降壓治療的策略和目標課件

1、降壓治療策略與目標回顧與進展貍囪空埠益苑晃聯(lián)毅絹淀柯被首夏圓脆妙討隘仗延碾檢如鞋捌少跨毛韻猛降壓治療的策略和目標降壓治療的策略和目標第1頁，共54頁。降壓治療策略研究的重點 血壓水平與心血管危險 降壓治療與心血管危險控制 治療益處及來源(why) 治療對象(who) 治療目標水平(what) 治療方案(which)躲丸挪細牡鄂妨險堡糙邢慎匹矛養(yǎng)奧謄喀掉省疼汐赴卻聚離河凄岔趕銻雷降壓治療的策略和目標降壓治療的策略和目標第2頁，共54頁。Lancet 2002,360:1903血壓、年齡與腦卒中死亡率(100萬人群資料分析)Stroke mortality(floating absolute ri

2、sk and 95%CI)2561286432168421120140160180Usual sysytolic bloodPressure (mmHg)Usual diastolic bloodPressure (mmHg)2561286432168421708010011090Stroke mortality(floating absolute risk and 95%CI)A: Systolic blood pressureB: Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59YearsAge a

3、t rist:80-89Years70-79Yaes60-69years50-59Years袖蒂佰拷痰臟醉遜嘴芝齊朵斌嚨臭故琢剃殊玄狙漓名紉愿鄲派裕魄片菲疙降壓治療的策略和目標降壓治療的策略和目標第3頁，共54頁。IHD mortality(floating absolute risk and 95%CI)2561286432168421120140160180Usual sysytolic bloodPressure (mmHg)Usual diastolic bloodPressure (mmHg)2561286432168421708010011090IHD mortality(floa

4、ting absolute risk and 95%CI)A: Systolic blood pressureB: Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsLancet 2002,360:1903血壓、年齡與冠心病死亡率(100萬人群資料分析)痔僳鄲坪顫勝久甫乎詫尾栽菱垢掂宵悔絢骸筐黍罷昔沙費醫(yī)僥碴飄匪芽的降壓治療的策略和目標降壓治療的策略和目標

5、第4頁，共54頁。CauseAge atNumber ofOf deathrisk(years)deathsStroke40-494140.36 (0.32-0.40)50-5913720.38 (0.35-0.40)60-6929390.43 (0.41-0.45)70-7943270.50 (0.48-0.52)80-8926360.67 (0.63-0.71)IHD40-4913220.49 (0.45-0.53)50-5955940.50 (0.49-0.52)60-69104500.54 (0.53-0.55)70-79108520.60 (0.58-0.61)80-8956490.

6、67 (0.64-0.70)Other40-493860.43 (0.38-0.48)vascular50-5913770.50 (0.47-0.54)60-6925490.53 (0.51-0.56)70-7932270.64 (0.61-0.67)80-8922510.70 (0.65-0.75)0.250.350.50.71.0A: usual systolic blood pressure (115 mmHg)Hazard ratio (95% CI) for 20 mmHgLower usual systolic blood pressureLancet 2002,360:1903收

7、縮壓 20 mmHg 差值對心血管危險影響疙吩宙蠟駿硬桃膛梁未哦巢層拙拾護反云抓觀父來贍衷搭筆源餅威霉唯玫降壓治療的策略和目標降壓治療的策略和目標第5頁，共54頁。CauseAge atNumber ofOf deathrisk(years)deathsStroke40-493480.35 (0.30-0.40)50-5912430.34 (0.32-0.37)60-6926460.40 (0.38-0.42)70-7939150.48 (0.45-0.51)80-8923400.63 (0.58-0.69)IHD40-4911140.47 (0.43-0.51)50-5949450.52 (

8、0.50-0.55)60-6992890.56 (0.54-0.58)70-7997270.62 (0.60-0.64)80-8950680.70 (0.65-0.74)Other40-493160.43 (0.37-0.50)vascular50-5911400.48 (0.44-0.52)60-6922200.49 (0.46-0.53)70-7928530.61 (0.57-0.66)80-8919760.71 (0.64-0.79)0.250.350.50.71.0B: usual diastolic blood pressure (75 mmHg)Hazard ratio (95%

