高血压问题优秀课件.ppt

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1、高血压问题第1页，本讲稿共24页内容提要关于血压水平的定义和分类关于血压水平的定义和分类关于危险度分层关于危险度分层关于卫生经济学关于卫生经济学关于用药问题关于用药问题第2页，本讲稿共24页高血压患者危险分层高血压患者危险分层-WHO/ISH 1999注：注：1999年中国高血压防治指南的危险分层参考的是年中国高血压防治指南的危险分层参考的是 1999年年WHO/ISH指南指南第3页，本讲稿共24页影响高血压患者预后的因素影响高血压患者预后的因素心血管危险因素心血管危险因素靶器官损害靶器官损害糖尿病糖尿病关联临床状况关联临床状况 血压水平血压水平 男性男性55岁岁 女性女性65岁岁 吸烟吸烟

2、血脂紊乱血脂紊乱（TC6.5mmol/L,LDL-C4.0 mmol/L,HDL-C男男1.0，女，女1.2mmol/L）早发心血管疾早发心血管疾病家族史病家族史(男男55,女女102,女女88cm)CRP 1 mg/dl 左心室肥厚左心室肥厚（心电图：（心电图：Sokolow-lyons38mm;Cornell2440mm*ms;超超声心动图：声心动图：LVMI 男男 125，女，女 110g/m2）超声证实动脉壁增超声证实动脉壁增厚厚（颈动脉（颈动脉IMT 0.9mm）或粥样硬化斑或粥样硬化斑块块 血清肌酐轻微升高血清肌酐轻微升高（男（男115-133，女，女107-124 mol/L）微

3、白蛋白尿症微白蛋白尿症（30-300mg/24H;白蛋白白蛋白/肌酐肌酐比值男比值男 22，女，女 31）空腹血浆葡空腹血浆葡萄糖萄糖7.0mmol/L 餐后血浆葡餐后血浆葡萄糖萄糖11.0mmol/L 脑血管疾病：脑血管疾病：缺缺血性脑卒中；脑出血；血性脑卒中；脑出血；一过性脑缺血发作一过性脑缺血发作 心血管疾病：心血管疾病：心心肌梗死；心绞痛；冠肌梗死；心绞痛；冠脉血运重建；心力衰脉血运重建；心力衰竭竭 肾脏病变：肾脏病变：糖尿糖尿病性肾脏病变；肾损病性肾脏病变；肾损害（肌酐升高男害（肌酐升高男133,女女124 mol/L）；蛋）；蛋白尿（白尿（300mg/24H）周围血管疾病周围血管疾

4、病 高度眼底病变：高度眼底病变：出血；或渗出，乳头出血；或渗出，乳头水肿水肿第4页，本讲稿共24页高血压患者危险分层高血压患者危险分层-2003欧洲高血压指南欧洲高血压指南III级级 高血压高血压II级级 高血压高血压I级级 高血压高血压正常血压高值正常血压高值正常血压正常血压其他危险因其他危险因素和疾病素和疾病关联临床状关联临床状况况 3危险因素危险因素或糖尿病或或糖尿病或靶器官损害靶器官损害12 危险危险因素因素0 危险因素危险因素：平均危险；：低度危险增加；：中度危险增加；：平均危险；：低度危险增加；：中度危险增加；：高度危险增加；：极高度危险增加高度危险增加；：极高度危险增加Risk

5、factor similar as 1999 guidelines except:1.abdominal obesity 2.Diabetes as a separate criterion 3.CRP is added 第5页，本讲稿共24页血压分类血压分类-JNC-VI(1997)-JNC-VI(1997)-类类 别别 收缩压（收缩压（mm Hg)舒张压（舒张压（mm Hg)-理想血压理想血压 120 80120 80正常血压正常血压 120-129 80-84120-129 80-84正常高值正常高值 130-139 85-89130-139 85-891 1级高血压级高血压 140 1

6、40 159 90 159 90 99 99 亚组：临界高血压亚组：临界高血压 140-149 90-94140-149 90-942 2级高血压级高血压 160 -179 100-109160 -179 100-109 3 3级高血压级高血压 180180 110110 单纯收缩期高血压单纯收缩期高血压 140140 90 90亚组：临界收缩期高血压亚组：临界收缩期高血压 140-149 90140-149 90-第6页，本讲稿共24页1.Distribution of NHANES I Epldemiologic Follow-up Study Participants with a Hi

7、gh-Normal BP or Hypertension at Baseline According to BP Lovel and Risk Categorization640(9.0)107(1.5)257(3.6)276(3.9)Risk Group A1366(19.2)5084(71.7)Total483(6.5)1505(21.2)160/100609(8.5)2208(31.1)140-159/90-99300(4.2)1371(19.3)130-139/85-89Risk Group CRisk Group BSBP/DBP,mmHgValues are n(%)第7页，本讲稿

8、共24页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 RiskRisk Group CRisk Group BRisk

9、Group A8167131016160/10091711192033140-159/90-99101913232541130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSee test or Table 1 for deflnition of risk groups.*Corrected for regression dilution bias using a reliability coefficient or 0.53 to correct for Impreci

10、sion in the measurement of SBP,第8页，本讲稿共24页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 Cardiovasc

11、ular RiskRisk Group CRisk Group BRisk Group A112012213449160/10018312744273394140-159/90-9921373660486701130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSee test or Table 1 for deflnition of risk groups.*Corrected for regression dilution bias using a reliabili

