2014高血压指南：清晨血压管理
两种临床常用CCB类降压药清晨血压控制情况的比较
两种临床常用CCB类降压药清晨血压控制情况的比较作者：杨洪刚来源：《中国当代医药》2014年第34期[摘要] 目的观察本院目前常用的两种CCB类降压药苯磺酸氨氯地平与硝苯地平控释片在清晨血压控制方面的疗效异同。
方法选取2013年3月～2014年3月在本院门诊就诊的158例轻、中度原发性高血压患者，按照统一设计的观察指标和分析内容，在征得患者同意后，进行初始信息收集。
对资料完整的患者按照服用降压药物的不同分为观察组（n=82）和对照组（n=76），观察组应用苯磺酸氨氯地平片5 mg，1次/d，对照组应用硝苯地平控释片30 mg，1次/d，分别监测用药后1、4、8周的清晨血压，比较两组患者清晨血压达标情况。
结果治疗1周后对照组血压达标率为32.9%，高于观察组的19.5%，差异有统计学意义（P0.05）；治疗8周后观察组血压达标率为65.9%，高于对照组的60.5%，但差异无统计学意义（P>0.05）。
结论苯磺酸氨氯地平和硝苯地平控释片治疗高血压的效果一致，没有明显差异，但是对于清晨时段血压较高的患者，苯磺酸氨氯地平具有一定优势。
[关键词] 原发性高血压；清晨血压；长效降压药；达标率[中图分类号] R972+.4 [文献标识码] A [文章编号] 1674-4721（2014）12（a）-0094-03高血压是一种以动脉血压持续升高为主要表现的慢性疾病，可导致心、脑、肾等重要脏器损害等严重并发症，致残、致死率高，给患者造成极大痛苦，并给家庭造成沉重负担。
高血压的防治已成为全球最大的公共社会问题[1]。
人们推测清晨血压的骤升是发生恶性心脑血管事件的危险因素之一[2]，因此，清晨血压达标成为高血压控制疗效的重要监测指标。
近几年，我国高血压的患病率明显增高。
估算2012年全国高血压患者约2.66亿[3]。
有效地控制血压能明显减少严重并发症。
本研究观察本院目前常用的两种CCB类降压药苯磺酸氨氯地平与硝苯地平控释片在清晨血压控制方面的疗效异同。
健康教育在清晨高血压患者社区管理中的意义
关键词 ： 清晨 高 血 压 ； 健康教育 ； 达标
中图分 类号 ： ４ ４ ． １ Ｒ ２ ５ ５ ． ３ 文献标 识码 ： Ｃ ｄ ｏ ｉ ： １ ０ ． ３ ９ ６ ９ ／ ｊ ． ｉ ｓ ｓ ｎ ． １ ６ ７ ２ —１ ３ ４ ９ ． ２ ０ １ ３ ． １ １ ． ０ ６ ６ 文章 编号 ： １ ６ ７ ２ —１ ３ ４ ９ （ ２ ０ １ ３ ） １ １ —１ ３ ９ ４ — ０ ２
・
ｌ ３９ ４ ・
ＣＨＩ ＮＥＳ Ｅ Ｊ ＯＵＲ ＮＡｌ （ Ｉ Ｆ Ｉ ＮＴＥ ＧＲＡＴＩ ＶＥ ＭＥ ＤＩ ＣＩ ＮＥ （ Ｉ Ｎ Ｃ ＡＲ ＤＩ Ｏ一 ／ ＣＥ ＲＥ ＢＲ ＯＶＡＳ Ｃ ＵＩ ＡＲ ＤＩ Ｓ ＥＡＳ Ｅ Ｎｏ ｖ ｅ ｍｂ ｅ ｒ ２ ０ｌ ３ Ｖｏ １ ． １ ｌ Ｎｏ ． １ １
１ ． １ 一般资料
选 取 丰 台 区 方 庄 社 区 卫 生 眼 务 中 心 确 诊 高 血
３ 讨 论
压且正在服药 、 １ ｏ ： （ ） （ ｊ 前 血压 未达 标 者 ３ １ ６例 为 研 究 对 象 ， 男
１ ８ ３ 例， 女 １ ３ ３ 例。 １ ． ２ 问 卷 调 查 在 社 区干 预 前 和 干 预 ３月 后 ， 采 取 问卷 形 式 对 高血压病相关知识进行测 评 ， 且 干预前 后连续 ３ ｄ监 测 清 晨 血
２ ４ ｈ无 创 动 态 血 压 监 测 显 示 清 晨 血 压 从 较 低 水 平 迅 速 上 升， 是一天内血 压变 化较 大 的 阶段 ， 收 缩 压平 均 升高 １ ４ Ｆ Ｉ １ ｍ
Ｈｇ ， 甚 至 可上 升 ８ ０ ｍｍＨｇ 。这 种 凌 晨 血 压 急 剧 上 升 的 现 象 被 称 为“ 血压晨峰” （ ＭＢ Ｐ Ｓ ） 一 ． 。心 脏 性 猝 死 、 心肌梗死 、 不 稳 定 型
高血压指南回顾和解读
高血压指南回顾和解读在中国，30％的成年人患有高血压，而50％~75％的脑卒中和40％~50％的心肌梗死发生与血压升高有关。
全国每年由于血压升高而导致的过早死亡人数高达200万，直接医疗费用每年至少达366亿元[1]。
中国疾病预防控制中心周脉耕研究员等[2]在《柳叶刀》杂志在线发表了1990~2013年中国的死因变化。
研究显示，1990年我国年龄校正的心血管病死亡为389.3/10万人，2013年则为307.18，降幅达到21％。
总体上看，我国年龄标化心血管死亡已出现下降拐点，这与我国高血压的防控是密不可分的。
纵观对所有疾病的管理，高血压的管理堪称典范，最早写出了指南，进行规范化管理；最先提出定量的治疗目标（140/90mmHg 或130/80mmHg），定期对降压药物进行评价等。
2015年又有哪些新的高血压指南发表？这些指南对血压目标设定和对各种降压药物地位的评价？已引起人们的关注和期待。
本文将按2015年新指南发表时间的顺序，逐一进行简要的回顾和解读，并就2015年最新发表高血压治疗临床证据对即将修改的高血压指南的影响进行展望。
1 2015年新发布的3项高血压指南简要回顾1.1 2015中国台湾地区高血压管理指南2014年12月中国台湾心脏病学会（TSOC）和高血压学会（THS）联合出台2015年高血压管理指南（以下简称新指南），在线发表于JAMA 杂志[3]。
该指南强调家庭血压监测（HBPM）和动态血压监测（ABPM）的重要性，以便更好地检出夜间高血压、晨起高血压、白大衣高血压和隐性高血压；该指南未采纳欧洲与美国降压目标宽松化的观点，认为糖尿病、冠心病、合并蛋白尿的慢性肾脏病以及接受抗栓治疗预防卒中的患者，血压靶目标值＜130/80mmHg，其他患者血压目标值＜140/90mmHg，80岁以上老年人血压目标值＜150/90mmHg；生活方式调整是所有高血压治疗的基础，包括S-ABCDE（限盐、限酒、减轻体重、戒烟、饮食、锻炼）几方面。
清晨血压临床管理中国专家指导建议从清晨血压看高血压的管理
清晨血压临床管理中国专家指导建议高血压是一种常见疾病，会给人体各个器官造成损伤。
而清晨血压特别重要，它与心血管疾病和脑卒中的风险密切相关。
中国专家制定了一些指导建议，以帮助医生和患者更好地管理高血压。
高血压的临床管理高血压有许多治疗方法，其中包括药物治疗、非药物治疗和手术治疗。
治疗的目标是使患者的血压降至正常水平，并预防心血管事件的发生。
对于大多数高血压患者来说，清晨血压的管理尤为重要。
清晨血压的意义清晨血压指的是在早晨醒来前和进食前的血压。
清晨血压的升高与心血管疾病和脑卒中的风险密切相关。
事实上，多项研究显示，清晨血压升高是心血管事件发生的独立危险因素。
此外，清晨血压升高与全天血压水平的升高和高血压病程的恶化也有关系。
指导建议以下是国内专家对清晨血压管理的一些指导建议：1.监测清晨血压，并在早晨醒来前和进食前测量血压。
2.对于诊断为高血压的患者，建议使用长效药物控制清晨血压。
3.对于永久性起搏器患者，清晨血压监测更为困难，在排除反复刺激或疾病恶化后，建议加强治疗以控制血压。
4.对于伴有睡眠呼吸暂停综合征的患者，建议采取有效的非药物治疗和药物治疗以控制清晨血压。
5.对于中年和老年人，建议注意保持规律作息时间，减少压力，积极进行体育锻炼，白天充分活动，睡觉前不饮酒、不吸烟，同时进行药物治疗。
对于老年患者，应当尽量减小药物的剂量，避免发生低血压。
6.对于年轻人，建议减少不良生活习惯，积极参加锻炼和休闲活动，保持心态平和，养成规律的作息习惯，在医生的指导下进行适当的药物治疗。
清晨血压是评估高血压患者临床管理效果的重要指标。
对于高血压患者和医护人员来说，掌握清晨血压的监测方法和有效控制方法非常有必要。
建议患者定期检查和治疗，积极采取非药物治疗和药物治疗控制高血压。
同时，医生应注意制定个性化的治疗方案，以最大程度满足患者的需求，达到优质医疗的目标。
为什么清晨是高血压管理的重要时机!如何做好清晨血压管理
为什么清晨是高血压管理的重要时机！如何做好清晨血压管理“我们如果能够每天早睡，清晨睡到自然醒，然后在懒洋洋的起来，之后，才开始一天工作的话，那简直就是太幸福了。
但事实却是，工作的压力和生活的压力再加上不良的作息习惯，每天晚上都会睡的很晚，第二天为了上班，也是有早早地爬起来。
如果单纯只是这些还要好一些，由于长期的这种习惯，很多人在不知不觉中就让身体患上了疾病，就比如现在人们都非常熟悉的高血压。
这种疾病的可怕性相信大部分接触过的人都是有所了解的。
特别是对于有熬夜早起习惯的人来说，身体的危害就更加的厉害了。
因为，一般在清晨的时候，血压是最高的，很多高血压并发症也都是在这个时候发作的。
所以，患有高血压的人们，如果不改变以前不好的习惯的话，是很有可能造成无法挽回的结果的。
不过，由于很多人都没有这种认识，所以，最近几年因清晨高血压问题而导致患者病情加重的人，就变得越来越多了。
由此，中国药科教育协会发起、辉瑞企业基金资助的“北京早安，共护血压-高血压管理改善项目”近日在京启动。
该项目的主要目的就是为了加强高血压患者对高血压疾病的认知。
通过对大医院和社区医院门诊护士进行一对一的病人教育，通过病人就诊间隙，传递正确的血压测量和高血压病知识，从而帮助更多的病人知道自己的血压情况，了解自己的血压，实现高血压早发现和早治疗，进而降低因高血压加重病情和引发并发症的发病几率。
清晨血压与血压管理的“把握”清晨血压异常升高与心脑血管事件是密切相关的。
以早晨血压为“重点”，对提高高血压综合管理水平是具有非常重要意义的。
所以，无论对医生还是患者来说，控制清晨血压，对于稳定控制一天24小时的血压都是非常重要的。
不过，要管理好早晨的血压，第一步就是：要有效地监测早晨的血压。
高血压最重要的一个特点就是24小时的血压是不断变化的。
一般来说，从早上6:00到10:00的时候，血压会在短时间内从相对较低的水平迅速上升到较高的水平，大多数人的血压这个时间段是一天内会达到的最高水平。
2014欧洲高血压学会动态血压监测指南简介_邹花一阳
·讲 座·２０１４欧洲高血压学会动态血压监测指南简介邹花一阳，卢新政南京医科大学第一附属医院心内科，江苏南京２１００２９通信作者：卢新政，Ｅ－ｍａｉｌ：ｘｚｌｕ＠ｎｊｍｕ．ｅｄｕ．ｃｎ ２０１４年８月，欧洲高血压学会（Ｅｕｒｏｐｅａｎ Ｓｏｃｉｅｔｙｏｆ Ｈｙｐｅｒｔｅｎｓｉｏｎ，ＥＳＨ）发布了动态血压监测（ａｍｂｕｌａ－ｔｏｒｙ ｂｌｏｏｄ ｐｒｅｓｓｕｒｅ ｍｏｎｉｔｏｒｉｎｇ，ＡＢＰＭ）指南［１］。
近年，关于ＡＢＰＭ的研究成为热点，２０１２年底，相关文献超过１万篇。
２０１１年，英国临床健康与优化研究所（ｔｈｅ ｎａｔｉｏｎａｌ ｉｎｓｔｉｔｕｔｅ ｆｏｒ ｈｅａｌｔｈ ａｎｄ ｃｌｉｎｉｃａｌ ｅｘｃｅｌ－ｌｅｎｃｅ，ＮＩＣＥ）推荐，ＡＢＰＭ可作为拟诊高血压患者的经济实用筛查手段。
基于ＡＢＰＭ的重要性，２０１１年ＥＳＨ血压监测与心血管疾病工作组在米兰举行了有关ＡＢＰＭ的专家共识会。
由３４位高血压专家，参考６００篇文献基础上于２０１３年发表立场观点。
围绕３个问题：①哪些患者需行ＡＢＰＭ？②如何规范实施ＡＢＰＭ？③如何在临床中推广ＡＢＰＭ？现对其主要内容作一简介。
１ 哪些患者需行ＡＢＰＭ？１．１ ＡＢＰＭ的优缺点 近年有数据显示，夜间血压能更好地预测心血管事件。
经过４０年不断发展和完善，目前ＡＢＰＭ逐渐渗透到临床工作中。
ＡＢＰＭ不仅真实提供各时间点的血压情况，也反映了高血压患者的血压波动特点及昼夜变化规律。
有助于鉴别白大衣性高血压、隐蔽性高血压等，并预示靶器官损害，更好地评价降压药疗效，指导合理降压。
指南强调，白大衣性高血压的诊断仅限于未治疗高血压人群。
与诊室血压相比，ＡＢＰＭ具有以下优势：①提供更多的血压读数；②提供２４ｈ、白天、夜间血压值，对未治疗高血压患者明确白大衣性高血压、隐蔽性高血压；③明确血压变化趋势；④提供夜间高血压、血压变化曲线；⑤评估２４ｈ血压变异性；⑥评估降压疗效；⑦明确２４ｈ内降压值，对心血管疾病的发生率、死亡率具有独立预测价值。
血压管理 赢在清晨 清晨血压是提高血压管理水平的杠杆点课件
评价血压测量指标：空间维度
诊室
or
家庭
评价血压测量标准：时间维度
or
(动态监测)
时间段
(诊室&家庭)Fra bibliotek时间点
诊室血压测量方法的优缺点
定 义
诊室血压（cinic blood pressure, CBP）又称办 公室血压（office blood pressure，OBP）,或 偶测血压（csaal blood pressure）是由经过专 业训练的医护人员在医院环境中用水银柱血压计 和柯氏音技术读数测量的血压。
研究证实：降低清晨血压带来心脑血管获益
荟萃分析61个前瞻性研究发现，有效控制清晨血压异常升高成为降压治疗的新目标
SBP下降10mmHg DBP下降5mmHg
Lewington S, et al. Lancet. 2002 Dec 14;360(9349):1903-13.
清晨血压是撬动血压管理“杠杆点”
优 势
诊室血压准确测量是临床诊断和治疗高血压的基 石。
诊室
缺 陷
柯氏听音未能本身的缺陷； 仪器方面的原因； 测量者、被测量者不按规程操作； “白大衣高血压”、隐性高血压不能被确诊； 不能及时了解病情变化及调整治疗方案。
Hypertension. 2005;45:142-161， J . Hum Hypertens. 2010 Dec;24(12):779-85
价值，其中最有说服力的证据是清晨血压 升高或24小时血压变异性与卒中或心血管 事件的关系。
Am J Cardiol. 2007;100[suppl]:3J–9J
二、清晨血压如此重要，如何落实到临床实践中？ ——清晨血压的测量
清晨血压测量的方法：
清晨血压临床管理中国专家指导建议从清晨血压看高血压的管理
SLD_NOR_141203_4373 Expire Date : 2015-12-9
《柳叶刀》杂志评论：全球亟需防控高血压
• 全球每年有940万人死因为高血压 • 年龄30岁的高血压患者终生心血管疾病风险为63% • 心血管疾病提早5年发生
Lancet. 2014 May 31;383(9932):1861
核心目标是实现24h血压长期达标，最终减少心脑血管事件
何时启动降压治疗
2014 பைடு நூலகம்NC 8 亮点小结
对于≥60岁的患者，收缩压≥150mmHg和/或 舒张压≥90mmHg 对于＜60岁的患者无论是否合并糖尿病、CKD， 收缩压≥140mmHg和/或舒张压≥90mmHg
SLD_NOR_141203_4373 Expire Date : 2015-12-9
• 老年人：老年人清晨血压升高幅度更大 • 钠盐摄入量：钠盐摄入量增加可导致清晨血压上升 • 吸烟 • 饮酒 • 糖尿病/空腹血糖异常 • 代谢综合征 • 精神焦虑
中华医学会心血管病学分会高血压学组. 中华心血管病杂志. 2014;42(9):721-5
《建议》的主要内容
WHAT
清晨血压的概念及其影响因素
《建议》的主要内容
WHAT
清晨血压的概念及其影响因素
SLD_NOR_141203_4373 Expire Date : 2015-12-9
WHY
清晨血压临床意义和控制情况
HOW
如何有效管理清晨血压
中华医学会心血管病学分会高血压学组. 中华心血管病杂志. 2014;42(9):721-5
SLD_NOR_141203_4373 Expire Date : 2015-12-9
《建议》详细阐述了清晨血压异常升高的危害
2014年成人高血压管理指南(JNC8)
