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最新高血壓指南的幾個問題

最新高血壓指南的幾個問題

劉力生
內容提要
關于血壓水平的定義和分類
關于危險度分層
關于衛生經濟學
關于用藥問題
高血壓患者危險分層--WHO/ISH 1999
注:《1999年中國高血壓防治指南》的危險分層參考的是
          1999年WHO/ISH指南
影響高血壓患者預后的因素
高血壓患者危險分層--2003歐洲高血壓指南
±:平均危險;+:低度危險增加;++:中度危險增加;+++:高度危險增加;++++:極高度危險增加
Risk factor similar as 1999 guidelines except :
1.abdominal obesity 2.Diabetes as a separate criterion 3.CRP is added
血壓分類--JNC-VI(1997)
---------------------------------------------------------
類  別             收縮壓(mm Hg)        舒張壓(mm Hg)
---------------------------------------------------------
理想血壓              <120                    <80
正常血壓             120 - 129               80 - 84
正常高值             130 - 139               85 - 89
1級高血壓            140 – 159               90 – 99
   亞組:臨界高血壓     140 - 149                 90 - 94
2級高血壓            160  - 179             100 -109
3級高血壓               ?180                  ?110
單純收縮期高血壓           ?140                  <90
亞組:臨界收縮期高血壓   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
Values 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 Risk
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 Among NHANES I Epidemiologic Follow-Up Study Participants According to Baseline BP Level and Category of Presumed Cardiovascular Risk
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.  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
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
不同危險程度高血壓患者的血壓水平(mmHg, x?s)
        男        女
危險度      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)
極高危   148.4(21.5)* 88.8(12.8) 145.9(22.6)* 87.6(34.2)
 
* P<0.05
心血管危險度分層的重要性(一)

高血壓常常伴隨其它危險因素
降壓治療的目的是減少心血管發病與死亡(CVD Risk),而不僅是降低血壓(RFs),所以對心血管危險的估算是不可或缺的
血壓升高是CVD RR 的重要指標,故以往只看血壓水平決定治療策略。此法對中重度高血壓行之有效,對輕度高血壓則否
心血管危險度分層的重要性(二)
NHANES-I根據 JNC VI,對7,090NHEFS隊列20年隨訪說明臨床決策不僅依靠平均血壓水平,并需考慮其他危險因素
1999年醫院門診人群高血壓抽樣調查報告表明,對門診高血壓患者的危險度評估中,如果只注意血壓水平,是很不夠的,會明顯低估危險度,必須全面評估其他危險因素,才能作出正確的判斷.

Problems With a Strategy Based on Absolute Cardiovascular Risk F. 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

Article 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?
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.
Cardiovascular risk evaluation: an inexact science (2)
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, 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



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