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1、 高血压合理用药最新要点讨论顼志敏 Xu Zhimin阜外心血管病医院中国医学科学院 北京协和医学院顼志敏介绍 XU Zhimin 中国医学科学院阜外心血管病医院主任医师、教授、博士 国家心血管病中心专家委员 中国临床药理分会 委员 中华全科医学分会 常委 北京高血压学会 常委 中美脑中风协作组 药物治疗核心专家 中国健康教育中心专家咨询委员会专家 中国老年保健协会心血管专业委员会常委 我国高血压患病率呈增长态势:血压管理任重道远发病率(%) 按2010年我国人口的数量与结构，目前我国约有2亿高血压患者，1/5的成人患有高血压 2010年高血压控制率、治疗率、知晓率有所提高，但血压控制管理仍任
2、重道远所占比例(%)1.2005中国高血压指南 2.中国高血压防治指南(2009 年基层版) 3.2010中国高血压指南这是最好的时代这是最好的时代? ?这是最坏的时代这是最坏的时代? ?美国美国3中国中国2经年龄调整总的心血管疾病、冠心病、脑卒 中死亡率的变化 1900-1996 美国标化死亡率(1/10万)冠心病脑卒中总的心血管疾病1002003004005000 19001920194019601990199603060901201501985 19901995 200020052010 (年 )脑卒中冠心病3.MMWR Weekly August6, 1999 / 48(30);649
3、-6562.中国心血管病报告2005仅供内部学习使用2009中国高血压门诊控制率仅为31.1% 合并并发症的患者达标率更低血压达标标准：糖尿病或肾病患者血压50%， Qd， 提高顺从、平稳降压据血压水平、RF、TOD、ACC,选单或多药联合制定个性化方案：2级以上高血压常需联合用药，配 合非药物疗法 达标快慢： (2009,oct ESH)“In 2007, we took a strong stance in favor of combination treatment. This has been shown again-trials such as ACCOMPLISH, ADVANCE
4、, HYVET, ASCOT and ONTARGET are changing the picture. We have to lower BP rather quickly in these patients to try to prevent a catastrophe,“ and more recently, studies have shown there is less discontinuation of treatment in this patient population if treatment is started with combination therapy, M
5、ancia said.对高危患者更倾向于：联合用药、尽快达标、预防事件-June 16, 2009 (Milan, Italy) The European Society of Hypertension (ESH)近期的大型高血压临床试验带来的启示v降压越显著，预后越佳; v达标越早，预后越好; v2/3高血压需联合治疗才能达标; v降压会对代谢影响; 因此，联合治疗至关重要Volpe M, 2006药物治疗战略理念3-1用药模式：1）套餐模式：195060s2）席餐模式: 197080s3）自助餐模式: 19902000s常用四大类药物及其配方：RAS拮抗剂：ACEI(普利) / ARB(沙
6、坦)钙拮抗剂： CCB(地平等)利尿剂 (噻嗪等)Beta阻滞剂： BB(洛尔等)联合治疗最新策略 （2+1/ 1+1模式）利尿剂CCB ARB /ACEI保护心脑肾作用突出： (2009,oct ESH) In no less than 1520% of hypertensive patients, BP control cannot be achieved by a two-drug combination. When three drugs are required, the most rational combination appears to be a blocker of the
7、 renin angiotensin system, a calcium antagonist, and a diuretic at effective doses. 至少1520% 高血压患者，需要三联用药： 最合理方案： RAS拮抗剂+CCB+利尿剂-Journal of Hypertension 2009, 27:21212158合理联合用药方案： (2009,oct ESH)The combination of two antihypertensive drugs may offer advantages also for treatment initiation, particula
8、rly in patients at high cardiovascular risk in which early BP control may be desirable.Whenever possible, use of fixed dose (or single pill) combinations should be preferred, because simplification of treatment carries advantages for compliance to treatment.在高危病人，两药联合还可尽快达标 应优先应用固定剂量的单片剂复方： 使治疗简化、顺应
9、性提高长效钙通道阻滞剂： 没有强制禁忌证。 推荐用于: 脑卒中、 老年单纯收缩期高血压、 心绞痛、 左室肥厚、 颈动脉或冠状动脉粥样硬化、 妊娠妇女、 黑人高血压等。 ACEI ： ACEI优先适应证共10项： 心力衰竭、左室肥厚、左室功能异常、 心肌梗死后、 糖尿病肾病、非糖尿病肾病、 颈动脉粥样硬化、 蛋白尿或微量蛋白尿、 心房颤动 和 代谢综合征等ARB优先适应证： 1.老年患者 2.糖尿病 3.肾功能不全 4.脑卒中 5.冠心病和心衰 6.房颤 7.代谢综合征个性化选药： (2009, June ESH)“Classifying agents as first choice, seco
10、nd choice, third choice, etc, betrays reference to an average patient who hardly exists in clinical practice,“ he said, adding: “It is much better to indicate which drug might be preferred in which patient under which circumstance. All drugs have advantages and disadvantages, and we have to try to s
11、ee in which conditions the advantages of a drug come out.“最好用药模式：在合适的情况，选择合适的药物，用于合适的病人；-June 16, 2009 (Milan, Italy) The European Society of Hypertension (ESH) 降压作用：85-90% 降压外作用：15-10% 降压外作用依赖降压作用 降压疗效依赖： 1）降压幅度、基线血压、危险程度、并发 症及合并症，降压对象等。 2）合适的药物：品种、剂量、用法、时程 、配伍，等。降压达标是关键，全面防治为根本降压降压 质量质量高质量降压、高效率保护
12、Beta阻滞剂： (2009, June ESH)The totality of evidence now shows different conclusions for different patient populations, he said. “For example, for stroke prevention, beta blockers are inferior to calcium antagonists, but for congestive heart failure prevention, beta blockers are superior to calcium ant
13、agonists and similar to other drugs,“ 对脑卒中预防，BB弱于CCB; 对心衰， BB强于CCB-June 16, 2009 (Milan, Italy) The European Society of Hypertension (ESH)Beta阻滞剂： (2009,oct ESH)a recent meta-analysis of 147 randomized trials (the largest meta-analysis so far available) reports only a slight inferiority of b-blocker
14、s in preventing stroke (17% reduction rather than 29% reduction with other agents), but a similar effect as other agents on preventing coronary events and heart failure, and a higher efficacy than other drugs in patients with a recent coronary event目前最大（n=147）RCT荟萃分析示：与其他 药物比，Beta阻滞剂， 预防脑卒中方面略弱； 预防冠
15、脉事件和心衰，相同； 预防近期冠脉事件，较好。老年高血压： (2009, Oct ESH)At variance from previous guidelines, evidence is now available from an outcome trial (HYVET) that antihypertensive treatment has benefits also in patients aged 80 years or more. BP-lowering drugs should thus be continued or initiated when patients turn 8
16、0, starting with monotherapy and adding a second drug if needed. The decision to treat should thus be taken on an individual basis, and patients should always be carefully monitored during and beyond the treatment titration phase80岁或以上的老年高血压降压也可获益； 常常一种药开始，如需要再加另一种； 小心谨慎、个性化。糖尿病高血压： (2009, Oct ESH)In diabetes, combination treatment is commonly needed to effectively lower