2014Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)Paul A.James,MD;Suzanne Oparil,MD;Barry L.Carter,PharmD;William C.Cushman,MD;Cheryl Dennison-Himmelfarb,RN,ANP,PhD;Joel Handler,MD;Daniel ckland,DrPH;Michael L.LeFevre,MD,MSPH;Thomas D.MacKenzie,MD,MSPH;Olugbenga Ogedegbe,MD,MPH,MS;SidneyC.Smith Jr,MD;Laura P.Svetkey,MD,MHS;Sandra J.Taler,MD;Raymond R.Townsend,MD;Jackson T.Wright Jr,MD,PhD;Andrew S.Narva,MD;Eduardo Ortiz,MD,MPHEditorialsAuthor Audio Interview at Supplemental content at Author Affiliations:Authoraffiliations are listed at the end of this article.Corresponding Author:Paul A.James,MD,University of Iowa,200Hawkins Dr,01286-D PFP,Iowa City,IA 52242-1097(paul-james@uiowa .edu).Clinical Review &EducationSpecial CommunicationE1H ypertension remains one of the most important prevent-able contributors to disease and death.Abundant evi-dencefromrandomizedcontrolledtrials(RCTs)hasshown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension.1-3Clinical guide-lines are at the intersection between research evidence and clinical actions that can improve patient outcomes.The Institute of Medi-cine Report Clinical Practice Guidelines We Can Trust outlined a path-way to guideline development and is the approach that this panel aspired to in the creation of this report.4The panel members appointed to the Eighth Joint National Committee(JNC8)used rigorous evidence-based methods, developing Evidence Statements and recommendations for blood pressure(BP)treatment based on a systematic review of the lit-erature to meet user needs,especially the needs of theprimary care clinician.Thisreport is an executive sum-mary of the evidence and isdesigned to provide clearrecommendations for allclinicians.Major differ-ences from the previousJNC report are summarizedin Table1.The completeevidence summary and detailed description of the evidence review and methods are pro-vided online(see Supplement).The ProcessThe panel members appointed to JNC8were selected from more than400nominees based on expertise in hypertension(n=14), primary care(n=6),including geriatrics(n=2),cardiology(n=2), nephrology(n=3),nursing(n=1),pharmacology(n=2),clinical trials(n=6),evidence-based medicine(n=3),epidemiology (n=1),informatics(n=4),and the development and implementa-tion of clinical guidelines in systems of care(n=4).The panel also included a senior scientist from the National In-stitute of Diabetes and Digestive and Kidney Diseases(NIDDK),a se-nior medical officer from the National Heart,Lung,and Blood Insti-tute(NHLBI),and a senior scientist from NHLBI,who withdrew from authorship prior to publication.Two members left the panel early in the process before the evidence review because of new job com-mitmentsthatpreventedthemfromcontinuingtoserve.Panelmem-bers disclosed any potential conflicts of interest including studies evaluated in this report and relationships with industry.Those with conflicts were allowed to participate in discussions as long as they declared their relationships,but they recused themselves from vot-ing on evidence statements and recommendations relevant to their relationships or conflicts.Four panel members(24%)had relation-ships with industry or potential conflicts to disclose at the outset of the process.In January2013,the guideline was submitted for external peer review by NHLBI to20reviewers,all of whom had expertise in hypertension,and to16federal agencies.Reviewers also had expertise in cardiology,nephrology,primary care,pharmacology,research(including clinical trials),biostatistics,and other impor-tant related fields.Sixteen individual reviewers and5federal agencies responded.Reviewers’comments were collected,col-lated,and ments were reviewed and discussed by the panel from March through June2013and incorporated into a revised document.(Reviewers’comments and suggestions, and responses and disposition by the panel are available on request from the authors.)Questions Guiding the Evidence ReviewThis evidence-based hypertension guideline focuses on the pan-el’s3highest-ranked questions related to high BP management iden-tified through a modified Delphi technique.5Nine recommenda-tions are made reflecting these questions.These questions address thresholds and goals for pharmacologic treatment of hypertension and whether particular antihypertensive drugs or drug classes im-proveimportanthealthoutcomescomparedwithotherdrugclasses.1.Inadultswithhypertension,doesinitiatingantihypertensivephar-macologic therapy at specific BP thresholds improve health out-comes?2.In adults with hypertension,does treatment with antihyperten-sive pharmacologic therapy to a specified BP goal lead to im-provements in health outcomes?3.In adults with hypertension,do various antihypertensive drugsor drug classes differ in comparative benefits and harms on spe-cific health outcomes?The Evidence ReviewThe evidence review focused on adults aged18years or older with hypertension and included studies with the following prespecified subgroups:diabetes,coronary artery disease,peripheral artery dis-ease,heart failure,previous stroke,chronic kidney disease(CKD), proteinuria,older adults,men and women,racial and ethnic groups, and smokers.Studies with sample sizes smaller than100were ex-cluded,as were studies with a follow-up period of less than1year, because small studies of brief duration are unlikely to yield enough health-relatedoutcomeinformationtopermitinterpretationoftreat-ment effects.Studies were included in the evidence review only if theyreportedtheeffectsofthestudiedinterventionsonanyofthese important health outcomes:•Overall mortality,cardiovascular disease(CVD)–related mortality, CKD-related mortality•Myocardial infarction,heart failure,hospitalization for heart fail-ure,stroke•Coronary revascularization(includes coronary artery bypass sur-gery,coronary angioplasty and coronary stent placement),other revascularization(includes carotid,renal,and lower extremity re-vascularization)•End-stage renal disease(ESRD)(ie,kidney failure resulting in di-alysis or transplantation),doubling of creatinine level,halving of glomerular filtration rate(GFR).The panel limited its evidence review to RCTs because they are less subject to bias than other study designs and represent the gold standard for determining efficacy and effectiveness.6The studiesACEI angiotensin-converting enzymeinhibitorARB angiotensin receptor blockerBP blood pressureCCB calcium channel blockerCKD chronic kidney diseaseCVD cardiovascular diseaseESRD end-stage renal diseaseGFR glomerular filtration rateHF heart failureClinical Review&Education Special Communication2014Guideline for Management of High Blood PressureE2JAMA Published online December18,Copyright 2013 American Medical Association. All rights reserved.in the evidence review were from original publications of eligible RCTs.These studies were used to create evidence tables and sum-mary tables that were used by the panel for their deliberations (see Supplement).Because the panel conducted its own systematic re-view using original studies,systematic reviews and meta-analyses of RCTs conducted and published by other groups were not in-cluded in the formal evidence review.InitialsearchdatesfortheliteraturereviewwereJanuary1,1966,through December 31,2009.The search strategy and PRISMA dia-gram for each question is in the online Supplement.To ensure that no major relevant studies published after December 31,2009,were excluded from consideration,2independent searches of PubMed and CINAHL between December 2009and August 2013were con-ducted with the same MeSH terms as the original search.Three panel members reviewed the results.The panel limited the inclusion cri-teria of this second search to the following.(1)The study was a ma-jor study in hypertension (eg,ACCORD-BP,SPS3;however,SPS3did not meet strict inclusion criteria because it included nonhyperten-sive participants.SPS3would not have changed our conclusions/recommendations because the only significant finding supporting a lower goal for BP occurred in an infrequent secondary outcome).7,8(2)The study had at least 2000participants.(3)The study was mul-ticentered.