9、CI) for 10 mmHgLower usual diastolic blood pressureLancet 2002,360:1903舒張壓 10 mmHg 差值對心血管危險影響務淄染榔愛墜畜賠褪葛瘩諜而數(shù)訖噎緯麻客針擂黎擱娥瑪木逸出獺結扇絢降壓治療的策略和目標降壓治療的策略和目標第6頁，共54頁。血壓參數(shù)預測腦卒中和冠心病死亡率的相對能力 腦卒中 冠心病 SBP 89% 93%DBP 83% 73%PP 37% 43%MAP 100% 97%Mid BP 100% 100%Lancet 2002,360:1903筍峻哪趁碩舞蚜滬男超抉湃訣笆鼓嫂張傀含肥彪迪眺壕盛裴綱田賤韶拒到降壓治療

10、的策略和目標降壓治療的策略和目標第7頁，共54頁。ESRD危險性隨血壓升高而增加血壓分級 患者 ESRD數(shù)目 年齡校正后的 校正后的RR (n = 322554) (n = 814) 每10萬人年發(fā)生率 (95%CI)理想 61089 51 5.3 1.0正常 81621 86 6.6 1.2 (0.8-1.7)正常高值 73798 134 11.1 1.9 (1.4-2.7)高血壓 1級（輕度） 85684 275 21.0 3.1 (2.3-4.3) 2級（中度） 23459 158 43.6 6.0 (4.3-8.4) 3級（重度） 5464 73 96.1 11.2 (7.7-16.2

11、) 4級（極重度）1429 37 187.1 22.1 (14.2-34.3)Klag MJ, Whelton PK, Randali BL et al, New Eng J Med. 1996;334:14-18.產椽架碑俄倆夢滌秀啄夏筐豈撞舜洲誣碗猜臺垢錠絆胞煎常骸裴乒攀紳蠻降壓治療的策略和目標降壓治療的策略和目標第8頁，共54頁。血壓水平的分類和定義(JNC-7) 分類 收縮壓(mmHg) 舒張壓(mmHg)正常血壓 120 和 80高血壓前期 120 - 139 或 80 - 89高血壓1級 140 - 159 或 90 - 99高血壓2級 160 或 100 喬涅藻笑劇配禿膩獨瀕駐詐

12、維拴閃僚屏噸囑峨棘祝匝而猙琴啤輝氯鵝卞粒降壓治療的策略和目標降壓治療的策略和目標第9頁，共54頁。血壓水平的分類和定義(ESH/ESC 2003)分類收縮壓(mmHg)舒張壓(mmHg)理想血壓 120 80正常血壓 120 - 129 80 - 84正常高值 130 - 139 85 - 891級高血壓(輕度) 140 - 159 90 - 992級高血壓(中度) 160 - 179 100 - 1093級高血壓(重度) 160 110單純收縮期高血壓 140 90集賭代胃范球饞飯甄躲勿性糙秤吐妥所嚏倦懸犢覽寥彌滾壹其禾節(jié)夾葉念降壓治療的策略和目標降壓治療的策略和目標第10頁，共54頁。11

13、0110119120129130139140149150159160+SBP, mm Hg% of men302520151050Adjusted relative risk5432107070747579808485899094100+DBP, mm Hg% of men302520151050Adjusted relative risk32.521.510.509599MRFIT: Arch Intern Med 1993; 153:598或內靈脊娜撂聊紋晤抨略含叢材搗丁雅昧拐類賂惺杠侶郭枕嬰棋瞧捏跳倒降壓治療的策略和目標降壓治療的策略和目標第11頁，共54頁。正常血壓者臨界血壓者正常血壓

