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
血压 ( mmHg)
其他危险因素和病史 1 级
SBP 140 — 159 或
DBP90-99
2 级
SBP 160-179 或
DBP 100-109
3 级
SBP? 180 或
DBP? 110
I 无其他危险因素
II 1-2 个危险因素
III? 3 个危险因素或器官损害或糖尿病
IV 并存临床情况低危中危高危很高危中危中危高危很高危高危很高危很高危很高危注：,1999年中国高血压防治指南,的危险分层参考的是
1999年 WHO/ISH指南影响高血压患者预后的因素心血管危险因素 靶器官损害 糖尿病 关联临床状况
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
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）
空腹血浆葡萄糖
>7.0mmol/L
餐后血浆葡萄糖
>11.0mmol/L
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，乳头水肿高血压患者危险分层 --2003欧洲高血压指南
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
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
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 CRisk
Group B
SBP/DBP,
mmHg
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
Risk Group CRisk Group BRisk Group A
8167131016≥160/ ≥100
91711192033140-159/90-99
101913232541130-139/85-89
Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/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,
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
Risk Group CRisk Group BRisk Group A
112012213449≥160/ ≥100
18312744273394140-159/90-99
21373660486701130-139/85-89
Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/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,
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
Risk Group CRisk Group BRisk Group A
9169172337≥160/ ≥100
122216276097140-159/90-99
1425193381130130-139/85-89
Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/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
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 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 of therapy
Article 2
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
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）
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
谢谢大家
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
血压 ( mmHg)
其他危险因素和病史 1 级
SBP 140 — 159 或
DBP90-99
2 级
SBP 160-179 或
DBP 100-109
3 级
SBP? 180 或
DBP? 110
I 无其他危险因素
II 1-2 个危险因素
III? 3 个危险因素或器官损害或糖尿病
IV 并存临床情况低危中危高危很高危中危中危高危很高危高危很高危很高危很高危注：,1999年中国高血压防治指南,的危险分层参考的是
1999年 WHO/ISH指南影响高血压患者预后的因素心血管危险因素 靶器官损害 糖尿病 关联临床状况
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
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）
空腹血浆葡萄糖
>7.0mmol/L
餐后血浆葡萄糖
>11.0mmol/L
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，乳头水肿高血压患者危险分层 --2003欧洲高血压指南
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
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
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 CRisk
Group B
SBP/DBP,
mmHg
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
Risk Group CRisk Group BRisk Group A
8167131016≥160/ ≥100
91711192033140-159/90-99
101913232541130-139/85-89
Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/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,
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
Risk Group CRisk Group BRisk Group A
112012213449≥160/ ≥100
18312744273394140-159/90-99
21373660486701130-139/85-89
Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/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,
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
Risk Group CRisk Group BRisk Group A
9169172337≥160/ ≥100
122216276097140-159/90-99
1425193381130130-139/85-89
Corrected*UncorrectedCorrected*UncorrectedCorrected*UncorrectedSBP/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
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 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 of therapy
Article 2
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
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）
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
谢谢大家