(4)The study met all the other inclusion/exclusion cri-teria.The relatively high threshold of 2000participants was used because of the markedly lower event rates observed in recent RCTs such as ACCORD,suggesting that larger study populations are needed to obtain interpretable results.Additionally,all panel mem-bers were asked to identify newly published studies for consider-ation if they met the above criteria.No additional clinical trials met the previously described inclusion criteria.Studies selected wererated for quality using NHLBI’s standardized quality rating tool (see Supplement)and were only included if rated as good or fair.An external methodology team performed the literature re-view,summarized data from selected papers into evidence tables,and provided a summary of the evidence.From this evidence re-view,the panel crafted evidence statements and voted on agree-ment or disagreement with each statement.For approved evi-dence statements,the panel then voted on the quality of the evidence (Table 2).Once all evidence statements for each critical question were identified,the panel reviewed the evidence state-ments to craft the clinical recommendations,voting on each rec-ommendationandonthestrengthoftherecommendation(Table3).For both evidence statements and recommendations,a record of the vote count (for,against,or recusal)was made without attribu-tion.The panel attempted to achieve 100%consensus whenever possible,but a two-thirds majority was considered acceptable,with the exception of recommendations based on expert opinion,which required a 75%majority agreement to approve.Results (Recommendations)The following recommendations are based on the systematic evi-dence review described above (Box ).Recommendations 1through 5address questions 1and 2concerning thresholds and goals for BP treatment.Recommendations 6,7,and 8address question 3con-cerning selection of antihypertensive drugs.Recommendation 9is asummaryofstrategiesbasedonexpertopinionforstartingandadd-ing antihypertensive drugs.The evidence statements supporting the recommendations are in the onlineSupplement.Abbreviations:ACEI,angiotensin-converting enzyme inhibitor;ARB,angiotensin receptor blocker;CCB,calcium channel blocker;CKD,chronic kidney disease;CVD,cardiovascular disease;JNC,Joint National Committee;RCT,randomized controlled trial2014Guideline for Management of High Blood Pressure Special Communication Clinical Review &EducationJAMA Published online December 18,2013E3Copyright 2013 American Medical Association. All rights reserved.Recommendation 1In the general population aged 60years or older,initiate pharma-cologic treatment to lower BP at systolic blood pressure (SBP)of 150mm Hg or higher or diastolic blood pressure (DBP)of 90mm Hg or higher and treat to a goal SBP lower than 150mm Hg and goal DBP lower than 90mm Hg.Strong Recommendation –Grade ACorollary RecommendationIn the general population aged 60years or older,if pharmacologic treatment for high BP results in lower achieved SBP (for example,<140mm Hg)and treatment is not associated with adverse effects on health or quality of life,treatment does not need to be adjusted.Expert Opinion –Grade ERecommendation 1is based on evidence statements 1through 3from question 2in which there is moderate-to high-quality evi-dence from RCTs that in the general population aged 60years or older,treating high BP to a goal of lower than 150/90mm Hg re-duces stroke,heart failure,and coronary heart disease (CHD).There isalsoevidence(albeitlowquality)fromevidencestatement6,ques-tion 2that setting a goal SBP of lower than 140mm Hg in this age group provides no additional benefit compared with a higher goal SBP of 140to 160mm Hg or 140to 149mm Hg.9,10To answer question 2about goal BP,the panel reviewed all RCTs thatmettheeligibilitycriteriaandthateithercomparedtreatmentwith a particular goal vs no treatment or placebo or compared treatment with one BP goal with treatment to another BP goal.The trials on whichtheseevidencestatementsandthisrecommendationarebased includeHYVET,Syst-Eur,SHEP ,JATOS,VALISH,andCARDIO-SIS.1-3,9-11Strengths,limitations,andotherconsiderationsrelatedtothisevidence reviewarepresentedintheevidencestatementnarrativesandclearly support the benefit of treating to a BP lower than 150mm Hg.The corollary to recommendation 1reflects that there are many treated hypertensive patients aged 60years or older in whom SBP is currently lower than 140mm Hg,based on implementation of pre-vious guideline recommendations.12The panel’s opinion is that in these patients,it is not necessary to adjust medication to allowBPThe strength of recommendation grading system used in this guideline was developed by the National Heart,Lung,and Blood Institute’s (NHLBI’s)Evidence-Based Methodology Lead (with input from NHLBI staff,external methodology team,and guideline panels and work groups)for use by all the NHLBI CVD guideline panels and work groups during this project.Additional details regarding thestrength of recommendation grading system are available in the online Supplement.aNet benefit is defined as benefits minus the risks/harms of theservice/intervention.Abbreviations:RCT,randomized controlled trialaThe evidence quality rating system used in this guideline was developed by the National Heart,Lung,and Blood Institute’s (NHLBI’s)Evidence-BasedMethodology Lead (with input from NHLBI staff,external methodology team,and guideline panels and work groups)for use by all the NHLBI CVD guidelinepanels and work groups during this project.As a result,it includes the evidence quality rating for many types of studies,including studies that were not used in this guideline.Additional details regarding the evidence quality rating system are available in the online Supplement.Clinical Review &Education Special Communication 2014Guideline for Management of High Blood PressureE4JAMA Published online December 18,2013Copyright 2013 American Medical Association. All rights reserved.to increase.In 2of the trials that provide evidence supporting an SBP goal lower than 150mm Hg,the average treated SBP was 143to 144mm Hg.2,3Many participants in those studies achieved an SBP lower than 140mm Hg with treatment that was generally well tolerated.Twoothertrials 9,10suggesttherewasnobenefitforanSBPgoallower than 140mm Hg,but the confidence intervals around the effect sizes were wide and did not exclude the possibility of a clinically impor-tant benefit.Therefore,the panel included a corollary recommen-dationbasedonexpertopinionthattreatmentforhypertensiondoes not need to be adjusted if treatment results in SBP lower than 140mm Hg and is not associated with adverse effects on health or qual-ity of life.While all panel members agreed that the evidence supporting recommendation 1is very strong,the panel was unable to reach una-nimity on the recommendation of a goal SBP of lower than 150mm Hg.Some members recommended continuing the JNC 7SBP goal of lower than 140mm Hg for individuals older than 60years based on expert opinion.12These members concluded that the evidence was insufficient to raise the SBP target from lower than 140to lower than 150mm Hg in high-risk groups,such as black persons,those with CVD including stroke,and those with multiple risk factors.The panel agreed that more research is needed to identify optimal goals of SBP for patients with high BP.Recommendation 2In the general population younger than 60years,initiate pharma-cologic treatment to lower BP at DBP of 90mm Hg or higher and treat to a goal DBP of lower than 90mm Hg.For ages 30through 59years,Strong Recommendation –Grade A For ages 18through 29years,Expert Opinion –Grade ERecommendation 2is based on high-quality evidence from 5DBPtrials(HDFP ,Hypertension-StrokeCooperative,MRC,ANBP ,and VA Cooperative)that demonstrate improvements in health out-comes among adults aged 30through 69years with elevated BP.13-18Initiation of antihypertensive treatment at a DBP threshold of 90mm Hg or higher and treatment to a DBP goal of lower than 90mm Hg reduces cerebrovascular events,heart failure,and overall mor-tality (question 1,evidence statements 10,11,13;question 2,evi-dence statement 10).In further support for a DBP goal of lower than 90mm Hg,the panel found evidence that there is no benefit in treat-ing patients to a goal of either 80mm Hg or lower or 85mm Hg or lower compared with 90mm Hg or lower based on the HOT trial,in which patients were randomized to these 3goals without statisti-cally significant differences between treatment groups in the pri-mary or secondary outcomes (question 