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1、高血压合理用药 最新要点讨论及处方分析,顼志敏 Xu Zhimin 中国医学科学院 阜外心血管病医院,我国高血压患病率愈来愈高,全国患病人数已超过2.0亿,中国居民营养与健康现状调查。卫生部、科技部、统计局，2004、10、12,我国18岁及以上居民高血压患病率为18.8%,中国高血压控制率,降压本身的益处,平均降低 卒中发生率 3540% 心肌梗死 2025% 心力衰竭 50%,JNC 7,收缩压降低1012mmHg或舒张压降低5-6mmHg,1、高血压治疗四大目标,长期、有效、平稳控制血压水平 预防(逆转)心、脑、肾等靶器官的损害 减少心、脑血管疾病的发病和死亡循证医学 改善生活质量,亚临
2、床靶器官损害之保护 (2009,oct ESH Reappraisal) Evidence on the important prognostic role of subclinical organ damage continues to grow. In both hypertensive patients and the general population, the presence of electrocardiographic and echocardiographic LVH, a carotid plaque or thickening, an increased arteria
3、l stiffness, a reduced eGFR (assessed by the MDRD formula), or microalbuminuria or proteinuria substantially increases the total cardiovascular risk, usually moving hypertensive patients into the high absolute risk range. 合并亚临床靶器官损害常为高危者：LVH,颈动脉斑块、增厚硬化， eGFR下降，微量/蛋白尿。 -Journal of Hypertension 2009,
4、27:21212158,血压目标 所有患者 140/90 140/90 DM/肾病 130/80(DM) 130/80 冠心病：130/80 mm Hg (2007/2009年欧洲高血压指南) *老年SBP难于140可适当灵活些(尤低危者)， 老年收缩压可降至150 mm Hg以下,血压目标 低限？ (ESH June, 2009 ) Key among the changes will be the recommendation of a lower threshold level-around 120 mm Hg systolic and 70 mm Hg diastolic-below
5、which it could be dangerous to reduce blood pressure in high-risk individuals, representing the so-called J-curve phenomenon, Mancia said. J-Curve: A Narrow Window of Optimum BP for High-Risk Individuals “J形曲线”可能存在，有些特定高危患者血压不宜过低（120/70） -June 16, 2009 (Milan, Italy) The European Society of Hyperten
6、sion (ESH),血压达标 (2009,oct ESH Reappraisal) Each drug class has contraindications as well favorable effects in specific clinical settings. The choice of drug(s) should be made according to this evidence. The traditional ranking of drugs into first, second, third, and subsequent choice, with an averag
7、e patient as reference, has now little scientific and practical justification and should be avoided. 每种药物均有利弊：应循证选药； 强调个性化用药，避免一线、二线、三线 -Journal of Hypertension 2009, 27:21212158,何时开始用药 (2009,oct ESH Reappraisal) it appears reasonable to recommend that, in grade 1 hypertensives (SBP 140159mmHg or DP
8、B 9099mmHg) at low and moderate risk, drug therapy should be started after a suitable period with lifestyle changes. Prompter initiation of treatment is advisable if grade 1 hypertension is associated with a high level of risk, or if hypertension is grade 2 or 3. 立即用药：a）2或3级高血压; b）1级HT +高危 改善生活方式后用药
9、：1级HT +低、中危,2、治疗策略（中国） 几周内渐降血压至目标, 更长/更短期间？（几天？） 推荐长效剂，持续24小时、T/P50%， 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, June ESH) “In 2007, we took a strong stance in favor of combination treatment. This has been shown again-trials such as ACCOMPLISH, ADVANCE, HYVET,
10、 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, Mancia sa
11、id. 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),3、药物治疗战略理念,3-1用药模式： 1）套餐模式：195060s 2）席餐模式: 197080s 3）自助餐模式: 19902000s,3-2常用五类药物及其配方： RAS拮抗剂：ACEI(普利) ARB(沙坦) 钙拮抗剂： CCB(地平等) 利尿剂 (噻嗪等) Beta阻滞剂： BB(洛尔等),2009 ESC/ESH 专家意见,利尿剂,CCB,ARB,ACEI,3-3 2007ESC/
12、ESH指南推荐联合: 噻嗪类利尿剂与ACEI， 噻嗪类利尿剂与ARB， 钙拮抗剂与ACEI， 钙拮抗剂与ARB， 钙拮抗剂与噻嗪类利尿剂， - 受体阻滞剂与二氢吡啶类钙拮抗剂。,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 blo
13、cker of the 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 initiati
14、on, particularly 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
15、单片剂复方： 使治疗简化、顺应性提高,4-2、2007欧洲高血压指南: 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/ARB类药物的绝对禁忌证,妊娠 血管神经性水肿 高钾血症 双侧肾动脉狭窄,4-2、2007欧洲高血压指南: 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,4-2、2007欧洲高血压指南: ARB优先适应证： 1.老
16、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,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 antagonists and similar to other drugs,“ 对脑卒中
