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最新高血压指南的几个问题_1.ppt
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最新高血压指南的几个问题_1.ppt介绍

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高血压患者危险分层--WHO/ISH 1999 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 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 Epldemiologic Follow-up Study Participants with a High-Normal BP or Hypertension at Baseline According to BP Lovel and Risk Categorization 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 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 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 不同危险程度高血压患者的血压水平(mmHg, x  s) 			  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<0.05 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) 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表明,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 RiskF. Olaf Simpson/Journal of Hypertension 1996, Vol 14 No 6 The 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 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)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? 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 HypertensionJ D Swales / The Lancet Vol 344. Aug. 6, 1994 Benefits 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 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  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 evaluated Non-personal interventions 	N1	 通过强制性合同使企业限盐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 + N4 * 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,乳头水肿空腹血浆葡萄糖>7.0mmol/L  餐后血浆葡萄糖>11.0mmol/L  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 )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<1.0 ,女<1.2mmol/L )早发心血管疾病家族史(男<55, 女<65)  腹型肥胖(腹围男>102, 女>88cm) CRP  1 mg/dl  关联临床状况糖尿病靶器官损害心血管危险因素III 级高血压II 级高血压I级高血压正常血压高值正常血压其他危险因素和疾病+++++++++++++++++++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 640(9.0) 107(1.5) 257(3.6) 276(3.9) Risk Group A 1366(19.2) 5084(71.7) Total 483(6.5) 1505(21.2) ≥160/ ≥100 609(8.5) 2208(31.1) 140-159/90-99 300(4.2) 1371(19.3) 130-139/85-89 Risk Group C Risk Group B SBP/DBP, mmHg Values are n (%) Risk Group C Risk Group B Risk Group A 8 16 7 13 10 16 ≥160/ ≥100 9 17 11 19 20 33 140-159/90-99 10 19 13 23 25 41 130-139/85-89 Corrected* Uncorrected Corrected* Uncorrected Corrected* Uncorrected SBP/DBP, 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, Risk Group C Risk Group B Risk Group A 11 20 12 21 34 49 ≥160/ ≥100 18 31 27 44 273 394 140-159/90-99 21 37 36 60 486 701 130-139/85-89 Corrected* Uncorrected Corrected* Uncorrected Corrected* Uncorrected SBP/DBP, 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, Risk Group C Risk Group B Risk Group A 9 16 9 17 23 37 ≥160/ ≥100 12 22 16 27 60 97 140-159/90-99 14 25 19 33 81 130 130-139/85-89 Corrected* Uncorrected Corrected* Uncorrected Corrected* Uncorrected SBP/DBP, 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 Article 1 Article 2 极高危高危中危低危(ESH/ESC/ISH--2003 )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极高危高危中危低危BP  140/90  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SBP  140-159 BP<140/90 DBP 90-99 考虑药物治疗继续监测(ESH/ESC/ISH--2003 )谢谢大家*

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