2,evidence statement 14).19In adults younger than 30years,there are no good-or fair-quality RCTs that assessed the benefits of treating elevated DBP on health outcomes (question 1,evidence statement 14).In the ab-senceofsuchevidence,itisthepanel’sopinionthatinadultsyounger than 30years,the DBP threshold and goal should be the same as in adults 30through 59years of age.Recommendation 3In the general population younger than 60years,initiate pharma-cologic treatment to lower BP at SBP of 140mm Hg or higher and treat to a goal SBP of lower than 140mm Hg.Expert Opinion –Grade E2014Guideline for Management of High Blood Pressure Special Communication Clinical Review &EducationJAMA Published online December 18,2013E5Copyright 2013 American Medical Association. All rights reserved.Recommendation3is based on expert opinion.While there is high-quality evidence to support a specific SBP threshold and goal forpersonsaged60yearsorolder(Seerecommendation1),thepanel found insufficient evidence from good-or fair-quality RCTs to sup-port a specific SBP threshold or goal for persons younger than60 years.In the absence of such evidence,the panel recommends an SBP treatment threshold of140mm Hg or higher and an SBP treat-ment goal of lower than140mm Hg based on several factors.First,in the absence of any RCTs that compared the current SBP standard of140mm Hg with another higher or lower standard in this age group,there was no compelling reason to change current rec-ommendations.Second,intheDBPtrialsthatdemonstratedtheben-efit of treating DBP to lower than90mm Hg,many of the study par-ticipants who achieved DBP of lower than90mm Hg were also likely to have achieved SBPs of lower than140mm Hg with treatment.It is not possible to determine whether the outcome benefits in these trials were due to lowering DBP,SBP,or both.Third,given the rec-ommended SBP goal of lower than140mm Hg in adults with dia-betes or CKD(recommendations4and5),a similar SBP goal for the general population younger than60years may facilitate guideline implementation.Recommendation4In the population aged18years or older with CKD,initiate pharma-cologic treatment to lower BP at SBP of140mm Hg or higher or DBP of90mm Hg or higher and treat to goal SBP of lower than140mm Hg and goal DBP lower than90mm Hg.Expert Opinion–Grade EBased on the inclusion criteria used in the RCTs reviewed by the panel,this recommendation applies to individuals younger than70years with an estimated GFR or measured GFR less than 60mL/min/1.73m2and in people of any age with albuminuria defined as greater than30mg of albumin/g of creatinine at any level of GFR.Recommendation4is based on evidence statements15-17from question2.In adults younger than70years with CKD,the evidence is insufficient to determine if there is a benefit in mortality,or car-diovascular or cerebrovascular health outcomes with antihyperten-sive drug therapy to a lower BP goal(for example,<130/80mm Hg) compared with a goal of lower than140/90mm Hg(question2,evi-dence statement15).There is evidence of moderate quality dem-onstrating no benefit in slowing the progression of kidney disease from treatment with antihypertensive drug therapy to a lower BP goal(for example,<130/80mm Hg)compared with a goal of lower than140/90mm Hg(question2,evidence statement16).Three trials that met our criteria for review addressed the effect of antihypertensive drug therapy on change in GFR or time to development of ESRD,but only one trial addressed cardiovas-cular disease end points.Blood pressure goals differed across the trials,with2trials(AASK and MDRD)using mean arterial pressure and different targets by age,and1trial(REIN-2)using only DBP goals.20-22None of the trials showed that treatment to a lower BP goal(for example,<130/80mm Hg)significantly lowered kidney or cardiovascular disease end points compared with a goal of lower than140/90mm Hg.For patients with proteinuria(>3g/24hours),post hoc analy-sis from only1study(MDRD)indicated benefit from treatment to a lower BP goal(<130/80mm Hg),and this related to kidney out-comes only.22Although post hoc observational analyses of data from this trial and others suggested benefit from the lower goal at lower levels of proteinuria,this result was not seen in the primary analyses or in AASK or REIN-2(question2,evidence statement 17).20,21Based on available evidence the panel cannot make a recom-mendation for a BP goal for people aged70years or older with GFR less than60mL/min/1.73m2.The commonly used estimating equations for GFR were not developed in populations with signifi-cant numbers of people older than70years and have not been validated in older adults.No outcome trials reviewed by the panel included large numbers of adults older than70years with CKD. Further,the diagnostic criteria for CKD do not consider age-related decline in kidney function as reflected in estimated GFR.Thus, when weighing the risks and benefits of a lower BP goal for people aged70years or older with estimated GFR less than60mL/min/ 1.73m2,antihypertensive treatment should be individualized,tak-ing into consideration factors such as frailty,comorbidities,and albuminuria.Recommendation5In the population aged18years or older with diabetes,initiate phar-macologic treatment to lower BP at SBP of140mm Hg or higher or DBP of90mm Hg or higher and treat to a goal SBP of lower than 140mm Hg and goal DBP lower than90mm Hg.Expert Opinion–Grade ERecommendation5is based on evidence statements18-21from question2,which address BP goals in adults with both diabetes and hypertension.Thereismoderate-qualityevidencefrom3trials(SHEP, Syst-Eur,and UKPDS)that treatment to an SBP goal of lower than 150mm Hg improves cardiovascular and cerebrovascular health out-comes and lowers mortality(see question2,evidence statement18) in adults with diabetes and hypertension.23-25No RCTs addressed whether treatment to an SBP goal of lower than140mm Hg com-pared with a higher goal(for example,<150mm Hg)improves health outcomes in adults with diabetes and hypertension.In the absence of such evidence,the panel recommends an SBP goal of lower than 140mm Hg and a DBP goal lower than90mm Hg in this population based on expert opinion,consistent with the BP goals in recom-mendation3for the general population younger than60years with e of a consistent BP goal in the general population younger than60years and in adults with diabetes of any age may facilitateguidelineimplementation.ThisrecommendationforanSBP goal of lower than140mm Hg in patients with diabetes is also sup-ported by the ACCORD-BP trial,in which the control group used this goal and had similar outcomes compared with a lower goal.7 The panel recognizes that the ADVANCE trial tested the ef-fects of treatment to lower BP on major macrovascular and micro-vascular events in adults with diabetes who were at increased risk of CVD,but the study did not meet the panel’s inclusion criteria be-cause participants were eligible irrespective of baseline BP,and there were no randomized BP treatment thresholds or goals.26 The panel also recognizes that an SBP goal of lower than130 mm Hg is commonly recommended for adults with diabetes and hy-pertension.However,this lower SBP goal is not supported by any RCT that randomized participants into2or more groups in whichClinical Review&Education Special Communication2014Guideline for Management of High Blood PressureE6JAMA Published online December18,Copyright 2013 American Medical Association. All rights reserved.treatment was initiated at a lower SBP threshold than140mm Hg or into treatment groups in which the SBP goal was lower than140 mm Hg and that assessed the effects of a lower SBP threshold or goal on important health outcomes.The only RCT that compared an SBP treatment goal of lower than140mm Hg with a