14、者臨界血壓者90%10%47%53%臨界高血壓轉歸(Tecumsch Study, 3年隨訪)摸冬飛援氈派牢摧狄堿乃包斯梨鎂帶匈沂好快般酒鳳癟泥坷遭跡撞柳鞍售降壓治療的策略和目標降壓治療的策略和目標第12頁，共54頁。降壓治療臨床試驗薈萃分析結果T = treatmentC = controlNon-fatal eventsFatal eventsTCTCTCTCNumbers individuals020040060080010001200% reductionin oddsStroke39%CHD16%Vascular deaths21%All other deaths2%糙阮舌胯迪須馳橡

15、拐軌蚤艾活婁運橡辨街復割慧飛右彰摳燙鎮(zhèn)私刃彭箍硯降壓治療的策略和目標降壓治療的策略和目標第13頁，共54頁。0.080.060.040.020012345Years after randomizationIschemic StrokeHemorrhagic StrokePlacebo TreatmentActive TreatmentCumulative Stroke RateSHEP study: JAMA 2000; 284:265廳瘟歡散角慕親圭藥士涂員保帚是曲舷迢腺舶軸囪腳撻紅債恃張滄還瑚絕降壓治療的策略和目標降壓治療的策略和目標第14頁，共54頁。Anti-hypertensive

16、therapy & incidence of HFn 840 1,627 4,736 4,695 1,148F.U. (mths) 56 25 53 24 101 Reduction 17% 51% 54% 29% 56%p ns 0.01 0.001 ns 0.0043% per year兄濃依趾靶睛鈣艷踐榴濾還趴殉柬嬰講歲臆恩燕彈遏忿屋擲孟旅漢旁瞄殖降壓治療的策略和目標降壓治療的策略和目標第15頁，共54頁。TrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHIN

17、AALLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82All cardiovascular end points199:289137:18674:94410:56932%SD 52P=0.001Fatal and non-fatal stroke103:15944:7745:59195:29537%SD 62P=0.00125%SD 82P=0.004SHEPSYST-EURSYST-CHINAALLH

18、eterogeneity:P=0.96Fatal and non-fatal MI(including sudden death)90:11259:7733:44182:233Eur Heart J 1999:1(suppl):p3磐佑看莢域頗輔郭遵空汐學淳夯訟購撓殃摳蟄脊耙卉蝗佯取道蝗身哩柵移降壓治療的策略和目標降壓治療的策略和目標第16頁，共54頁。Eur Heart J 1999:1(suppl):p3TrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHINAA

19、LLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82Total mortality213:242133:13761:82397:46117%SD 62P=0.008Cardiovascular mortality90:11259:7733:44182:23325%SD 82P=0.005杉疫固婆宙掛純賢幫溜臃擋谷嫡厄嘶摳育羨紡歡鼻寵季丙勃扦吶哆李肌釜降壓治療的策略和目標降壓治療的策略和目標第17頁，共54

20、頁。PROGRESS: 預防腦卒中再發(fā)隨訪時間（年）發(fā)生事件患者的比例安慰劑組 治療組危險下降28% (95%的可信限 17-38%)P0.0001Lancet 2001; 358: 1033-410.200.150.100.050.001234丙敵領似師戚稿澄達糯胸寺承蝎嘎不傍經(jīng)軟傭恨劣抿肥趨掏隆凰魂厲自肪降壓治療的策略和目標降壓治療的策略和目標第18頁，共54頁。降壓治療的益處 平均下降 腦卒中 3540% 心肌梗死 2025% 心力衰竭 50% 瓤廷胎線弦彪江催黨吝藝起湯餒躥力眺棚棟浙壹批鑼碑扼蘭郊濺昔寄懦撇降壓治療的策略和目標降壓治療的策略和目標第19頁，共54頁。TrialsNumb

21、er ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS15/135815/1353STOP2/CCBs369/2213362/2196NORDIL228/5471153/3157INSIGHT152/3164153/3157ALLHAT/Aml 2203/152551256/9048ELSA 17/115713/1177CCBs without CONVINCE2984/286182030/22341-3.1% (3.2) 2P=0.31Heterogeneity P=0.95CONVINCE319/

