台湾高血压管理之南

740 J Formos Med Assoc | 2010 • Vol 109 • No 10 Contents lists available at ScienceDirect Journal of the Formosan Medical Association Journal homepage: http://www.jfma-online.com J Formos Med Assoc 2010;109(10):740–773 Journal of the Formosan Medical Association ISSN 0929 6646 Formosan Medical Association Taipei, Taiwan Volume 109 Number 10 October 2010 New Delhi metallo-b-lactamase-1 HTLV-1 and adult T-cell leukemia Detection of nighttime melatonin level in Chinese original quiet sitting Solifenacin and Tolterodine in the treatment of overactive bladder symptoms Guideline 2010 Guidelines of the Taiwan Society of Cardiology for the Management of Hypertension Chern-En Chiang,1 Tzung-Dau Wang,2 Yi-Heng Li,3 Tsung-Hsien Lin,4 Kuo-Liong Chien,5 Hung-I Yeh,6 Kou-Gi Shyu,7 Wei-Chuen Tsai,3 Ting-Hsing Chao,8 Juey-Jen Hwang,2 Fu-Tien Chiang,9 Jyh-Hong Chen3* Hypertension is one of the most important risk factors for atherosclerosis-related mortality and morbidity. In this document, the Hypertension Committee of the Taiwan Society of Cardiology provides new guide- lines for hypertension management. The key messages are as follows. (1) The life-time risk for hyperten- sion is 90%. (2) Both the increase in the prevalence rate and the relative risk of hypertension for causing cardiovascular events are higher in Asians than in Caucasians. (3) The control rate has been improved sig- nificantly in Taiwan from 2.4% to 21% in men, and from 5% to 29% in women in recent years (1995–2002). (4) Systolic and diastolic blood pressure (BP) ≥ 130/80 mmHg are thresholds of treatment for high-risk patients, such as those with diabetes, chronic kidney disease, stroke, established coronary heart disease, and coronary heart disease equivalents (carotid artery disease, peripheral arterial disease, and abdominal aortic aneurysm). (5) Ambulatory and home BP monitoring correlate more closely with end-organ damage and have a stronger relationship with cardiovascular events than office BP monitoring, but the feasibility of home monitoring makes it a more attractive alternative. (6) Patients with masked hy- pertension have higher cardiovascular risk than those with white-coat hypertension. (7) Lifestyle changes should be encouraged in all patients, and include the following six items: S-ABCDE (Salt restriction; Alcohol limitation; Body weight reduction; Cessation of smoking; Diet adaptation; Exercise adoption). (8) When pharmacological therapy is needed, physicians should consider “PROCEED” (Previous experi- ence of patient; Risk factors; Organ damage; Contraindication or unfavorable conditions; Expert or doctor judgment; Expense or cost; Delivery and compliance) to decide the optimal treatment. (9) The main ben- efits of antihypertensive agents are derived from lowering of BP per se, and are generally independent of ©2010 Elsevier & Formosan Medical Association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Division of Cardiology and General Clinical Research Center, Taipei Veterans General Hospital and National Yang-Ming University, 2Division of Cardiology, Department of Internal Medicine and 9Department of Laboratory Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, 5Institute of Preventive Medicine, College of Public Health, National Taiwan University, 6Department of Internal Medicine, Mackay Memorial Hospital and Mackay Medical College, and 7Division of Cardiology, Shin Kong Wu Ho-Su Memorial Hospital, Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, 3Division of Cardiology, Department of Internal Medicine, National Cheng Kung University College of Medicine and Hospital, Tainan, 8Department of Medicine, National Cheng Kung University Hospital Dou-Liou Branch, Yun-Lin, and 4Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. Received: April 7, 2010 Revised: May 29, 2010 Accepted: May 31, 2010 *Correspondence to: Dr Jyh-Hong Chen, Division of Cardiology, Department of Medicine, National Cheng Kung University Medical College and Hospital, 138 Sheng Li Road, Tainan, 704 Taiwan. E-mail: jyhhong@mail.ncku.edu.tw Taiwan hypertension guidelines J Formos Med Assoc | 2010 • Vol 109 • No 10 741 The writing group of the 2010 Guidelines of the Taiwan Society of Cardiology for the Management of Hypertension: Jyh-Hong Chen (Chairperson), Chern-En Chiang (Co-Chairperson), Tzung-Dau Wang, Yi-Heng Li, Tsung-Hsien Lin, Kuo-Liong Chien, Hung-I Yeh, Kou-Gi Shyu, Wei-Chuen Tsai, and Ting-Hsing Chao Taiwan Society of Cardiology Committee for Hypertension: Jyh-Hong Chen (Chairperson), Chern-En Chiang (Co-Chairperson), Tzung-Dau Wang, Chun-Yi Wu, Li-Ping Chou, Tsung-Hsien Lin, Kwan-Lih Hsu, Jaw-Wen Chen, Chuen-Den Tseng, Chao-Hung Yang, Wei-Chuen Tsai, Po- Ming Ku Taiwan Society of Cardiology Executive Board Members: Fu-Tien Chiang (President), Gwo-Ping Jong, Chern-En Chiang, Chang-Chyi Lin, Charles Jia-Yin