lower SBP goal and assessed the effects on important health outcomes is ACCORD-BP, which compared an SBP treatment goal of lower than120mm Hg with a goal lower than140mm Hg.7There was no difference in the primary outcome,a composite of cardiovascular death,nonfatal myocardial infarction,and nonfatal stroke.There were also no dif-ferences in any of the secondary outcomes except for a reduction in stroke.However,the incidence of stroke in the group treated to lower than140mm Hg was much lower than expected,so the ab-solute difference in fatal and nonfatal stroke between the2groups was only0.21%per year.The panel concluded that the results from ACCORD-BP did not provide sufficient evidence to recommend an SBP goal of lower than120mm Hg in adults with diabetes and hy-pertension.The panel similarly recommends the same goal DBP in adults with diabetes and hypertension as in the general population(<90 mm Hg).Despite some existing recommendations that adults with diabetes and hypertension should be treated to a DBP goal of lower than80mm Hg,the panel did not find sufficient evidence to sup-port such a recommendation.For example,there are no good-or fair-quality RCTs with mortality as a primary or secondary prespeci-fied outcome that compared a DBP goal of lower than90mm Hg with a lower goal(evidence statement21).In the HOT trial,which is frequently cited to support a lower DBP goal,investigators compared a DBP goal of90mm Hg or lower vs a goal of80mm Hg or lower.19The lower goal was associated with a reduction in a composite CVD outcome(question2,evidence state-ment20),but this was a post hoc analysis of a small subgroup(8%) of the study population that was not prespecified.As a result,the evidence was graded as low quality.Another commonly cited study to support a lower DBP goal is UKPDS,25which had a BP goal of lower than150/85mm Hg in the more-intensively treated group compared with a goal of lower than 180/105mm Hg in the less-intensively treated PDS did show that treatment in the lower goal BP group was associated with a significantly lower rate of stroke,heart failure,diabetes-related end points,and deaths related to diabetes.However,the comparison in UKPDS was a DBP goal of lower than85mm Hg vs lower than105 mm Hg;therefore,it is not possible to determine whether treat-ment to a DBP goal of lower than85mm Hg improves outcomes compared with treatment to a DBP goal of lower than90mm Hg. In addition,UKPDS was a mixed systolic and diastolic BP goal study (combined SBP and DBP goals),so it cannot be determined if the benefits were due to lowering SBP,DBP,or both.Recommendation6In the general nonblack population,including those with diabetes, initial antihypertensive treatment should include a thiazide-type di-uretic,calcium channel blocker(CCB),angiotensin-converting en-zyme inhibitor(ACEI),or angiotensin receptor blocker(ARB). Moderate Recommendation–Grade BFor this recommendation,only RCTs that compared one class of antihypertensive medication to another and assessed the effects on health outcomes were reviewed;placebo-controlledRCTs were not included.However,the evidence review was informed by major placebo-controlled hypertension trials,includ-ing3federally funded trials(VA Cooperative Trial,HDFP,and SHEP),that were pivotal in demonstrating that treatment of hypertension with antihypertensive medications reduces cardio-vascular or cerebrovascular events and/or mortality.3,13,18These trials all used thiazide-type diuretics compared with placebo or usual care as the basis of therapy.Additional evidence that BP lowering reduces risk comes from trials ofβ-blocker vs placebo16,27and CCB vs placebo.1Each of the4drug classes recommended by the panel in rec-ommendation6yielded comparable effects on overall mortality and cardiovascular,cerebrovascular,and kidney outcomes,with one ex-ception:heart failure.Initial treatment with a thiazide-type di-uretic was more effective than a CCB or ACEI(question3,evidence statements14and15),and an ACEI was more effective than a CCB (question3,evidence statement1)in improving heart failure out-comes.While the panel recognized that improved heart failure out-comes was an important finding that should be considered when se-lecting a drug for initial therapy for hypertension,the panel did not conclude that it was compelling enough within the context of the overall body of evidence to preclude the use of the other drug classes for initial therapy.The panel also acknowledged that the evidence supported BP control,rather than a specific agent used to achieve that control,as the most relevant consideration for this recommen-dation.The panel did not recommendβ-blockers for the initial treat-ment of hypertension because in one study use ofβ-blockers re-sulted in a higher rate of the primary composite outcome of cardio-vascular death,myocardial infarction,or stroke compared to use of an ARB,a finding that was driven largely by an increase in stroke (question3,evidence statement22).28In the other studies that com-pared aβ-blocker to the4recommended drug classes,theβ-blocker performed similarly to the other drugs(question3,evidence state-ment8)or the evidence was insufficient to make a determination (question3,evidence statements7,12,21,23,and24).α-Blockers were not recommended as first-line therapy be-cause in one study initial treatment with anα-blocker resulted in worse cerebrovascular,heart failure,and combined cardiovascular outcomes than initial treatment with a diuretic(question3,evi-dence statement13).29There were no RCTs of good or fair quality comparing the following drug classes to the4recommended classes: dualα1-+β-blocking agents(eg,carvedilol),vasodilatingβ-block-ers(eg,nebivolol),centralα2-adrenergic agonists(eg,clonidine),di-rect vasodilators(eg,hydralazine),aldosterone receptor antago-nists(eg,spironolactone),peripherally acting adrenergic antagonists (reserpine),and loop diuretics(eg,furosemide)(question3,evi-dence statement30).Therefore,these drug classes are not recom-mended as first-line therapy.In addition,no eligible RCTs were iden-tified that compared a diuretic vs an ARB,or an ACEI vs an ARB. ONTARGET was not eligible because hypertension was not re-quired for inclusion in the study.30Similar to those for the general population,this recommenda-tion applies to those with diabetes because trials including partici-pants with diabetes showed no differences in major cardiovascular or cerebrovascular outcomes from those in the general population (question3,evidence statements36-48).2014Guideline for Management of High Blood Pressure Special Communication Clinical Review&Education JAMA Published online December18,2013E7 Copyright 2013 American Medical Association. All rights reserved.。
美国高血压指南(中文版)
JAMA杂志今天发布了2014年成人高血压治疗指南（2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults），新指南包含9条推荐和一种治疗流JNC8高血压管理流程图：图1. JNC8推荐管理流程图新指南回答了三个常见问题：•何时开始降压治疗专家组对需要开始治疗的血压水平进行明确。
指南推荐，60岁以上老年人，血压达到150/90即应开始降压治疗；治疗目标值如上述。
但是，专家组强调，新指南规定的这一血压界值并不是重新定义高血压，此前由Joint National Committee 7定义的高血压水平（>=140/90 mm Hg ）仍然有效。
血压处于这一范围的人群，均应通过生活方式进行干预。
•血压治疗目标值新指南对以上三个问题的回答总体概括如下：60岁以上老年高血压患者的高血压治疗目标值应为150/90 mm Hg；30-59岁高血压患者舒张压应低于90mmHg。
但是这一年龄段高血压患者收缩压的推荐治疗目标值目前没有充足的证据支持，30岁以下高血压患者舒张压的治疗目标值也没有证据支持。
因此专家组推荐，这类人群的高血压治疗目标应低于140/90 mm Hg。
此外，对于60岁以下罹患高血压合并糖尿病，或高血压合并非糖尿病性慢性肾脏疾病(CKD)患者，指南推荐的治疗目标值和60岁以下普通高血压人群一致。
•高血压治疗起始用药专家点评：•Harold C. Sox, M.D.：新指南证据级别更有说服力Harold C. Sox, M.D.，达特茅斯学院教授Harold C. Sox, M.D.指出，新版指南以及撰写指南的专家小组权威性更高。
他指出，评价指南是否权威，可以从以下四个方面进行考察：1，指南中最可信的部分是什么？2，指南是如何撰写制定的？3，撰写指南的专家小组成员扮演何种角色？4，指南获取公众信任的途径是什么？Harold博士认为，从这四个角度来看，新版指南权威性更高。
社区高血压患者健康管理
家庭血压
推荐使用符合国际标准的上臂式电子血压计。 家庭血压一般低于诊室血压，正常上限参考值： 135/85 mmHg，相对应于诊室血压 140/90mmHg。治疗的血压目标值是＜ 135/85mmHg。对新诊断的或未达标的高血压， 建议连续监测家庭血压７d，每天6:00－9:00 和 18:00－21:00各1次，每次测量2－3遍取平均值， 两次测压间隔1min.