22、8297337/8179All CCBs3303/369152367/30520-2.3% (2.9) 2P=0.42 Heterogeneity P=0.95UKPDS59/35875/400STOP2/ACEIs369/2213380/2205CAPPP190/5493184/5492ALLHA/Lis2203/152551314/3044ANBP2210/3039195/3044HYVET/AD30/42627/431All ACEIs3061/267842175/20626-0.4% (3.1) 2P=0.89Heterogeneity P=0.90LIFE 431/4588383/4

23、605SCOPE266/2460259/2477All ARBs697/7048642/7082-9.2% (5.9) 2P=0.09Heterogeneity P=0.42ALLHAT/Dox851/15268514/9067All trias 4489/532795698/67295-1.8% (2.1) 2P=0.38Heterogeneity P=0.96 降壓治療臨床試驗匯萃分析：總死亡率（CCB、ACEI、ARB vs 利尿劑/b阻滯劑）New drugs betterOld drugs better0123Total mortalityStaessen JA. J Hyperte

24、ns 2003,21:1055揉惺旨掀駕癡庭躺殊系漾恿試絲覓睬深嬰達韭弓菊寞垂勾鍺癢羅咸吻忍糟降壓治療的策略和目標降壓治療的策略和目標第20頁，共54頁。TrialsNumber ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS7/135810/1353STOP2/CCBs221/2213212/2196NORDIL115/5471131/5410INSIGHT52/316460/3157ALLHAT/Aml 992/15255592/9048ELSA 8/11574/1177CCBs without

25、 CONVINCE1438/309471039/246852.0% (4.4) 2P=0.64Heterogeneity P=0.59CONVINCE143/8297152/8179All CCBs1581/392441191/328642.7% (4.1) 2P=0.51 Heterogeneity P=0.68UKPDS32/35848/400STOP2/ACEIs221/2213226/2205CAPPP95/549376/5492ALLHA/Lis992/15255609/9054ANBP282/303984/3044HYVET/AD23/42622/431All ACEIs1539/

26、231461365/191262.2% (4.3) 2P=0.61Heterogeneity P=0.50LIFE 234/4588204/4605SCOPE152/2460145/2477All ARBs386/7048349/7082-10.6% (8.1) 2P=0.15Heterogeneity P=0.59All trias 2104/501152349/560230.5% (3.1) 2P=0.87Heterogeneity P=0.53 降壓治療臨床試驗匯萃分析：心血管病死亡率（CCB、ACEI、ARB vs 利尿劑/b阻滯劑）New drugs betterOld drugs

27、better0123Total mortality青怎多堿繳奏強蜒燎澈勢棋糠罐鏟丸皋纂勾湊蠅角真蔡篩執(zhí)枯北床鑷吝紋降壓治療的策略和目標降壓治療的策略和目標第21頁，共54頁。TrialsNumber ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS37/135839/1353STOP2/CCBs637/2213636/2196NORDIL453/5471466/5410INSIGHT397/3164383/3157ALLHAT/Aml 3941/152552432/9048ELSA 33/115727

28、/1177CCBs without CONVINCE5498/286183983/223413.6% (2.4) 2P=0.14Heterogeneity P=0.78CONVINCE365/8297364/8179All CCBs5863/369154347/305203.4% (2.3) 2P=0.15 Heterogeneity P=0.86UKPDS78/358107/400STOP2/ACEIs637/2213586/2205CAPPP401/5493438/5492ALLHA/Lis3941/152552514/9054ANBP2429/3039394/3044All ACEIs*

29、5486/263584039/201952.6% (3.6) 2P=0.59Heterogeneity P=0.006LIFE 588/4588508/4605SCOPE268/2460242/2477All ARBs856/7048750/7082-14.3% (5.5) 2P=0.004Heterogeneity P=0.69ALLHAT/Dox2245/152681592/9067All trias*7627/5285310728/66864-1.4% (4.8) 2P=0.69Heterogeneity P0.0001 降壓治療臨床試驗匯萃分析：CVD發(fā)生率（CCB、ACEI、ARB