Hou, Jyh-Hong Chen, Jun-Jack Cheng, Shih-Chung Huang, San-Jou Yeh, Chiau-Suong Liau, Wen-Ter Lai, Ji-Hung Wang, Kuo-Yang Wang, Shih-Ping Wu, Jiunn-Ren Wu, Chiung-Jen Wu, Mei- Hwan Wu, Li-Ping Chou, Chin-Lon Lin, Yu-Lin Ko, Kou-Gi Shyu, Tsui-Lieh Hsu, Wei-Hsian Yin, Chih-Kuang Chang, Chung-I Chang, Chi-Tai Kuo, Chung-Huo Chen, Thay-Hsiung Chen, Tsuei- Yuan Huang, Be-Tau Hwang, Chao-Hung Yang, Hung-I Yeh, Liang-Miin Tsai, Cheng-Ta Chung, Jeng Wei Taiwan Society of Cardiology Control Boards: Dr. Nen-Chung Chang, Ruey-Jen Sung, Chung- Sheng Lin, Chi-Ren Hung, Sheng-Hsiung Sheu, Ming-Fong Chen, Morgan Mao-Young Fu, Chuen- Den Tseng, Wen-Jin Cherng, Cheng-Ho Tsai, Hung-Shun Lo Preface Hypertension is the most important risk factor for cardiovascular morbidity and mortality.1 Since the Seventh Report of the Joint National Com- mittee Guidelines (JNC 7) on hypertension in 20032 and the European Society of Hypertension and European Society of Cardiology Guidelines for the Management of Arterial Hypertension in 2007,3 there have been many new data from the drugs being used, except that certain associated cardiovascular conditions might favor certain classes of drugs. (10) There are five major classes of drugs: thiazide diuretics; β-blockers; calcium channel blockers; angiotensin-converting enzyme inhibitors (ACEIs); and angiotensin receptor blockers (ARBs). Any one of these can be used as the initial treatment, except for β-blockers, which are only indicated in patients with heart failure, a history of coronary heart disease, and hyperadrenergic state. (11) A standard dose of any one of the five major classes of antihypertensive drugs can produce an ∼10-mmHg decrease in systolic BP (rule of 10) and a 5-mmHg decrease in diastolic BP (rule of 5), after placebo subtraction. (11) Combination therapy is frequently needed for optimal control of BP, and the amount of the decrease in BP by a two-drug combination is approximately the same as the sum of the decrease by each individual drug (∼20 mmHg in systolic BP and 10 mmHg in diastolic BP) if their mechanisms of action are independ- ent, with the exception of the combination of ACEIs and ARBs. (13) An ACEI or ARB plus a calcium chan- nel blocker or a diuretic (A + C or A + D) are reasonable two-drug combinations, and A + C + D is a reasonable three-drug combination, unless patients have special indications for β-blockers. (14) Single- pill (fixed-dose) combinations that contain more than one drug in a single tablet are highly recom- mended because they reduce pill burden and cost, and improve compliance. (15) Very elderly patients (≥ 80 years) should be treated without delay, but BP should be reduced gradually and more cautiously. Finally, these guidelines are not mandatory; the responsible physician’s decision remains most important in hypertension management. Key Words: blood pressure, disease management, drug therapy, hypertension C.E. Chiang, et al 742 J Formos Med Assoc | 2010 • Vol 109 • No 10 epidemiological studies and randomized control trials. The Hypertension Committee of the Taiwan Society of Cardiology believes it is an appropriate time to provide updated guidelines for the man- agement of hypertension. This report serves as a guide, and the Committee continues to recognize that the judgment of the responsible physician remains paramount. Classification According to the largest meta-analysis of obser- vational data carried out to date, cardiovascular morbidity and mortality have a continuous rela- tionship with both systolic (down to 115 mmHg) and diastolic (down to 75 mmHg) blood pres- sure (BP).4 For every 20 mmHg difference in sys- tolic BP, or 10 mmHg difference in diastolic BP, there is a twofold increases in the stroke death rate, and twofold differences in the death rates from coronary heart disease (CHD) and from other vas- cular causes.4 However, for descriptive purpose and therapeutic guidance, hypertension needs to be classified. The definition and classification of hypertension in these guidelines is based on of- fice BP, as shown in Table 1. For patients with high Framingham risk (≥ 20% in 10 years), such as pa- tients with diabetes, chronic kidney disease, stroke, established CHD, and CHD equivalents (carotid artery disease, peripheral arterial disease, and ab- dominal aneurysm), a target of < 130/80 mmHg is recommended.5 Epidemiology Hypertension is one of the most important risk factors for atherosclerosis-related mortality and morbidity. According to the Prospective Studies Collaboration, hypertension produced the great- est mortality burden in 2001, accounting for more than 7 million deaths worldwide, more than any other known risk factors.1 About 54% of stroke and 47% of ischemic heart disease worldwide are attributable to high BP.6 Overall, about 80% of the attributable burden occurred in low- and middle- income