12、ty coefficient or 0.53 to correct for Imprecision in the measurement of SBP,第9页，本讲稿共24页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

13、 Category of Presumed Cardiovascular RiskRisk Group CRisk Group BRisk Group A9169172337160/100122216276097140-159/90-991425193381130130-139/85-89Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/DBP,mmHgSee test or Table 1 for definition of risk groups.*Corrected for regression dilu

14、tion bias using a reliability coefficient or 0.53 to correct for Imprecision in the measurement of SBP第10页，本讲稿共24页不同危险程度高血压患者的血压水平不同危险程度高血压患者的血压水平(mmHg,x s)男男 女女危险度危险度 SBP DBP SBP DBP低危低危 141.3(12.0)88.7(7.9)141.7(10.8)88.4(10.1)中危中危 144.7(15.6)89.3(9.7)144.1(26.7)86.4(10.6)高危高危 144.0(17.7)88.8(11.5

15、)139.6(18.6)85.6(14.5)极高危极高危 148.4(21.5)*88.8(12.8)145.9(22.6)*87.6(34.2)*P0.05第11页，本讲稿共24页心血管危险度分层的重要性心血管危险度分层的重要性（一）（一）高血压常常伴随其它危险因素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（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（而不仅是降低血压（RFs)，所以对心血管危，所以对心血管危险的估算是不可或缺的险的估算是不可或缺的血压升高是血压升高是CVD RR 的重要指标，故以往只看血压水平的重要指标，故以往只看血压水平

16、决定治疗策略。此法对中重度高血压行之有效，对轻决定治疗策略。此法对中重度高血压行之有效，对轻度高血压则否度高血压则否 第12页，本讲稿共24页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根据根据 JNC VI，对，对7,090NHEFS队列队列20年随访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因素 1999年医院门诊人群高血压抽样调查报告表明年医院门诊人群高血压抽样调查报告表明,对门对门诊高血压患者的危险度评估中诊高血压患者的危险度评估中,如果只注意血压水平如果只注意血压水平,是是很不够的很不

17、够的,会明显低估危险度会明显低估危险度,必须全面评估其他危险必须全面评估其他危险因素因素,才能作出正确的判断才能作出正确的判断.第13页，本讲稿共24页Problems With a Strategy Based on Absolute Cardiovascular RiskF.Olaf Simpson/Journal of Hypertension 1996,Vol 14 No 6The proposed New Zealand guidelines:the 10-year absolute CVD risk strategyConsequences of the 10-year absol

18、ute-risk strategyPossible age-related modifications of the 10-year absolute-risk strategyProblems raised by inclusion of other risk factors in the calculationsProblems in calculation of the expected gains from antihypertensive therapyProblems in calculations of CVD risk from raised blood pressureArt

19、icle 1第14页，本讲稿共24页Cardiovascular risk evaluation：an inexact science（1）Failure to consider the full risk of the metabolic syndrome in current guidelinesFailure to appreciate the total benefit of antihypertensive therapyExcessive weighting of advanced age in the assessment of cardiovascular riskHow ac

20、curate is current risk assessment for uncomplicated mild hypertension?第15页，本讲稿共24页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

21、-decision making.To date,cardiovascular risk evaluation is an inexact science.Cardiovascular risk evaluation：an inexact science（2）第16页，本讲稿共24页Enhancing risk stratification in hypertensive subjects:How far should we go in routine screening for target organ damage?First,it appears timely to include th

22、e 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.第17页，本讲稿共2

23、4页Pharmacological Treatment of HypertensionJ D Swales/The Lancet Vol 344.Aug.6,1994Benefits of treatmentTreatment of severe hypertensionMild to moderate hypertensionDefining the high-risk patientValue of repeated measurementsSystolic hypertensionTarget blood pressureSelection of therapyArticle 2第18页

24、，本讲稿共24页血压水平为正常高值血压水平为正常高值SBP 130-139或或DBP 85-89mmHg（多次测量）（多次测量）其它危险因素、靶器官损害（肾）其它危险因素、靶器官损害（肾）糖尿病、高血压关联临床状况糖尿病、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生活方式改变、纠正其它危险因素或疾病绝对危险分层绝对危险分层 药物治疗药物治疗 药物治疗药物治疗 经常监测经常监测 无需干预无需干预BP极高危极高危高危高危中危中危低危低危(ESH/ESC/ISH-2003）第19页，本讲稿共24页血压水平为I-II级高血压SBP 140-179 或或 DBP 90-109mmHg其它危险

25、因素、靶器官损害（肾）其它危险因素、靶器官损害（肾）糖尿病、高血压关联临床状况糖尿病、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生活方式改变、纠正其它危险因素或疾病危险分层危险分层 极高危极高危高危高危中危中危低危低危BP 140/90 BP140/90药物治疗药物治疗 继续监测继续监测 及时药物治疗及时药物治疗 及时药物治疗及时药物治疗 监测（监测（BP/RF)至少至少3个月个月 监测监测(BP/RF)3-12个月个月SBP 140-159 BP160 mmHg 或或 P2:SBP 140 mmHg)P3&P4 高胆固醇的个体治疗和教育高胆固醇的个体治疗和教育 (P3:TC 6.2 mmol/L 或或 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 高危人群管理高危人群管理(35%,25%,15%,5%)Combined personal and non-personal intervention (C1 to C4)P6 to P9+N4第22页，本讲稿共24页第23页，本讲稿共24页谢谢大家第24页，本讲稿共24页