列研究：包括42,765名高血压患者和22,147名正常血压无RF对照 者，评价危险因素与心血管病风险间的关系1.000.980.960.94心血管病存活率 (%)*与正常血压无RF对照者者相比，P0.01高血压合并 3RFs者* (N=3,994)高血压合并 12RFs者* (N=26,321)高血压不合并RF者 (N=12,450)正常血压无RF对照者 (N=22,147)随访时间（年）135791113151719冠心病等危症l 有临床表现的冠脉以外动脉的动脉粥样硬化l 糖尿
16、病l BP140/90mmHg或正在接受降血压药物治疗合并3项心血管病危险因素者2007年 中国成人血脂异常防治指南高血压合并多个危险因素是冠心病等危症Equal Priority！中国成人血脂异常防治指南，人民卫生出版社(2)Whom合并冠心病（二级预防）30%全部高血压患者从高血压合并多个 RF的患者开始！(3)How ESH/ESC 高血压防治指南 (2007) 中国成人血脂异常防治指南European Heart Journal 2007 人民卫生出版社病人类型血压治疗目标值 mmHgLDL-C治疗目标值 mg/dL (mmol/L)高血压3个危险因素130/80100 (2.6)高血压