④ 随访过程中出现新的严重临床疾患；⑤ 患者服降 压药后出现不能解释或难以处理的不良反应；⑥ 高血压伴发多重危险因素或靶器官损害而处理困 难者。
3.上级医院转回基层社区的条件 ①高血压诊断已 明确；② 治疗方案已确定；③ 血压及伴随临床疾 患已控制稳定。
基层高血压防治工作效果评估
人群高血压防治“三率”指标 高血压知晓率 高血压治疗率 高血压控制率 切忌单纯追求理想化数字，要讲究管理质量和实际 效果，逐步将高血压患者心脑血管 事件发生变化 作为评估防治管理效果的“硬指标”。
高血压患者健康管理
《中国高血压基层管理指南2014年修订版》要点
1）定期测量血压，将人群中未知的高血压检测出来， 提高人群高血压知晓率。
2）规范测量血压，推荐使用经国际标准认证合格的 上臂式自动（电子）血压计。
3）因地制宜检查、评估高血压患者的总体心血管风 险，根据总危险决定治疗时机和措施。
4）中国是脑卒中高发区，明确治疗高血压的主要目 标是预防脑卒中。降低高血压患者的血压水平是 预防脑卒中的关键。
5）长期坚持生活方式改善是高血压治疗的基石，限 盐、限酒、减轻体质量有利于高血压的控制。
6）五大类降压药：钙拮抗剂、血管紧张素转换酶抑 剂 、血管紧张素受体拮抗剂、利尿剂、β受体阻 滞剂、复方制剂均可作为高血压治疗的选择，根 据药物的强适应证选择使用。
清晨高血压管理
2023ESC/ESH高血压指南推出：家庭自测 血压与动态监测血压有更加好地预测价值
与诊室血压相比，家庭测量血压能够更加好地预测高血压诱导旳靶器官 损害，尤其是LVH，近期对几项前瞻性研究（研究人群涉及一般人群、 初级保健人群和高血压患者）旳荟萃分析显示家庭自测血压在预测心血 管发病率和死亡率方面明显好于诊室血压。针对动态血压监测和家庭血 压监测旳研究显示，家庭自测血压在预测器官损害方面旳价值与动态血 压相同，在校正年龄和性别原因后，家庭自测血压旳预后价值与动态血 压相同。
血压变异明显增长心血管事件发生和死亡风险
风险比例, 卒 中, 17
风心险血比管例事,件发生和死亡风险增加比例 CHD, 27
风险比例, CVD 死亡, 22 风险比例, 全因 死亡, 20
风险比例,
7项研究，HR=1.17， 4项研究，HR=1.27， （95%[CI], 1.07-1.28 ） （95%[CI], ）
Hypertension. 2023 Nov;64(5):965-82. doi: 10.1161/HYPERTENSIONAHA.114.03903. Epub 2023 Jul 28.
清晨高血压病理生理机制
清晨时段
血流介导旳血管 扩张能力减弱 [3]
外周血管 收缩增强[5]
外周阻力 增长[8]
化模式
120
90
60
30
诊室血压
0
Thomas G.et al. N Engl J Med 2023;354:2368-74
在24 h内，血压变 异程度最大旳时间段 是在清晨，即从睡眠 状态转为清醒并开始 活动时，血压从相对 较低旳水平在短时间 内迅速上升到较高旳 水平，甚至到达一天 内最高旳水平。
3.2014年基层版中国高血压防治指南(钟江华)
（2014年基层版）
钟江华
海口市人民医院 心血管内科
高血压的危害
脑卒中发病和死亡增加 冠心病发病和死亡增加
血压水 平升高
心力衰竭发病和死亡增加
肾脏疾病发生危险增加
大动脉及周围动脉病变危险增加
2000万人
大医院 10%
城镇社区 30% 农村 60%
1.2 亿人
6000万人
我国2亿高血压患者应就诊区域分布；90%应分布在城镇社区和乡村
•
－：选择性检查项目； ＋：应当检查项目； 基本要求
：最低要求完成的检查
高血压治疗目标
• 高血压治疗主要目标是血压达标，以便最大限度地降低心脑血管病发病 率及死亡率；
• 目标血压：
普通高血压患者血压降至<140/90 mmHg以下； 老年（＞65岁）患者的收缩压降至<150/90mmHg以下,如能耐受,可
基层（社区和乡村）是高血压防治的主战场 基层医生是防治高血压的主力军
基层指南目录
• • • • • • • 第一节、高血压的检出 第二节、高血压的诊断与评估 第三节、高血压的治疗 第四节、高血压预防和教育 第五节、高血压的管理 第六节、高血压患者的双向转诊 第七节、高血压防治工作考核及评估
高血压检出
治疗中血压未达标，可原药加量或加另外一种药
联合用药方式
• 采取各药的按需剂量配比处方，其优点是可以根 据临床需要调整品种和剂量 • 采用固定配比复方，其优点是方便，有利于提高
病人的依从性。
• 传统复方制剂：复方降压片、降压 0 号、珍菊降
压片；
表7 基层小剂量两种药联合方案（范例）
价格低廉药物的组合方案 价格中上药物的组合方案
控制清晨高血压预防脑卒中
作者 ：廖 裔学，内科 副主任 医师 ，长期从事神 经 内科 工 作 ，擅 长 脑 血 管病 预 治 。
峰每升高 １０ｍｍＨｇ，卒中风险升高 １倍 。有研 究 显 示 ，４４％的缺 血 性 脑 卒 中发 生 在 ６：００～
１
ｌ０：ＯＯ。清 晨 血 压 升 高 者 发 生 脑 卒 中的 危 险是 ３．３ ＭＨ 的控 制现 状
引／
控制清晨高血压 预防脑卒中
廖裔学 口钢 医 院）
摘 要 ：介绍清晨血压的概念、诊 断、影响 因素、发 生机制、评估 、治疗以及 管理模式 ，认 为 清晨 高血压是脑卒 中最强的独立危险因素 ，提 出清晨血压监控是预防脑卒 中的关键 。
关键词 ：清晨高血压；诊断 ；脑卒中；治疗与预防
Ｋｅｙ Ｗ ｏｒｄｓ： Ｍｏｒｎ ｉｎｇ Ｈｙｐｅｒｔｅｎｓｉｏｎ； Ｄｉａｇｎ ｏｓｉｓ； Ｓｔｒｏｋｅ； Ｔｒｅａｔｍｅｎｔ ａｎｄ Ｐｒｅｖｅｎｔｉｏｎ
１ 前 言
睡眠 时 增 高 ｌ０％％ ～２０％。从 ２：００—３：Ｏ０最
我 国每 ５个 成 年 人 就 有 １人 患 有 心 脑 血 管 疾病【１１，而与西方 国家不同，我国脑卒中的比例 明显增高 ，是 心肌梗死 的 ５倍 。我国每 ５个成 年 人 就 有 １人 患 有 高血 压 病 ，全 国共 有 高 血压 患 者 约 ２亿 人 ，高 血 压 的 防治 已成 为 全球 最 大 的公共社会问题［２１。高血压是影 响脑卒中的首位
Ｃｏｎｔｒｏｌ ｔｈｅ Ｍ ｏｒｎｉｎｇ Ｈｙｐｅｒｔｅｎｓｉｏｎ ｔｏ Ｐｒｅｖｅｎｔ ｔｈｅ Ｓｔｒｏｋｅ
ＬＩＡ Ｏ Ｙｉｘｕｅ
（Ｈｏｓｐｉｔａｌ ｏｆ Ｌｉｕｚｈｏｕ Ｓｔｅｅ１）
Ａｂｓｔｒａ ｃｔ： Ｔｈｅ ｃｏｎｃｅｐｔ， ｄｉａｇｎｏｓｉｓ， ｉｎｆ ｌｕｅｎｃｉｎｇ ｆａｃｔｏｒｓ， ｍｅｃｈａｎｉｓｍ ， ｅｖａｌｕａｔｉｏｎ， ｔｒｅａｔｍｅｎｔ ａｎｄ ｍ ａｎａｇｅｍｅｎｔ ｍ ｏｄｅｌ ｏｆ ｔｈｅ ｍｏｒｎｉｎｇ ｂｌｏｏｄ ｐｒｅｓｓｕｒｅ ｗｅｒｅ ｉｎｔｒｏｄｕｃｅｄ．Ｔｈｅ ｍｏｒｎｉｎｇ ｈｙｐｅｒｔｅｎｓｉｏｎ ｗａｓ ｒｅｇａｒｄｅｄ ａｓ ｔｈｅ ｓｔｒｏｎｇｅｓｔ ｉｎｄｅｐｅｎｄｅｎｔ ｒｉｓｋ ｆａｃｔｏｒｓ ｆｏｒ ｓｔｒｏｋｅ， ａｎｄ ｆｕｒｔｈｅｒｍｏｒｅ， ｔ ｈ ｅ ｅａｒｌｙ ｍｏｒ ｎ ｉｎｇ ｂｌｏｏｄ ｐｒｅｓｓｕｒｅ ｍｏｎｉｔｏｒ－ ｉｎｇ ｉｓ ｔｈｅ ｋｅｙ ｔｏ ｐｒｅｖｅｎｔ ｓｔｒｏｋｅ．