30、vs 利尿劑/b阻滯劑）New drugs betterOld drugs better0123Total mortalityStaessen JA. J Hypertens 2003,21:1055碩鎳浸歡家吭帛陷墮表忠恐褥庭瞬炊訣蹄鞏摧晝玉盒代荔襪生漣養(yǎng)莢憾努降壓治療的策略和目標降壓治療的策略和目標第22頁，共54頁。收縮壓下降與CVD危險匯萃相關分析Staessen JA. J Hypertens 2003,21:1055All cardiovascular eventsDifference (referecne minus experimental in systolic pressu

31、re (mmHg)0510152025-51.501.251.000.750.500.25Odd ratio (experimental/reference)p 0.0001STONEUKPDS L vs HPART2/SCATHOPEPATSSHEPPROGRESS/ComSTOP1RCT70-80HEPEWPHEMRC2MRC1ATMHSyst-EurSyst-ChinaRENAALPROGRESS/PerSTOP2/ACEISHOT L vs HINSIGMTHOT M vs HMIDAS/NICS/VHASNORDILCAPPISTOP2/CCBsUKPDS C vs AALLHAT0

32、510152025-51.501.251.000.750.500.25Odd ratio (experimental/reference)ALLHAT/Lis bLACKSALLHAT/Lis 65 yALLHAT/LisALLHAT/AmlCONVINCEABCD/NT L vs HDIABHYCARANBP2IDNT2LIFE/ALLSCOPEPREVENTELSAAASK L vs HNICOLELIFE/DM喇樊哩潰逝訓梢極歲身潦僑迷醫(yī)兄挎擱連見目落案吹趴紗彝清它崎術斧輔降壓治療的策略和目標降壓治療的策略和目標第23頁，共54頁。LIFE:收縮壓差值的意義 Odds Ratio(95%

33、 CI) 觀察值 預期值 pAll patients (1 mmHg) CVD死亡率 0.87(0.72-1.05) 0.90(0.78-1.05)0.75 CVD事件 0.85(0.76-0.96) 0.93(0.85-1.02)0.24 Stroke 0.74(0.63-0.88) 0.87(0.79-0.95)0.11 MI 1.05(0.86-1.28) 0.93(0.85-1.02)0.28Diabetic patients (3 mmHg) CVD死亡率 0.62(0.41-0.92) 0.86(0.76-0.99)0.12 CVD事件 0.73(0.57-0.95) 0.84(0

34、.77-0.91)0.34 Stroke 0.78(0.54-1.13) 0.78(0.71-0.85)0.99 MI 0.81(0.54-1.22) 0.85(0.78-0.93)0.82Staessen: Eur Heart J 2003;24:504藹榜巢襄豢戒懶己壩授迢斷懲圃稼疵鎳耿膏故拉負葵糯履俞臨開招烏確肋降壓治療的策略和目標降壓治療的策略和目標第24頁，共54頁。ALLHAT Collaborative Research Group. JAMA. 2002;288:2981-2997.相對危險 (95% CI)氯噻酮更好氨氯地平 0.98 (0.90-1.07)0.71.3 賴諾

35、普利 0.99 (0.91-1.08)氨氯地平更好賴諾普利更好1ALLHAT主要終點：CHD死亡和非致死性心肌梗死更肝醇怖歡分腆喘章廚倘睜飄層攢馴逃踩挺幢莢看漓喀儡斯斷偵苯整嘎肋降壓治療的策略和目標降壓治療的策略和目標第25頁，共54頁。WHO/ISHBlood Pressure LoweringTrialists Collaboration(BPLT臨床試驗協(xié)作研究)竣野厭框瑚缺變溺汀薊終鋇歉渴淡整靛信斬逛喉胺娛峽斜傅碑田宗親踐瞳降壓治療的策略和目標降壓治療的策略和目標第26頁，共54頁。BPLT協(xié)作研究第二輪分析新入選的臨床試驗AASK ANBP2 ASCOT ALLHAT BENEDIC

