老年性高血压的最新指南与治疗-2014
最新美国高血压指南JNC8
Liyang 分享JAMA：美国成人高血压治疗指南(JNC8)【完整版】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程图来帮助医生治疗高血压患者。
JNC8九条推荐：表1 2014年美国高血压指南（JNC8）推荐意见表JNC8高血压管理流程图：图1. JNC8推荐管理流程图来源：中国医学论坛报高血压是一种常见疾病，如果不能早期发现和治疗，容易引发心血管事件、中风、肾衰甚至死亡。
新指南中推荐的起始治疗血压水平、治疗目标、以及治疗用药均有严格的证据支持。
该指南制定专家组成员来自于Eighth Joint National Committee协会。
新旧指南有何不同？该指南制定专家组指出，与旧指南相比，新指南的证据级别更高。
新指南的证据均来自于随机对照研究，所有证据级别和推荐均根据它们对于人体健康的影响程度进行了评分。
专家组指出，新指南旨在为高血压人群建立一个相同的治疗目标。
不过，专家小组强调，尽管新指南提供了高血压开始治疗的时间点、治疗用药以及治疗目标等。
但是，指南并不能作为临床决策的替代品，临床医生在具体治疗时仍需考虑患者的个体差异。
表2，高血压新旧指南对比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。
美国成人高血压指南(JNC)概述
2014美国成人高血压指南（JNC8）概述美国JNC8委员会于2013年12月发布了2014美国高血压管理指南，12月17日晚北京阜外心血管病医院心内科张宇清教授率先通过微信发布这一消息，指南“全文14页，45篇文献；回答了3个问题，做了9个推荐。
”【新指南内容简介】（1）60岁以上人群的目标血压为150/90mmHg，60岁以下人群目标值为140/90mmHg，包括糖尿病和肾脏病患者。
（2）噻嗪类利尿剂、CCB、ACEI和ARB四大类药物作为初始治疗药物（一线治疗药物，黑人仅利尿剂与CCB），可单独或联合使用；β受体阻滞剂退出一线，降至四线，与螺内酯同等地位。
（3）新指南强调了达标和维持目标（长期达标）[The main objective of hypertension treatment is toattain and maintain goal BP]。
（4）新指南不是那么强烈推荐起始联合了[Some committee members recommend]，而是“起始单药再单药加量”、“起始单药再加第二种”、“起始两种联合”三种策略都可以。
（5）肾病患者首选RAS阻断剂；糖尿病患者没有优先推荐RAS阻断剂，而是四种都可以；CCB减少卒中优于ACEI（中国的主要问题是卒中）。
【新指南的变化】河北省人民医院的郭艺芳教授对备受关注的2014年美国高血压治疗指南与旧版指南（JNC7）进行了相比（见图1），新指南的主要变化包括以下几个方面：1．降压治疗目标值在JNC7指南中，分别为无合并症的高血压患者（目标血压<140/90mmHg）与糖尿病和慢性肾病等心血管高危人群（目标血压＜130/80 mmHg）推荐了不同的目标值。
但JNC8指南认为，旧版指南中的上述建议缺乏充分依据，为心血管风险水平增高的高血压患者进行更为严格的血压控制可能不会使患者更多获益。
JNC7指南中建议将老年高血压患者控制在＜140/90 mmHg同样存在此问题。
最新：老年高血压管理解读指南要点
最新：老革高血压筐理解读指南要点人口老龄化己成为重大的社会问题，资料显示半数以上老年人患有高血压，在主80岁的高龄人群中，高血压的患病率接近90%，是罹患脑卒中、心梗乃至造成心血管死亡的首要危险因素。
老年人群是一个独特的群体，莫高血压的预防、诊断、评估和治疗策略与一般人群显著不同。
老军高血压有哪些特点？在｜｜伍床上，老年高血压患者常有以下几个特点：〉收缩压（SBP）升高和脉压增大；〉’异常血压波动；〉合并多种疾病；〉’假性高血压发生率增加。
老董事高血压患者应该选行哪些评估？老年高血压的诊断性评估包括以下几点：①确定血压水平；②了解心血管危险因素；③明确引起血压升高的可逆和／gx,可治疗的因素，如有无继发性高血压；④评估靶器官损害和相关临床情况，判断可能影响预后的合并疾病。
进行上述评估，再助于指导老年高血压患者的治疗。