economies.6 The life-time risk of having hypertension is about 90%.7 The prevalence rate of hypertension is also growing. There were 972 million patients (26.4%) with hypertension in 2000 and the num- ber will reach 1.56 billion (29.2%) in 2025, a 60% increase in 25 years.8,9 The rampant increase in prevalence is most serious in Asia. For men, there will be a 65.4% increase in Asia compared with a 51.2% increase for men in the rest of the world. It is even more severe in women; an 81.6% increase in Asia compared with a 54.4% increase in the rest of the world.8 In a recent survey in Taiwan, the nationwide prevalence rates of hypertension, de- fined by systolic BP > 140 mmHg or diastolic BP >90mmHg, were 25% in men and 18% in women, and the rate increased to 47% among individuals of age ≥ 60 years.10 The community-based data on a 10-year follow-up cohort in Taiwan have shown that the incidence rates have increased among individuals with prehypertension, obesity and metabolic syndrome.11 Furthermore, baseline BP categories play an important role in predicting cardiovascular risks; the hazard ratios of prehy- pertension and hypertension increased from 1.73 to 4.52, compared with baseline normotensive subjects.11 The impact of hypertension on cardiovascular events in Asian is higher than that in Cau- casian.12 With the same increase in systolic BP of 15 mmHg, the hazard ratio for CHD and stroke is Table 1. Definition and classification of hypertension by office blood pressure* Stage Systolic BP Diastolic BP (mmHg) (mmHg) Normal < 120 and < 80 Prehypertension 120–139 or 80–89 Stage 1 hypertension 140–159 or 90–99 Stage 2 hypertension ≥ 160 or ≥ 100 Stage 3 hypertension ≥ 180 or ≥ 110 *Systolic BP ≥ 130 or diastolic BP ≥ 80 is considered hypertension for patients with coronary heart disease, coronary heart disease equiva- lent (carotid artery disease, peripheral arterial disease, abdominal aortic aneurysm), stroke, diabetes and chronic kidney disease. BP = Blood pressure. Taiwan hypertension guidelines J Formos Med Assoc | 2010 • Vol 109 • No 10 743 higher in Asian than in Caucasian.12 The hazard ratio of hypertension for fatal vascular events is higher for men in China and Japan, compared to men in Australia and New Zealand.13 In 6105 pa- tients with a history of stroke or transient ischemic attack, treatment of hypertension resulted in a 38% reduction in the risk of recurrent stroke in Asian patients, compared with a 20% reduction in Caucasian patients with a similar decrease in BP.14 In a recent survey from 10 developed countries, the prevalence rate of hypertension was higher in men than in women before the age of 60 years.8 After that, it was higher in women. An epidemio- logical study in Taiwan has shown similar find- ings, in that the age-related rise in systolic BP was steeper in women than in men between ages 40 to 80 years.10 Despite the mean systolic BP in men being higher than that in women before the age of 60 years, it becomes lower than that in women after 60 years.10 The control rate for hypertension, defined by office BP < 140/90 mmHg in non-high-risk pa- tients and < 130/80 mmHg in high-risk patients, is generally low. No single country has an overall control rate > 40%.2,15 In Taiwan, compared with the national survey in 1993,16 there was a signif- icant improvement in the awareness, treatment, and control rate in the 2002 survey,10 a finding that could be attributable to the implementation of the National Health Insurance system since 1995.10 Hypertension control rate increased from 2.4% to 21% in men, and from 5% to 29% in women.10 In fact, the control rate in Taiwan is higher than that in Korea (10.7%),17 Japan (12%)18 and China (5%).19 The control rate of hyperten- sion varies in different areas in Taiwan; it reaches about 50% for women in the northern area, but is < 10% for men in eastern parts, which reflects the disparity in medical resources.20 Etiology Blood pressure is a product of the interaction be- tween genetic determinants and environmental in- terfering factors, where the causes of hypertension arise. Currently, the etiology of hypertension is divided into two categories: essential and second- ary hypertension. Essential hypertension In patients with high BP, essential hypertension is diagnosed after secondary causes of hypertension are excluded.21 Essential hypertension accounts for nearly 95% of all cases of hypertension. The development of study into human genetics has lead to the recognition of several genes that are involved in regulation of BP.22–24 These associa- tions between common variants and BP and hy- pertension offer mechanistic insights into the regulation of BP, and point to novel targets for interventions to prevent cardiovascular disease. However, genetic analysis for most patients with hypertension is not practical at present. In