清晨高血压与血压晨峰差异及在血压管理中的位置
清晨高血压与血压晨峰差异及在血压管理中的位置返回上一级单选题（共10题，每题10分）1 . 下列关于清晨血压动态监测说法错误的是（）• A.定时测量日常生活状态下的血压• B.可获得24小时、白昼、夜间和每小时的血压均值,24小时血压均值有较好重复性;无白大衣效应• C.需记录起床后2小时或早餐6—10点时间段的血压平均值• D.每次测量2—3次取均值，每周测3—4天我的答案：D参考答案：D答案解析：暂无2 . 关于晨峰血压在血压管理中的位置，说法不正确的是（）• A.血压晨峰与心脑血管事件的发生密切相关• B.难以广泛用于临床实践• C.血压晨峰定义明确• D.目前尚无统一的计算方法我的答案：C参考答案：C答案解析：暂无3 . 关于血压晨峰，下列说法正确的是（）• A.起床后2h内的收缩压平均值—夜间睡眠时的收缩压最低值• B.起床后1h内的收缩压平均值—夜间睡眠时的收缩压最低值• C.起床后2h内的收缩压平均值+夜间睡眠时的收缩压最低值• D.起床后1h内的收缩压平均值+夜间睡眠时的收缩压最低值我的答案：A参考答案：A答案解析：暂无4 . 关于清晨血压在血压管理中的位置，说法不正确的是（）• A.目前尚无统一的定义和计算方法• B.更容易获取参数• C.可在临床工作中广泛使用• D.清晨高血压与心脑血管事件密切相关我的答案：A参考答案：A答案解析：暂无5 . 关于家庭血压监测，正确的是（）• A.应在起床后1h内进行，通常在6-10点之间• B.尽可能在服药后，早饭前测量血压• C.测压尽可能取卧位• D.每次测量2-4次取其均值，每周测2-4天我的答案：A参考答案：A答案解析：暂无6 . 下列关于清晨诊室血压说法错误的是（）• A.可能存在白大衣性高血压及隐匿性高血压• B.不能及时了解病情变化、调整治疗方案• C.应服药后测量血压• D.测量诊室血压无法作为长期监测评估清晨血压的方法我的答案：C参考答案：C答案解析：暂无7 . 关于血压晨峰和清晨血压的区别说法错误的是（）• A.血压晨峰定义不统一• B.血压晨峰正常值不确定• C.血压晨峰除了能用24小时动态血压监测还可通过家庭血压测量• D.清晨血压可通过家庭血压测量、24小时动态血压、诊室血压测量实现，操作方便，实践性更强我的答案：C参考答案：C答案解析：暂无8 . 清晨血压增高的影响因素包括（）• A.糖尿病• B.代谢综合征• C.精神焦虑• D.以上均是我的答案：D参考答案：D答案解析：暂无9 . 清晨血压治疗方案的选择应遵循四项原则说法不正确的是（）• A.使用半衰期24小时及以上、真正长效、每日服药1次就能控制24小时血压的药物，避免因治疗方案选择不当导致的医源性清晨血压控制不佳；• B.使用安全可长期坚持使用并能控制每一个24小时血压的药物，提高患者的治疗依从性；• C.对于单纯清晨高血压患者，不可调整服药时间；• D.使用心脑获益临床试验证据充分，并可真正降低长期心脑血管事件的药物，减少心脑血管事件，改善高血压患者的生存质量我的答案：C参考答案：C答案解析：暂无10 . 关于人类通常情况下24小时血压变化，下列说法正确的是（）• A.在24h内，血压变异程度最大的时间段是在傍晚• B.在24h内，血压变异程度最大的时间段是在清晨• C.在24h内，血压变异程度最大的时间段是在中午• D.以上均不是我的答案：B参考答案：B答案解析：暂无【下载本文档，可以自由复制内容或自由编辑修改内容，更多精彩文章，期待你的好评和关注，我将一如既往为您服务】。
苯磺酸氨氯地平和厄贝沙坦治疗清晨高血压效果对比
苯磺酸氨氯地平和厄贝沙坦治疗清晨高血压效果对比陈延庆【摘要】目的：比较苯磺酸氨氯地平和厄贝沙坦治疗清晨高血压的效果差异。
方法：选择清晨高血压患者72例，随机分为苯磺酸氨氯地平组36例服用苯磺酸氨氯地平5mg，口服，每日1次；厄贝沙坦组36例服用厄贝沙坦150mg，口服，每日1次。
疗程为12周，比较两组患者治疗前后的清晨血压的变化情况。
结果：两组治疗后清晨血压均较治疗前明显下降（P<0.01），治疗后苯磺酸氨氯地平组清晨血压明显低于厄贝沙坦组（P<0.05），苯磺酸氨氯地平组清晨血压下降幅度明显大于厄贝沙坦组（P<0.01）。
苯磺酸氨氯地平组治疗前后的清晨血压下降幅度收缩压14.77±6.58 mmHg，舒张压12.94±6.08 mmHg；厄贝沙坦组治疗前后的清晨血压下降幅度收缩压10.17±5.60 mmHg，舒张压7.83±2.84 mmHg。
结论：苯磺酸氨氯地平和厄贝沙坦均能有效控制清晨高血压，但苯磺酸氨氯地平控制清晨高血压的疗效优于厄贝沙坦。
【期刊名称】《交通医学》【年(卷),期】2015(000)004【总页数】3页(P375-376,378)【关键词】高血压;苯磺酸氨氯地平;厄贝沙坦【作者】陈延庆【作者单位】南通市妇幼保健院内科，江苏226018【正文语种】中文【中图分类】R544.1多项研究表明心源性猝死、心肌梗死、脑卒中等心脑血管疾病均于清晨高发，清晨时段血压变化与心脑血管风险关系密切，血压晨峰幅度异常增大会导致心脑血管风险显著增加[1-2]。
清晨高血压指在清晨觉醒时段血压高于正常。
根据2014清晨血压管理的中国专家临床指导建议[3]，清晨家庭血压测量平均值≥135/85mmHg 即可诊断清晨高血压。
清晨血压是指清晨醒后1h内、服药前、早餐前的家庭血压测量结果或动态血压记录的起床后2h或早晨6：00-10：00间血压。
本研究选取2014年10月—2015年03月在我院内科以及我院分部社区卫生服务中心门诊就诊的轻、中度高血压病患者中符合清晨高血压诊断标准的72例患者，依据我国专家制定发布的血压测量指南[4]以及家庭血压监测中国专家共识[5]，通过家庭自测血压的方法，比较苯磺酸氨氯地平和厄贝沙坦控制清晨高血压的疗效。
- 1、下载文档前请自行甄别文档内容的完整性，平台不提供额外的编辑、内容补充、找答案等附加服务。
- 2、"仅部分预览"的文档,不可在线预览部分如存在完整性等问题,可反馈申请退款(可完整预览的文档不适用该条件!)。
- 3、如文档侵犯您的权益，请联系客服反馈,我们会尽快为您处理(人工客服工作时间：9:00-18:30)。
优 势
异或降压治疗效应; ➢ 避免白大衣效应; ➢ 了解患者生活常态下的血压水平;
➢ 改善治疗依从性;
缺
有严重焦虑症的患者，会自行改变治疗方案的患
点
者不建议使用家庭血压监测。
Hypertension. 2005;45:142-1.61， J Hum Hypertens. 2010 Dec;24(12):779-85
动态血压监测方法的优缺点 使血压监测从“点”到“面”
定 义
动态血压测量（Ambulatory blood pressure measurement, ABPM）通过仪器自动间断性定时 测量日常生活状态下血压的一种检测技术。
时间段 (动态监测)
➢ 无观察误差和读数选择偏差；
优 势
➢ 有较多血压读数，可获得24h、白昼、夜间和每小时 的血压均值，24h血压均值有较好重复性；
Yano Y, Kario K. Curr Hypertens Rep. 2012 Jun;14(3):219-27.