评估老年高血压患者的整体危险度，也高助于确定降压治疗时机、优化治疗方案，并进行心血管风险综合管理。
因老年本身即是一种危险因素，故老年高血压患者至少属于心血管疾病中危人群。
表1老年高血压危险分层真他危险因素和病史血压水平1级2级3级1～2个危险因素中危中危很高危主3个危险因素或靶器官高危高危很高危损害或糖尿病并存临床情况很高危很高危很高危此外，还应评估老年高血压患者的衰弱和认知功能情况。
？旨南建议，对于高龄高血压患者，推荐制定降压治疗方案前进行衰弱评估，特别是近1年内非刻意节食情况下体质量下降＞5%或高跌倒风险的高龄老年高血压患者（I I B ）。
可采用国际老年营养和保健学会提出的FRAIL量表或步速测定进行衰弱筛查。
如高条件也可进一步采用经典的Fried衰弱综合征标准进行评估。
但F ried量表相对比较麻烦，在门诊恐难以实施，所以仍推荐应用Frail量表。
停号般目篝乏组为.11111/j自:h溅遗自由活动下降疾病偏)R5 保艇’下降表2Frail量表询问万骂过去4周内大部分的酶’E毒所膏时雨’E到ll乏在平用任何疆助工具以及不用他λ帮砌的情况币，中越不保息’巳1 E直接撼菁岱雄在不用任何辅助工虞以及不用他λ稼助的情况芋，走完1个街区（100 m）驳回难医童曾经告诉你存在药”细下疾病：离血Iii，’跟病、急性，t,11£穰衡发作．事中．忽位肿”｛徽，J，皮肤德骸外）．充血性心力量R蝇．嗨嘱．关暂炎．慢’童筋瘸．晴艇疾病、，b级籍’1萃戴更短时揭内出现停霹．下降泊’‘具备以上5象中ξ3条被$断为襄弱；＜3虽是为囊鹏钢黯；01;;为无襄揭．老军高血压患者该如何避行障压治疗1障压目标〉年龄注65岁，血压注140/90mmH g，在生活方式干预的同时启动降压药物治疗，将血压降至＜140/90 mmH g ( I , A）。
老年性高血压
老年性高血压一、疾病定义及概述老年性高血压是指发生在老年人群体中的高血压疾病。
高血压是一种常见的疾病，根据世界卫生组织的定义，血压超过140/90mmHg即可被诊断为高血压。
老年人由于身体状况的变化和生理功能的下降，更容易患上高血压。
二、病因分析老年性高血压的发生可以有多种原因，主要包括以下几个方面：1.年龄因素：随着年龄的增长，血管的弹性逐渐下降，血管内膜发生变化，导致血压升高的几率增加。
2.遗传因素：如果家族中有高血压的病史，那么患上高血压的风险也会增加。
3.不良饮食习惯：高盐饮食、高脂肪饮食和高糖饮食都会增加老年人患上高血压的风险。
4.缺乏运动：年龄大了后，老年人的运动能力下降，长期缺乏运动也会增加高血压的风险。
5.心理因素：老年人常常面临生活压力大、精神紧张等因素，这些因素都可能导致高血压的发生。
三、临床表现老年性高血压的临床表现多样，包括以下几个方面：1.头晕、头痛：由于血压升高，老年人常常出现头晕、头痛等症状。
2.心悸、胸闷：心脏负担增加，容易出现心悸、胸闷等不适感。
3.眩晕、失眠：血管病变会导致老年人出现眩晕、失眠等症状。
4.尿频、尿急：高血压患者常常会出现尿频、尿急等泌尿系统相关的症状。
5.视力模糊：高血压会影响视网膜供血，导致视力模糊。
四、诊断与治疗老年性高血压的诊断主要依据以下几点：1.定期测量血压：对老年人进行定期的血压测量，一般以早晨、晚上测量两次为宜。
2.心电图检查：可以了解心脏的工作状态，进一步判断是否存在高血压引起的心脏损害。
3.尿常规检查：通过尿常规检查，了解肾功能是否受损。
4.血液生化指标检查：测定血液中的各项生化指标，判断是否存在其他并发症。
治疗方面，主要包括以下几个方面：1.药物治疗：针对老年性高血压，可以选用ACEI类、ARB类、钙离子拮抗剂等抗高血压药物。
2.饮食调理：减少高盐、高脂肪和高糖的食物摄入，增加富含纤维的蔬菜水果摄入。
3.运动治疗：适量的有氧运动，如散步、慢跑等，有助于降低血压、增加心肺功能。
最新老年高血压的诊断与治疗中国专家共识
七 、 老年高血压患者心血管病危险因素的综合 管理
• 老年人高血压患者常与其他疾病或心血管疾病的危险因 素（如血脂异常、糖尿病等）并存。多种危险因素并存 时，其对心血管系统的危害将显著增加。因此，在积极 降压治疗的同时，还应加强对危险因素的综合管理。老 年高血压患者的血脂、血糖管理以及抗血小板治疗原则 与一般成年人群相似，其具体治疗方法参见我国现行的 相关指南。
老年高血压的诊断与治疗中国专 家共识