con- trast, detection of environmental interfering fac- tors is useful for BP control. These factors include: (1) obesity; (2) insulin resistance; (3) high alco- hol intake; (4) high salt intake (in salt-sensitive patients); (5) aging; (6) sedentary lifestyle; (7) stress; (8) low potassium intake; and (9) low cal- cium intake. Many of these factors occur in clus- ters and the effects are additive, such as obesity, insulin resistance, and sedentary lifestyle. Secondary hypertension Secondary hypertension is a potentially curable condition if the cause is eliminated.25 The most common form is secondary to renal parenchymal disease; the causes of which include acute and chronic glomerulonephritis of varying causes, autosomal dominant polycystic kidney disease, diabetic nephropathy, and hydronephrosis sec- ondary to obstructive uropathy. Renovascular disease is also a common cause of secondary hy- pertension related to the kidneys, which is due to renal artery stenosis, which is often caused by atherosclerosis in elderly patients. Apart from the kidneys, other common causes of secondary hy- pertension are endocrine-related, due to either hyperactivity or hypoactivity, depending on the glands involved. Table 2 summarizes the causes of secondary hypertension. C.E. Chiang, et al 744 J Formos Med Assoc | 2010 • Vol 109 • No 10 Office Blood Pressure, Ambulatory Blood Pressure, Home Blood Pressure, and Other Blood Pressure Parameters Blood pressure can be measured by doctors or nurses in the office or clinic (office BP), by auto- matic machine over 24 hours (ambulatory BP monitoring; ABPM), or by the patient or a relative at home (home BP monitoring; HBPM). Although office BP is used for staging of hypertension, there is increasing evidence that it might not reflect the true cardiovascular risk for hypertensive patients.26 ABPM and HBPM have become increasingly im- portant for the management of hypertension.26,27 They both make use of automated, validated oscil- lometric devices, and the BP values are operator- independent.28 They also eliminate the alarm reaction and the “white-coat” effect associated with office BP measurement, and provide more stable and reproducible readings of BP values.29 A new electronic device for HBPM, which imp- lements an algorithm for the diagnosis of atrial fibrillation, has an excellent diagnostic accuracy.30 A much larger number of values than office BP measurements make HBPM and ABPM more ac- curate estimates of future cardiovascular events.31 Office blood pressure The measurement of BP is likely to be the clinical procedure of greatest importance that is performed in the sloppiest manner. Blood pressure measure- ment should follow the guidelines outlined by Pickering et al,32 and is not mentioned further in this paper. In brief, the diagnosis of hypertension should be based on multiple measurements on separate occasions over a period of time. The pa- tients should be seated with their back supported and both feet lying flat on the floor for at least 5 minutes in a quiet room, with an empty bladder. At least two measurements of BP should be taken each time, separated by at least 1 minute. Blood pressure can be measured by a mercury sphyg- momanometer or other noninvasive electronic devices. The latter is becoming an important mo- dality because of its simplicity of use and the pro- gressive banning of the medical use of mercury. For mercury sphygmomanometry, phase I and V Korotkoff sounds are taken to identify systolic and diastolic BP, respectively. The BP should be taken in both arms at first visit and the higher value is used as reference. For follow-up, one only needs to measure the BP in the arm with the higher value. Although the data from the Framingham Heart Study have shown that diastolic BP is a stronger predictor for future coronary events than systolic BP in patients aged < 50 years,33 it is generally believed that systolic BP is a more important Table 2. Causes of secondary hypertension Acute stress Isolated systolic related secondary hypertension due to an hypertension increased cardiac output Diseases of the aorta Neurological causes Coarctation of the Guillain–Barre aorta syndrome Rigidity of the aorta Idiopathic, primary, or familial dysautonomia Drugs and exogenous Increase intracranial hormones pressure Endocrine Quadriplegia Acromegaly Obstructive sleep apnea Adrenal cortical Pregnancy induced hypertension Apparent Renal mineralocorticoid excess Cushing syndrome Increased intravascular volume Primary Primary sodium aldosteronism retention (Liddle’s syndrome) Adrenal medulla Renal parenchymal disease Carcinoid syndrome Renin-producing tumors Pheochromocytoma Renal vascular disease Hyperparathyroidism Hyperthyroidism Hypothyroidism Taiwan hypertension guidelines J Formos Med Assoc | 2010 • Vol 109 • No 10 745 predictor for overall