《临床医学》课程教学资源（PPT课件讲稿）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

最新高血压指南的几个问题 刘力生

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

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/SH 1999 血压(mHg) 其他危险因素和病史 1级 2级 3级 SBP140159或|SBP160-179或SBP≥180或 DBP90-99 DBP100-109 DBP≥110 无其他危险因素 低危 中危 高危 11-2个危险因素 中危 中危 很高危 1l≥3个危险因素或 高危 高危 很高危 器官损害或糖尿病 V并存临床情况 很高危 很高危 很高危 注:《1999年中国高血压防治指南》的危险分层参考的是 1999年WHO/SH指南

高血压患者危险分层--WHO/ISH 1999 血压(mmHg) 其他危险因素和病史 1级 SBP 140—159或 DBP90-99 2级 SBP 160-179 或 DBP 100-109 3级 SBP 180 或 DBP 110 I 无其他危险因素 II 1-2个危险因素 III 3个危险因素或 器官损害或糖尿病 IV 并存临床情况 低危 中危 高危 很高危 中危 中危 高危 很高危 高危 很高危 很高危 很高危 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 心血管危险因素靶器官损害 糖尿病 关联临床状况 血压水平 左心室肥厚 空腹血浆葡·脑血管疾病:缺 男性>55岁 (心电图: Sokolow 萄糖 血性脑卒中;脑出血 lyons>38mm; 过性脑缺血发作 女性>65岁 .7.0mmol/L Corne>2440mm*ms;超声 吸烟 心动图:LVMI男≥125, 餐后血浆葡心血管疾病:心 肌梗死;心绞痛;冠 女≥110gm2) 血脂紊乱 萄糖 脉血运重建;心力衰 (TC>6.5mmol/l 超声证实动脉壁增>110mmo/L竭 LDLC>4.0mmoM,厚(颈动脉M≥09mm) 肾脏病变:糖尿 HDLC男133 早发心血管疾(男1513,女107 女>124μmoⅥ/L);蛋 白尿(>300mg24H) 病家族史(男102,女>88cm) 值男≥22,女≥31) 出血;或渗出,乳头 水肿 CRP>1 mg/dl

影响高血压患者预后的因素 心血管危险因素 靶器官损害 糖尿病 关联临床状况 ▪ 血压水平 ▪ 男性>55岁 ▪ 女性>65岁 ▪ 吸烟 ▪ 血脂紊乱 （TC>6.5mmol/L, LDL-C>4.0 mmol/L, HDL-C男102, 女>88cm) ▪ CRP1 mg/dl ▪ 左心室肥厚 （心电图：Sokolow￾lyons>38mm; Cornell>2440mm*ms; 超声 心动图：LVMI 男 125， 女 110g/m2） ▪ 超声证实动脉壁增 厚（颈动脉IMT  0.9mm） 或粥样硬化斑块 ▪ 血清肌酐轻微升高 （男115-133，女107- 124mol/L） ▪ 微白蛋白尿症（30- 300mg/24H; 白蛋白/肌酐比 值男 22，女 31） ▪ 空腹血浆葡 萄糖 >7.0mmol/L ▪ 餐后血浆葡 萄糖 >11.0mmol/L ▪ 脑血管疾病：缺 血性脑卒中；脑出血； 一过性脑缺血发作 ▪ 心血管疾病：心 肌梗死；心绞痛；冠 脉血运重建；心力衰 竭 ▪ 肾脏病变：糖尿 病性肾脏病变；肾损 害（肌酐升高男>133, 女>124mol/L）；蛋 白尿（>300mg/24H） ▪ 周围血管疾病 ▪ 高度眼底病变： 出血；或渗出，乳头 水肿

高血压患者危险分层200洲高血压指南 其他危险因正常血压正常血压高值I级高血压I级高血压I级高血压 素和疾病 0危险因素 ++ 1-2危险 + ++++ 因素 ≥3危险因素++ ++ ++ +++ ++++ 或糖尿病或 靶器官损害 关联临床状+++++++++++++++++++ 况 士:平均危险;+:低度危险增加;++:中度危险增加;++ 十:高度危险增加;十十++: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