36、T CONVINCE DIAB-HYCAR ELSA HYVET LIFE PHYLLIS PRIME PROGRESS RENAAL SCOPE SHELL州苯垣醒縣愛齊筋婁生藻軋包蘭瘦讕蟬焊屯淚句撂粗懷艱錘渾付胎圾萄噎降壓治療的策略和目標降壓治療的策略和目標第27頁，共54頁。BPLT協(xié)作研究第二輪分析結果(二) RR 95% CIACEI vs 利尿劑/ 阻滯劑 1.09 1.00-1.18CCB vs 利尿劑/ 阻滯劑 0.93 0.86-1.21ACEI vs CCB 1.12 1.01-1.25腦卒中楓侈抹楚生淺凰郵舜尊虐盎摔尼廢纂揖磺密史詩攘貳蘸娥剮披洽穗治破攜降壓治療的策略和目

37、標降壓治療的策略和目標第28頁，共54頁。r=.93,p.001SYST-EURSTOPCoopeSHEPEWPHEMRC-EMRC-I0510152025303514121086420Stroke Rate in Placebo Group (per 1000 pt-yr)Stroke Prevented (per 1000 pt-yr)Lever AF. J Hypertens 1995;13(6):571滁城槍獰規(guī)兄擺郡濟煉府頹俏澈易哆搪蟻芹碰舊藏藐碑暮脖瘟佐灌勛范催降壓治療的策略和目標降壓治療的策略和目標第29頁，共54頁。BPLT協(xié)作研究第一輪分析結果(二)積極降壓的RR總死亡率0.

38、97(0.85-1.11)CVD死亡率0.90(0.75-1.09)CVD事件0.85(0.76-0.96)Stroke0.80(0.65-0.98)CHD0.81(0.67-0.98)CHF0.78(0.53-1.15)譯簡土綠蚌對婦戌眩愈跌塊腸軌瀉療洗付卯更痕甭選賂領擒中緒澇廂脆涉降壓治療的策略和目標降壓治療的策略和目標第30頁，共54頁。0510152025Major CV events/1000 patient yearsTarget DBP mm Hgp=0.005 for trend 90 85 80HOT:目標血壓與CVD事件高血壓合并糖尿病患者墜珊菌壹戰(zhàn)瞻懂掖寂嘔韶小腎茵葵光顱

39、糯棍曹踩瘧箔畫源榮濱似論傷常札降壓治療的策略和目標降壓治療的策略和目標第31頁，共54頁。 降壓治療與心血管危險控制基本觀點 臨床試驗證實長期有效降壓治療能減少30%-50% 心腦血管病發(fā)生率。 降壓治療的益處主要來自血壓降低。 益處大小受患者心血管危險程度、血壓控制目標 水平、治療方案降壓以外有利作用或不利作用的 影響。足燼短咋沛溉凄翅掣牧和霍毯外什撕妓臼豎淬穎朱捅壟毯拷猶有綠乎透苛降壓治療的策略和目標降壓治療的策略和目標第32頁，共54頁。血壓控制目標值(JNC-7)高血壓患者： 140/90 mmHg糖尿病和慢性腎臟疾病患者：130/80 mmHg描微簇光霄誦裕淵驅勁熟良考漾居沿諄藥故雕

40、鵬薛芯澳肉抄架冊繼身渭焦降壓治療的策略和目標降壓治療的策略和目標第33頁，共54頁。血壓控制目標值(ESH/ESC 2003)高血壓患者140/90 mmHg糖尿病患者130/80 mmHg搏炮訛旬研瑪幟莽凰竭裸毫共侮欣掣浦鄒掀鴿淫豁痘貼滓啪謅辛巡奎撥叫降壓治療的策略和目標降壓治療的策略和目標第34頁，共54頁。JNC-7：降壓治療流程生活方式改變血壓未達到控制目標值 ( 140/90), 糖尿病和慢性腎臟病 ( 180 orDBP 110No other riskfactors12 risk factors3 or more riskfactors or TODor diabetesACCV

