高血压与降压治疗策略中国高血压防治指南解读.ppt

高血压与降压治疗策略中国高血压防治指南解读,中国高血压防治指南(2005)血压水平分类和定义,分类 收缩压(mmHg)舒张压(mmHg)正常血压 120 和 80正常高值 120-139 或 80-89高血压 140 或 90 1级 140-159 或 90-99 2级 160-179 或 100-109 3级 180 或 110单纯收缩期高血压 140 和 90,中国大陆成年人群血压水平分类(2002),卫生部心血管病防治研究中心，中国心血管病报告 2007,中国大陆人群血压正常高值检出率(%)1991(29.0%)2002(34.0%),18-24 25.4 28.525-34 26.0 30.935-44 30.2 36.745-54 32.9 38.055-64 32.7 34.965-74 31.2 30.375 28.7 28.1,年龄组 1991年 2002年,卫生部心血管病防治研究中心，中国心血管病报告 2007,Prospective Studies Collaboration.Lancet.2002;360:1903-1913.,Stroke,CHD,256,128,64,32,16,8,4,2,1,120,140,160,180,Usual SBP(mmHg),Stroke mortality(floating absolute risk and 95%CI),Age at risk(y):,80-89,70-79,60-69,50-59,80-89,70-79,60-69,50-59,Age at risk(y):,256,128,64,32,16,8,4,2,1,120,140,160,180,Usual SBP(mmHg),40-49,Stroke and CHD Mortality Rate in Each Decade of Age versus Usual Systolic Blood Pressure at the Start of That Decade,100%,80%,60%,40%,20%,0%,40,40-49,50-59,60-69,70-79,80+,17%,16%,16%,20%,20%,11%,Age(y),Frequency of hypertensionsubtypes in all untreatedsubjects(%),Frequency distribution of untreated hypertensive individuals by age and hypertension subtype.Numbers at the tops of bars represent the overall percentage distribution of untreated hypertension in that age group.,ISH(SBP140 mm Hg and DBP90 mm Hg);,SDH(SBP140 mm Hg and DBP90 mm Hg);,IDH(SBP140 mm Hg and DBP90 mm Hg).,IDH,SDH and ISH Subtypes in American Patients,Franklin SS.Hypertension 2001;37:869,Huang J,et al.J Hypertens 2004;17:955-962,IDH,SDH and ISH Subtypes in Chinese Patients,中国高血压防治指南(2005)心血管危险水平分层,收缩压、微量蛋白尿与心血管危险,Borch-Johnsen K,et al.Arteioscler Thromb Vasc Biol 1999;19:1992,HOT：心血管危险分层与CVD事件,BMJ 2002,324:71,RR：1.58 1.38 1.60 1.79 1.51Cl:1.45-1.72 1.18-1.61 1.41-1.82 1.56-2.05 1.38-1.66P:0.0001 0.0001 0.0001 0.0001 0.0001,Majorcardiovascularevents,All myocardialinfarction,All stroke,Cardiovascularmortality,Totalmortality,Risk:,Medium,High,Very High,20,15,10,5,0,Events per 1000 patient years,中国高血压防治疗指南(2010)心血管高危患者建议,收缩压180mmHg 和/或 舒张压110mmHg糖尿病3 个心血管危险因素伴1个或多个亚临床器官损害:心电图(尤其是心肌劳损)或超声心动图(尤其是向心性)左心室肥厚超声检查显示颈动脉壁增厚或斑块动脉硬度增加血清肌酐轻度升高估测的肾小球滤过率或肌酐清除率下降微量白蛋白尿或蛋白尿 临床心、脑血管病或慢性肾脏疾病,中国高血压防治指南(2005)降压治疗的实施过程,对高血压患者临床评价后，进行心血管危险水平分层(低危、中危、高危、很高危)所有患者都应采用非药物治疗措施制定降压治疗计划，确定血压控制目标值很高危、高危患者：立即开始药物治疗中危：随访观测数周，然后决定是否开始药物治疗低危：随访观测数月，然后决定是否开始药物治疗治疗随访，调整治疗方案,Relative risk estimates of CHD events and stroke in clinical trials and in epidemiological cohort studiesMeta-analysis of 147 randomised trials,Law MR,et al.Online from BMJ.com on 24 