最新高血压指南推荐 最佳控制清晨高血压方案是优先应用长效制剂
2010中国高血压防治指南 优先应用长效制剂：尽可能使用1次/日给药而有持续24小时降压作用的长效药物， 以有效控制夜间血压与晨起血压，更有效预防心脑血管并发症发生1
64-80 34-43
20
与硝苯地平相比，氨氯地平更好控制清晨血压
140 SBP
130
P<0.02
120
氨氯地平
硝苯地平控释 片
血压(mmHg)
110 90 DBP P<0.02
80
70 65
5 6 8 10 1 14 16 18 20 22 0 2 一天中的时间点
24
➢ 开放、交叉对照研究，共40名轻中度高血压患者接受起始剂量氨氯地平5 mg / 天或硝苯地平控释
➢ 无白大衣效应；无安慰剂效应；
➢ 可评估长时血压变异；可评估昼夜血压节律；
➢ 可评估降压治疗后24h血压控制状况
➢每次测得血压读数可能欠准确，尤其在活动时；
缺
➢睡眠质量影响夜间血压读数；
点
➢每小时血压均值的重复性较差；
➢费用较高，很难长期频繁使用
中国血压测量工作组，中华高血压杂志，2011年12月第19卷第12期：
Muller et al. N Engl J Med 1985;313:1315–1322; Marler et al. Stroke 1989;20:473–476.
但是，清晨时段血压最容易被忽视
已经超过清晨时段 或已服降压药
通常诊室血压衡量血压水 平是否控制达标
诊室血压已控制的患者中，超过60%清晨血压未控制（家庭清晨血压≥135/85mmHg ）1 诊室血压未控制的患者中94.9%清晨血压未控制（家庭清晨血压≥135/85mmHg ） 2
Parti G, Stergiou G, et al. J Hypertens. 2008 ; 26:
家庭血压测量：方法 血压未达标、血压不稳定的高血压患者：
连续测7天，每日清晨（6:00-10:00）和晚上（18:00-21:00）各1次 血压达标且稳定的高血压患者：
每周测量1-2天，早晚各一次
Kazuomi Kario AJH 2005; 18:149-151
清晨血压是临床血压管理的一个盲点， 对于高血压患者而言，有效管理好清 晨血压是带来更多心脑获益的有效方
法
主要内容
1
清晨血压是提高整体血压管理水平的杠杆点
2
管理清晨血压的有效手段
家庭血压测量 （HBPM）
一、要评估监测清晨服药前血压 诊室血压测量（OBPM）
达
来自真实世界的观察性研究同样显示： 含络活喜的治疗方案控制清晨血压达标率最高
清晨血压控制率
络活喜 其他
硝苯地平
汪宇鹏. 中华心血管病杂志2013；7：587-589
国产氨氯地平
氨氯地平为基础的治疗显著降低心梗风险
研究亚组
氨氯地平
心梗 事件
总计
心事对梗件照组总计（权%重）M95风.H%险,C随I比机，
Pickering TG, et al. Hypertension. 2008 ; 52: 1-9.
欧洲高血压学会(ESH) 家庭测量血压临床指南 HBPM临床指征 如可能，家庭测量血压（HBPM)应该用于所有接受治疗的高血压患者 HBPM同样推荐于“白大衣高血压”和“隐匿性高血压”患者的血压监测。
风险比 M.H,随机， 95%CI
氨氯地平 vs 非CCB为基础的常规治
疗方案
AASK_BB 2006
5 217
18
441
0.7
0.55(0.20 -1.51)
ACCOMPLI SH 2008
125
5,74 4
159 5,762
9.2
0.78(0.62 -0.99)
2014高血压指南：清晨血压管理
全球范围内，高血压可控的重要危险因素 世界卫生组织：全球高血压发病率
http://gamapserver.who.int/mapLibrary/Files/Maps/Global_BloodPressurePrevalence_Both
有效管理高血压势在必行 中国高血压防控形势不容乐观
2
两组平均收缩压差值(mmHg)
1
缬沙坦更好
0
-1
-2
-3
氨氯地平 更好
-4
1
6
11
16
21 24
给药后时间(小时) Ole Lederballe Pedersen, et al. Journal of Hypertension 2007, 25:707–712
* P=0.039
最后4个小 时
即2.清7m晨m时H段g 收缩压差值
中国疾病预防控制中心慢病防控中心2013年 公布的一项横断面研究显示：
• 中国高血压人数已突破3.3亿 • 每3名成人中有1人患高血压 • 每死亡5人中至少有2个与高血压相关
主要内容
1
清晨血压是提高整体血压管理水平的杠杆点
2
管理清晨血压的有效手段
血压管理核心目标平稳控制24H血压 血压在24小时内是不断变化的
160
清晨时段血
50
压
45
140
40
120
35
100
30
25
80
20
60
15
40
10
20
5
0
0
18:00
0:00
6:00
12:00
时间
1, 清晨时段（6:00至中午） 心肌梗死的发病率显著高 于其他3个时段平均值的 1.28倍(p<0.01)。
2，卒中的发病率最高时段 与一天中血压最高时段 （清晨）不谋而合。
对于血压的特殊组成在心血管疾病中的中心作用，我们才刚刚开始认识。 例如：SBP的预测价值大于DBP；中心动脉压的临床相关性比外周或上 臂血压更大；每天的血压改变对终点有重要的临床价值，其中最有说服 力的证据是清晨血压升高或24小时血压变异性与卒中或心血管事件的关 系。
Am J Cardiol. 2007;100[suppl]:3J–9J
AHA/ASH/PCNA专家共识
HBPM
Pickering TG, et al. Hypertension. 2008 ; 52: 1-9.
➢ 家庭测量血压（HBPM）与动态血压监测(ABPM)相比，成本更低，监测更方便 ➢ HBPM应该成为大多数已确诊或者疑似高血压患者的血压监测常规项目 ➢ HBPM在新诊断或疑似高血压患者中可用来鉴别“白大衣高血压”和“隐匿性高血压” ➢ 推荐用于评估治疗反应 ➢ 具有改善医疗质量的同时降低医疗费用的潜在作用——应该得到重视
清晨时段血压水平最高
未治疗高血压患者24小时动态血压变化
变化最大
血压水平最高
Br J Cardiol. 2008;15:3
清晨时段心脑血管事件风险最高
卒中 (per 2 h) 心肌梗死 (per h)
一天中各时间段脑卒中与心肌梗死的发生率
180
卒中 (n=1,167) 心肌梗死(n=2,999)
最佳控制血压方案应该是保证降压疗效覆盖整个24小时，尤其是对清晨时段血压 的控制2
1.中国高血压指南防治修订委员会. 中华心血管病杂志,2011;39(7):579-616. 2.Radauceanu A, et al. .Fundam Clin Pharmacol. 2004 Aug;18(4):483-91.
＜140/90mmHg
or ＜135/85mmHg
Family Practice. 2011;0:16.doi:10.1093/fampra/cmr121.
三、 清晨血压的药物治疗
治疗清晨血压：药物治疗是根本
控制清晨血压升高的根本途径是使用长效降压药物，如长效钙通 道阻滞剂或肾素 - 血管紧张素 - 醛固酮系统抑制剂。
早晨血压测量最好在排尿后、早餐前和服药物前 中国血压测量工作组，中华高血压杂志，2011年12月第19卷第12期：
家庭血压监测方法：早晚测压的注意事项 家庭血压监测中国专家共识. 中华高血压杂志 2012. 第6期.
清晨诊室外血压： 清晨诊室外未服药前
二、清晨血压管理的目标
清晨家庭血压： 通常是清晨6:00到10:00
欧洲ABPM专家声明： 要监测清晨服药前血压
最新欧洲24小时动态血压专家声明 强调24小时ABPM要关注清晨血压监测
家庭测量血压方法的优缺点
定 义
家庭测量血压（Home blood pressure measurement, HBPM）由被测量者在家完成， 这时称家庭血压测量，可由家庭成员等协助完成。