高血壓的分級、分期、分型管理

-血管與心、腦、腎等器官結構與功能檢測-上海交通大學醫學院附屬瑞金醫院上海市高血壓研究所王繼光jiguangw@0306090120150198519901995200020052010(year)StrokeCHDStandardizedrate(1/100,000)DeathsattributedtostrokeandCHD《ChinaCVDreport2005》100120140160180200無血管或靶器官損害有血管或靶器官損害血管或靶器官并發癥分級(stageorgrade)高血壓分級、分期、分型的基本理念708090100110120舒張壓，mmHg收縮壓，mmHg分型(phenotypingorpathophysiology)分期(stratificationorseverity)繼發性高血壓有可測量異常的高血壓動脈硬化性高血壓高血壓分級--準確測量血壓，使用普遍有效的降壓藥物高血壓分期--測量血管與靶器官的結構與功能，選擇強適應癥藥物高血壓分型--篩查病因以及影響血壓的主要因素，采取病因治療措施坐位袖帶血壓計24-hambulatoryBPmonitoring

1501401301201101009080706050812161014182024422268HourofthedayBP(mmHg)135120857024-hmeanDaytimemeanNight-timemeanWhitecoathypertensionMaskedhypertensionJingNing:Prevalenceofwhite-coat,masked,andsustainedhypertension806040200Prevalence(%)Normotension46.4%(n=322)7.8%(n=54)10.8%(n=75)35.0%(n=243)White-coatHTMaskedHTSustainedHTWangGL,etal.JHypertens2007;25:2398–2405.n=694NICE2011:DefinitionsStage1hypertension:ClinicBPis140/90

mmHgorhigherandABPMorHBPMaverageis135/85

mmHgorhigher.Stage2hypertension:

ClinicBPis160/100

mmHgorhigherandABPMorHBPMdaytimeaverageis150/95

mmHgorhigher.Severehypertension:

ClinicsystolicBPis180

mmHgorhigherorClinicdiastolicBPis110

mmHgorhigher.KrauseT,etal.BMJ2011;343:d4891.A：ACEI

orARB；B：β-blockers；C：DihydropyridineCCBs；D：Thiazides；α：α-blockers；F：FixeddosecombinationDefinitivehypertensionMonotherapyCombinationBP<160/100mmHg；orlowriskpatientsBP≥160/100mmHg；orhighriskpatientswithaBP>20/10mmHgfromthegoalCADBC+AA+DC+DC+BFStep1FC+AA+DC+BC+DC+D+AC+A+BA+D+αStep2C+A+DC+A+BA+D+αOtherantihypertensivedrugs,suchasclonidipine,etc.Step3Chinesehypertensionguidelines:

ChoiceofantihypertensivedrugsChinJCardiol2011;39:579-616.Step4NICE2011:SummaryofantihypertensivedrugtreatmentAged

55yorblackpersonofAfricanorCaribbeanfamilyoriginofanyageAgedunder

55yearsCAA+CA+C+DResistanthypertensionA+C+D+considerfurtherdiuretic

oralpha-orbeta-blocker5ConsiderseekingexpertadviceStep1Step2Step3KeyA–ACEinhibitororlow-costangiotensin

IIreceptorblocker(ARB)1

C–Calcium-channelblocker(CCB)D–Thiazide-likediureticKrauseT,etal.BMJ2011;343:d4891.ASCOT-BPLA:Primaryandsecondaryendpoints0.500.701.001.45Primaryendpoint

NonfatalMI(includingsilentMI)+fatalCHD

Secondaryendpoint

NonfatalMI(excludingsilentMI)+fatalCHDAllcoronaryevents

AllCVeventsandprocedures

Totalmortality

CVmortalityFatalandnonfatalstroke

Fatalandnonfatalheartfailure2.00UnadjustedHazard

ratio(95%CI)0.90(0.79-1.02)0.87(0.76-1.00)0.87(0.79-0.96)0.84(0.78-0.90)0.89(0.81-0.99)0.76(0.65-0.90)0.77(0.66-0.89)0.84(0.66-1.05)Dahl?fBetal.Lancet2005:366;895-906.Amlodipine

PerindoprilbetterAtenolol

Bendrofluathiazidebetter0.51.02.0ACCOMPLISH:

PrimaryendpointandcomponentsCompositeCVmortality/morbidityCardiovascularmortalityNon-fatalMINon-fatalstrokeHospitalizationforunstableanginaCoronaryrevascularizationprocedureResuscitatedsuddendeathRiskRatio

(95%)FavorsCCB/ACEIFavorsACEI/HCTZ0.80(0.72–0.90)0.81(0.62-1.06)0.81(0.63-1.05)0.87(0.67-1.13)0.74(0.49-1.11)0.85(0.74-0.99)1.75(0.73-4.17)JamersonKetal.NEnglJMed2008;359:2417-28.高血壓分級--準確測量血壓，使用普遍有效的降壓藥物高血壓分期--測量血管與靶器官的結構與功能，選擇強適應癥藥物高血壓分型--篩查病因以及影響血壓的主要因素，采取病因治療措施Pulsediagnostics中國高血壓指南：危險分層其他危險因素和病史血壓(mmHg)1級高血壓SBP140-159或DBP90-992級高血壓SBP160-179或DBP100-1093級高血壓SBP≥180或DBP≥110無低危中危高危1-2個其他危險因素中危中危很高危≥3個其他危險因素，或靶器官損害高危高危很高危臨床并發癥或合并糖尿病很高危很高危很高危中華心血管病雜志2011;39:579-616.ART.LAB

TheArterialAnalyserBloodvesselwallthicknessRFQIMTNormalthicknessDiameter:7.04mmIMT:536mBrightnessmodescanning(B-mode)Framerate30frames/sAssessmentof:ZhangY,etal.Submitted.ConcentricRemodelingN=107(12.7%)ConcentricHypertrophyN=16(1.9%)NormalGeometry