高血压患者危险分层--2003欧洲高血压指南 其他危险因 正常血压 正常血压高值 I级 高血压 II级 高血压 III级 高血压 素和疾病 关联临床状 ＋＋＋ ＋＋＋＋ ＋＋＋＋ ＋＋＋＋ ＋＋＋＋ 况 3危险因素 ＋＋ ＋＋＋ ＋＋＋ ＋＋＋ ＋＋＋＋ 或糖尿病或 靶器官损害 1－2 危险 ＋ ＋ ＋＋ ＋＋ ＋＋＋＋ 因素 0 危险因素 ± ± ＋ ＋＋ ＋＋＋ ±：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

血压分类一JNV(1997) 类别 收缩压(mmHg)舒张压(mmHg) 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

血压分类--JNC-VI(1997) --------------------------------------------------------- 类 别 收缩压（mm Hg) 舒张压（mm Hg) --------------------------------------------------------- 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 ---------------------------------------------------------------

1. Distribution of NHANES I Epidemiologic Follow-up Study Participants with a High-Normal Bpor Hypertension at Baseline according to BP lovel and risk categorization SBP/DBP Risk Risk Risk Group c mmHg Group a Group b 130-13985-89276(3.9)1371(193) 300642) 140-15990-99257(3.6)2208(31.1) 609(8.5) 160/≥100 107(15) 1505(212) 483(6.5) Total 6409.0)5084(71.7) 366(192) Values are n(%)

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 Categorization 640(9.0) 107(1.5) 257(3.6) 276(3.9) Risk Group A Total 5084(71.7) 1366(19.2) ≥160/ ≥100 1505(21.2) 483(6.5) 140-159/90-99 2208(31.1) 609(8.5) 130-139/85-89 1371(19.3) 300(4.2) Risk Risk Group C Group B SBP/DBP, mmHg Values are n (%)

Estimated Effect of a 12mmHg Reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent a Cardiovascular Disease Event to Baseline BP level and Category of Presumed Cardiovascular RisK Among Nhanes I Epidemiologic Follow-Up Study Participants Accordi Risk group a Risk group b Risk Group C SBP/DBP. Uncorrected Corrected* Uncorrected Corrected* Uncorrected Corrected* mmh 130-139/85-89 23 140-159/90-99 33 20 11 17 ≥160/≥100 10 8 See testor Table 1 for defInition of risk groups *Corrected for regression dilution bias using a re liability coefficient or 0.53 to correct for Imprecision in the measure ment of sBP

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 Risk Risk Group A Risk Group B Risk Group C ≥160/ ≥100 16 10 13 7 16 8 140-159/90-99 33 20 19 11 17 9 130-139/85-89 41 25 23 13 19 10 SBP/DBP, Uncorrected Corrected* Uncorrected Corrected* Uncorrected Corrected* mmHg See 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 to Baseline BP level and Category of Presumed Cardiovascular RisK Among Nhanes I Epidemiologic Follow-Up Study Participants Accordi Risk group a Risk group b Risk Group c SBP/DBP, Uncorrected Corrected* Uncorrected Corrected* Uncorrected Corrected* mmhg 130-13985-89 701 486 60 36 140-159/90-99 394 273 44 31 18 160/>100 34 21 12 20 See testor Table 1 for defInition of risk groups. Corrected for regression dilution bias using a re liability coefficient or 0.53 to correct for Imprecision in the me asure ment 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 Risk Risk Group A Risk Group B Risk Group C ≥160/ ≥100 49 34 21 12 20 11 140-159/90-99 394 273 44 27 31 18 130-139/85-89 701 486 60 36 37 21 SBP/DBP, Uncorrected Corrected* Uncorrected Corrected* Uncorrected Corrected* mmHg See 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. EstImated Effect of a 12mmHg reduction in SBP Over 10 years on the Number-Needed-to-Treat to Prevent An al-Cause Death Among nhanes I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and category of Presumed Cardiovascular risk Risk group a Risk group b Risk Group C SBP/DBP. Uncorrected Corrected* Uncorrected Corrected* Uncorrected Corrected* mmh 130-139/85-89 130 140-159/90-99 60 27 16 ≥160/≥100 17 See testor Table 1 for de finition of risk groups *Corrected for regression dilution bias using a re liability coefficient or 0.53 to correct for Imprecision in the measure ment 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 Risk Risk Group A Risk Group B Risk Group C ≥160/ ≥100 37 23 17 9 16 9 140-159/90-99 97 60 27 16 22 12 130-139/85-89 130 81 33 19 25 14 SBP/DBP, Uncorrected Corrected* Uncorrected Corrected* Uncorrected Corrected* mmHg See 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