May,2009,For reduction of 10mmHg SBP and/or 5mmHg DBP,在中国大陆的降压治疗临床试验,STONE 57%41%CNIT 50%44%Syst-China 38%37%FEVER 28%28%,Stroke CVD,心血管危险程度与降压治疗绝对获益CHD Events,心血管危险程度与降压治疗绝对获益STROKE,0.5,1.0,2.0,Relative Risk,RR(95%CI),BP Difference(mm Hg),FavorsFirst Listed,FavorsSecond Listed,Major CV events,CV mortality,Total mortality,1.02(0.98,1.07),2/0,ACEI vs D/BB,1.03(0.95,1.11),2/0,ACEI vs D/BB,1.00(0.95,1.05),2/0,ACEI vs D/BB,1.04(0.99,1.08),1/0,CA vs D/BB,1.05(0.97,1.13),1/0,CA vs D/BB,0.99(0.95,1.04),1/0,CA vs D/BB,0.97(0.92,1.03),1/1,ACEI vs CA,1.03(0.94,1.13),1/1,ACEI vs CA,1.04(0.98,1.10),1/1,ACEI vs CA,Blood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.,BP-Lowering Treatment TrialistsComparisons of Different Active Treatments,BPLTT:STROKEComparisons of different active treatments2003,RR(95%CI),Favours first listed,Favours second listed,0.5,1.0,2.0,Relative Risk,BP difference(mm Hg),1.09(1.00,1.18),ACEI vs.D/BB,0.93(0.86,1.01),CA vs.D/BB,1.12(1.01,1.25),ACEI vs.CA,2/0,1/0,1/1,Relative risk estimates of CHD events and stroke according to class of drug,Law MR,et al.Online from BMJ.com on 24 May,2009,Excluding CHD events in trials of blockers in people with a history of CHD,SBP difference between randomized groups(mmHg),Relative risk of outcome event,Blood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.,BPLTTC(WHO/ISH,2003),中国高血压防治指南(2005)血压控制目标值,中青年高血压患者 140/90 mmHg老年高血压患者 150/90 mmHg 糖尿病或肾病患者130/80 mmHg,INVEST血压控制达标与终点事件发生的关系,15.0,5.7,2.4,10.8,4.3,2.3,9.2,3.8,1.6,8.1,3.1,1.1,1614121086420,25%25%至50%50%至75%75%,随诊时血压达标百分比（140/90 mmHg）,患者总数（n）3838 3757 6664 8316,一级终点心肌梗死（致死非致死性）脑卒中（致死非致死性）,发生临床终点事件百分比,P 值均小于0.001,VALUE：BP Control and Outcomes,Major cardiovascular events(per 100 patients-years)in all treated hypertensive and in hypertensive patients with diabetes in relation to target blood pressures of 90.85,and 80 mm Hg.,HOT:糖尿病患者血压控制与CV事件发生率,ADVANCE:Achieved BP levels and all renal events,De Galan BE,et al.J Am Soc Nephrol.2009;Feb.18,online,SBPs achieved by treatment in placebo-controlled trials in elderly hypertensives,EWPHE 840 72 182 150 172 Coope and Warrender 884 68 196 162 180 SHEP 4376 72 170 143 155 STOP-1 1627 76 195 167 186 MRC elderly 4396 70 185 156 165 Syst-Eur 4695 70 174 151 161 Syst-China 2394 67 171 151 160SCOPE 4964 76 166 145 148 HYVET 3845 83 173 144 159JATOS 4418 74 171 138 147,Zanchetti A,et al.J Hypertens.2009;27:,N Age(years)Baseline SBP,Achieved SBP,Active Control,中国高血压防治指南(2005)长期治疗随访实施过程,继续治疗血压控制1年以上可减少剂量,治疗3个月后，达到降压目标值,治疗3个月后，未达到降压目标值,有明显副作用,增加剂量改用另一类降压药联合治疗,改用另一类降压药减少剂量,降压治疗后血压下降幅度主要取决于：血压水平和药物平均剂量 SBP=9.1+0.1(P-154)DBP=5.5+0.11(P-97),Law MR,et al.BMJ.2003;326:1427-1431.,降压药物联合治疗的依据(一),150/90时，一种药物在标准剂量下，血压平均 降低仅8.7/4.7 mmHg；一种、两种、三种药物 在1/2标准剂量下，血压分别平均降低6.7/3.7、13.3/7.3、19.9/10.7 mmHg。