null最新高血压指南的几个问题最新高血压指南的几个问题
刘力生内容提要内容提要关于血压水平的定义和分类
关于危险度分层
关于卫生经济学
关于用药问题高血压患者危险分层--WHO/ISH 1999高血压患者危险分层--WHO/ISH 1999注:《1999年中国高血压防治指南》的危险分层参考的是
1999年WHO/ISH指南影响高血压患者预后的因素影响高血压患者预后的因素高血压患者危险分层--2003欧洲高血压指南高血压患者危险分层--2003欧洲高血压指南±:平均危险;+:低度危险增加;++:中度危险增加;+++:高度危险增加;++++:极高度危险增加Risk factor similar as 1999 guidelines except :
1.abdominal obesity 2.Diabetes as a separate criterion 3.CRP is added
血压分类--JNC-VI(1997)
血压分类--JNC-VI(1997)
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类 别 收缩压(mm Hg) 舒张压(mm Hg)
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理想血压 <120 <80
正常血压 120 - 129 80 - 84
正常高值 130 - 139 85 - 89
1级高血压 140 – 159 90 – 99
亚组:临界高血压 140 - 149 90 - 94
2级高血压 160 - 179 100 -109
3级高血压 180 110
单纯收缩期高血压 140 <90
亚组:临界收缩期高血压 140 - 149 <90
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1. Distribution of NHANES I Epldemiologic Follow-up Study Participants with a High-Normal BP or Hypertension at
Baseline According to BP Lovel and Risk Categorization1. Distribution of NHANES I Epldemiologic Follow-up Study Participants with a High-Normal BP or Hypertension at
Baseline According to BP Lovel and Risk CategorizationValues are n (%)2. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Event Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk2. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Event Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular RiskSee test or Table 1 for deflnition of risk groups.
*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,3. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk3. Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular RiskSee test or Table 1 for deflnition of risk groups.
*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP,4. Estlmated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent An AI-Cause Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk4. Estlmated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent An AI-Cause Death Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular RiskSee test or Table 1 for definition of risk groups.
*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP不同危险程度高血压患者的血压水平(mmHg, xs)不同危险程度高血压患者的血压水平(mmHg, xs) 男 女
危险度 SBP DBP SBP DBP
低危 141.3(12.0) 88.7(7.9) 141.7(10.8) 88.4(10.1)
中危 144.7(15.6) 89.3(9.7) 144.1(26.7) 86.4(10.6)
高危 144.0(17.7) 88.8(11.5) 139.6(18.6) 85.6(14.5)
极高危 148.4(21.5)* 88.8(12.8) 145.9(22.6)* 87.6(34.2)
* P<0.05null心血管危险度分层的重要性(一)
高血压常常伴随其它危险因素
降压治疗的目的是减少心血管发病与死亡(CVD Risk),而不仅是降低血压(RFs),所以对心血管危险的估算是不可或缺的
血压升高是CVD RR 的重要指标,故以往只看血压水平决定治疗策略。此法对中重度高血压行之有效,对轻度高血压则否 心血管危险度分层的重要性(二)
心血管危险度分层的重要性(二)
NHANES-I根据 JNC VI,对7,090NHEFS队列20年随访说明临床决策不仅依靠平均血压水平,并需考虑其他危险因素
1999年医院门诊人群高血压抽样调查报告
明,对门诊高血压患者的危险度评估中,如果只注意血压水平,是很不够的,会明显低估危险度,必须全面评估其他危险因素,才能作出正确的判断.
Problems With a Strategy Based on Absolute Cardiovascular Risk
F. Olaf Simpson/Journal of Hypertension 1996, Vol 14 No 6Problems With a Strategy Based on Absolute Cardiovascular Risk
F. Olaf Simpson/Journal of Hypertension 1996, Vol 14 No 6The proposed New Zealand guidelines: the 10-year absolute CVD risk strategy
Consequences of the 10-year absolute-risk strategy
Possible age-related modifications of the 10-year absolute-risk strategy
Problems raised by inclusion of other risk factors in the calculations
Problems in calculation of the expected gains from antihypertensive therapy
Problems in calculations of CVD risk from raised blood pressure
Article 1Cardiovascular risk evaluation:
an inexact science (1)Cardiovascular risk evaluation:
an inexact science (1)Failure to consider the full risk of the ‘metabolic syndrome’ in current guidelines
Failure to appreciate the total benefit of antihypertensive therapy
Excessive weighting of advanced age in the assessment of cardiovascular risk
How accurate is current risk assessment for uncomplicated mild hypertension?Cardiovascular risk evaluation:
an inexact science (2)Cardiovascular risk evaluation:
an inexact science (2)Although the absolute risk assessment methods may lack sufficient sensitivity, they still represent an improvement over that only the level of blood pressure and prior cardiovascular disease were relevant to therapeutic-decision making. To date, cardiovascular risk evaluation is an inexact science.Enhancing risk stratification in hypertensive subjects: How far should we go in routine screening for target organ damage? Enhancing risk stratification in hypertensive subjects: How far should we go in routine screening for target organ damage? First, it appears timely to include the search for microalbuminuria as a routine component of the work-up of all hypertensive patients worldwide;
Second, it seems reasonable to recommend that the search for target organ damage should extend to cardiac and carotid ultrasound for high risk and very high risk hypertensive subjects.Pharmacological Treatment of Hypertension
J D Swales / The Lancet Vol 344. Aug. 6, 1994Pharmacological Treatment of Hypertension
J D Swales / The Lancet Vol 344. Aug. 6, 1994Benefits of treatment
Treatment of severe hypertension
Mild to moderate hypertension
Defining the high-risk patient
Value of repeated measurements
Systolic hypertension
Target blood pressure
Selection of therapy
Article 2血压水平为正常高值血压水平为正常高值SBP 130-139或DBP 85-89mmHg(多次测量)
其它危险因素、靶器官损害(肾)
糖尿病、高血压关联临床状况
生活方式改变、纠正其它危险因素或疾病
绝对危险分层
药物治疗 药物治疗 经常监测 无需干预BP
(ESH/ESC/ISH--2003)null血压水平为I-II级高血压SBP 140-179 或 DBP 90-109mmHg
其它危险因素、靶器官损害(肾)
糖尿病、高血压关联临床状况
生活方式改变、纠正其它危险因素或疾病
危险分层
BP140/90 BP<140/90
药物治疗 继续监测 及时药物治疗 及时药物治疗 监测(BP/RF)至少3个月 监测(BP/RF)3-12个月SBP140-159 BP<140/90
DBP 90-99
考虑药物治疗 继续监测(ESH/ESC/ISH--2003)内容提要内容提要关于血压水平的定义和分类
关于危险度分层
关于卫生经济学
关于联合用药问题Interventions evaluatedInterventions evaluatedNon-personal interventions
N1 通过强制性
使企业限盐
N2 全民限盐条例
N3 大众传媒的健康宣传
N4 N2 & N3 的综合干预
Personal interventions
P1 & P2 基于抗高血压的个体治疗和教育 (P1: SBP >160 mmHg 或 P2: SBP > 140 mmHg)
P3 & P4 高胆固醇的个体治疗和教育
(P3: TC >6.2 mmol/L 或 P4: TC > 5.7mmol/L)
P5 收缩期高血压和胆固醇个体治疗和健康教育 (P2+P3)
P6 to P9 高危人群管理 (35%, 25%, 15%, 5%)
Combined personal and non-personal intervention
(C1 to C4) P6 to P9 + N4nullnull谢谢大家