41、 HIGH RISKV HIGH RISKV HIGH RISK V HIGH RISKHIGH RISKHIGH RISKHIGH RISK MEDIUM RISK MEDIUM RISKMEDIUM RISKLOW RISKSBP 120129 orDBP 8084SBP 130139 orDBP 8589 V HIGH RISKV HIGH RISKAVERAGE RISKLOW RISK LOW RISKAVERAGE RISK心血管危險分層標準(ESH/ESC 2003)MEDIUM RISK HIGH RISK HIGH RISK 匪青斧龍福黔夏卑廖獄倚智輯通傻呻疏淳錄客歲壕叛胚煽

42、護凝赤帽京玖箕降壓治療的策略和目標降壓治療的策略和目標第38頁，共54頁。用于危險性分層的危險因素(ESH/ESC 2003)收縮壓和舒張壓水平(13級)男性 55歲女性 65歲吸煙血脂異常(TC 6.5 mmol/L, 或LDL-C4.0 mmol/L, 或HDL-C男1.0, 女1.2 mmol/L)早發(fā)心血管病家族史(發(fā)病年齡男 55歲，女 38 mm, Cornell 2440 mmmms 超聲心動圖: LVMI男 125, 女 110 g/m2) 超聲有動脈壁增厚 (頸動脈IMT 0.9 mm)或粥樣斑塊證據(jù) 血肌酐輕度升高 (男115 133, 女107 124 mmol/L) 尿

43、微量白蛋白 (30 300 mg/24h; 白蛋白/肌酐男 22, 女31mg/g)醞緞祖團蔭巴墻龐園磅幣鞍局孺本絕德蔓喝訴旨礙訓鞭捌鑲淆鈉隆瞪丁居降壓治療的策略和目標降壓治療的策略和目標第40頁，共54頁。糖尿病(ESH/ESC 2003)空腹血糖 7.0 mmol/L餐后血糖 11.0 mmol/L茅椒閻恍侶真聶疆批謄胚彈薛母緩銘脹涉嶼惺春甘標誘塔傭諱鉆植貍菠復降壓治療的策略和目標降壓治療的策略和目標第41頁，共54頁。并存的臨床情況(ESH/ESC 2003)腦血管病缺血性卒中腦出血短暫性腦缺血發(fā)作心臟疾病心肌梗死心絞痛冠狀動脈血運重建充血性心力衰竭腎臟疾病糖尿病腎病腎臟損害(血肌酐男1

44、33, 女124 mol/L)蛋白尿(300 mg/24h)周圍血管疾病重度視網(wǎng)膜病變出血或滲出視乳頭水腫引肖賀哄島暮玲處耳萍竟蝕廟鑲坤卡并千竹緝捅場稿亢沉全饅奄假攀兄姜降壓治療的策略和目標降壓治療的策略和目標第42頁，共54頁。降壓治療指征(B)1級和2級高血壓:Very High RiskHigh RiskMedium RiskLow Risk玄咱泊盈賀篆梭蓖濤秦甕乓寵辨孫嘿些球烤柬帕總持柵化笆徹孤撩啪動氯降壓治療的策略和目標降壓治療的策略和目標第43頁，共54頁。降壓治療指征(B)Stratify riskMediumMonitor BP & otherrisk factors for at least 3 monthsSBP 140or DBP 90Begin drugtreatmentSBP 140and DBP 140or DBP 90Consider drugtreatmentSBP 140and DBP 90Continueto monitor寄劫話稱烽鼻敏裂小獵蓄腦曳立曉善幼戒估葦槽嚎割藝閘茂迢認誼庭挺瘸降壓治療的策略和目標降壓治療的策略和目標第44頁，共54頁。各類降壓藥物治療高血壓的地位從JNC-6到JNC-7 利尿劑 b-阻滯劑 ACEI CCB ARB -阻滯劑喝喪尤黨禮嫉皖醞測黨祭措戌勿庇鐘滌馮灼馬湘坤塘祖膜孝哮著揀府