,Law MR,et al.BMJ.2003;326:1427-1431.,SBP=R+n0.078(P-150)DBP=R+n0.088(P-90),降压药物联合治疗的依据(二)Combination Therapy Versus MonotherapyMeta-analysis from 42 trials,Wald DS,et al.Am J Med.2009;122:290-300.,通过不同的药理作用，中和或对抗相互的不良反应。通过降低剂量减少和减轻不良反应。,降压药物联合治疗的依据(三),不良反应(A+B)不良反应(A)+不良反应(B)不良反应(A+B)不良反应(2A)或 不良反应(2B),优化降压联合治疗方案,DHP-CCB+ACEI/ARB(ASCOT,ACCOMPLISH)DHP-CCB+blocker(HOT,INSIGHT,ALLHAT)ACEI/ARB+Diuretics(LIFE,VALUE,ACCOMPLISH)DHP-CCB+Diuretics(VALUE,FEVER)ACEI/ARB+blocker(ALLHAT)blocker+Diuretics(LIFE,ASCOT,INSIGHT)ACEI+ARB(ONTARGET),INSIGHT：糖尿病患者终点事件,患者百分数(%),0.0,4.0,8.0,Co-amilozide,12.0,p=0.03,14.2,Nifedipine GITS,16.0,20.0,18.7,Mancia G,et al.Hypertension 2003;41:4316.,所有主要终点,非心脑血管性死亡,ESRD,心绞痛和短暂性脑缺血,Co-amilozide,Nifedipine GITS,INSIGHT serious and metabolic adverse events,Serious adverse events,0%,5%,10%,15%,20%,25%,30%,0%,2%,4%,6%,8%,10%,Nifedipine GITSCo-amilozide,Hypokalaemia,p=0.02,p0.0001,Hyponatraemia,Hyperlipidaemia,Hyperglycaemia,Impaired renal function,Hyperuricaemia,p0.0001,p0.0001,p=0.001,p0.0001,p0.0001,Brown M,et al.Lancet 2000;356:36672.,176(5.6%),INSIGHT:对新发糖尿病的影响,Nifedipine GITS,0,20,40,60,80,100,120,140,160,180,Co-amilozide,136(4.3%),p=0.023,Patients with newly diagnosed diabetes mellitus(n),Mancia G,et al.Hypertension 2003;41:4316.,（氨氯地平+/-培哚普利 Vs.阿替洛尔+/-苄氟噻嗪）,*P0.05,降低百分比(%),-35,-30,-25,-20,-15,-10,-5,0,*,*,*,*,*,*,*,非致死心梗和冠心病死亡,心血管死亡,总死亡,总冠脉事件,致死/非致死性卒中,总心血管事件和介入,新发糖尿病,肾损害,Dahlof B,Sever P,et al.Lancet.2005;366:895-906.,ASCOT-BPLA:终点事件发生率,Cumulative event rate,HR(95%CI)0.80(0.72,0.90),Time to 1st CV morbidity/mortality(days),p=0,650,526,.0,0,0,2,ACCOMPLISH:主要终点,中国高血压人群的临床特点,最主要的心血管危险是脑卒中高血压发生和血压水平与摄盐量或饮食钠/钾比值较高密切有关老年人占的比例很高约定1/10男性患者有嗜酒行为,脑卒中与心肌梗死的比值不同临床试验比较,STONE8.0Syst-China8.7NICS-EH4.0SHEP1.2MRC II0.8STOP-H1.2Syst-Eur1.7,ACTION:Events in Patients with Hypertension vs ISH,降压治疗方案推荐流程,New recommendation,Reinforcement of previous recommendation,Different interpretations of results/potential for confusing messages to clinical practice,欧洲高血压治疗指南修改背景(ESC/ESH,2009),欧洲高血压治疗指南修改要点(ESC/ESH,2009),重申心血管危险分层 推荐80岁以上高龄高血压患者实施降压治疗 解释启动降压治疗血压水平和血压控制目标 一般人群：140/90，140/90 高危以上人群：130/85，130/80 建议在心血管高危患者血压控制不低于120/70。淡化一线降压药物概念，强调首选联合治疗，重视ACEI、ARB和CCB的治疗地位。,