• 一. 前言 • 二. 老年高血压的定义 • 三. 老年高血压的流行病学与防治现状 • 四. 老年高血压的临床特点 • 五. 老年高血压的治疗 • 六. 高龄老年高血压患者降压治疗 • 七. 老年高血压患者心血管病危险因素的综合管理 • 八. 小结
五 、 老年高血压的治疗
• 注意事项：
• 老年人（特别是高龄老年人）过于严格的控制饮 食及限制食盐摄入可能导致营养障碍及电解质紊 乱（如低钠血症），应根据患者具体情况选择个 体化的饮食治疗方案。过快、过度减轻体重可导 致患者体力不佳影响生活质量，甚至导致抵抗力 降低而易患其他系统疾病。因此，老年人应鼓励 适度逐渐减轻体重而非短期内过度降低体重。运 动方式更应因人而异，需结合患者体质状况及并 存疾病等情况制定适宜的运动方案。
• 由于老年患者存在特殊性，在临床实践中应予以关注：1） 血脂异常的老年人可从他汀的治疗中获益。通常，常规
剂量他汀治疗可使多数患者总胆固醇和低密度脂蛋白胆
固醇达标，一般无需服用大剂量他汀。此外，老年人常
服用多种药物，在应用他汀过程中需注意药物之间的相 互作用并监测不良反应；2）与一般成年患者相比，低血 糖对老年人危害更大。因此，应尽量避免使用容易发生
八 、 小结
• 高血压对于老年人的危害更大，老年高血压患者发生靶 器官损害以及死亡的危险显著增高。积极控制老年患者 血压可获得与中青年患者相似甚至更大的益处。目前， 我国老年高血压患者的治疗率、控制率和达标率均很低， 防治工作任重道远，亟待加强。希望借助于老年高血压 诊断与治疗中国专家共识的推广，提高临床医生和患者 对老年人群降压治疗的关注，使更多的老年高血压患者 获益。
老年高血压指南
LOGO 老年高血压合并心力衰竭的降压治疗推荐
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LOGO 高血压合并慢性肾脏病的降压治疗推荐
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LOGO 老年高血压合并糖尿病患者的降压药物选择
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LOGO 老年难治性高血压
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难治性高血压的处理 老年高血压患者在改善生活方式的基础上，合理并足量应用 3 种不同机制的降压药物(包括 1 种利尿剂)治疗＞1 个月血压仍未达标(＜140/90 mmHg) 或至少需要 4 种不同机制的降压药物才能使血压达标，称为老年难治性高血压 (resistant hypertension，RH) 。 诊断老年难治性高血压，首先应排除假性 RH，包括: 血压测量方法不正确、治疗依 从性差( 患者未坚持服药) 、白大衣高血压和假性高血压等。
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诊室血压测量是指由医护人员在医院环境下按照血压测 量规范进行的血压测量，是目前评估血压水平以及观察 降压疗效的常用方法。
LOGO 诊室外血压（家庭自测）
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测量方法 ①使用经过国际标准方案认证合格的上臂式家用自动电子血压计，不推荐 腕式血压计和手指血压计，不推荐使用水银柱血压计进行家庭血压监测。电子血压 计使用期间应定期校准，每年至少 1 次。②家庭血压值一般低于诊室血压值，高血 压的诊断标准为≥135 /85 mmHg( 对应于诊室血压的 140 /90 mmHg) 。③监测频率， 初始治疗阶段、血压不稳定者或是调整药物治疗方案时建议每天早晨和晚上测量血 压( 每次测 2 ～ 3 遍，取平均值) ，连续测量 7 d，取后 6 d 血压计算平均值。血压 控制平稳者，可每周只测 1 d 血压; 长期药物治疗患者，建议监测服用前的血压状 态，以评估药物疗效。④最好能详细记录每次测量血压的日期、时间以及所有血压 读数，而不是只记录平均值，以便医生指导和评价血压监测和控制效果。⑤精神高 度焦虑患者，不建议开展家庭血压监测。
老年高血压患者降压治疗的目标值和低限值
老年高血压患者降压治疗的目标值和低限值高血压的患病率随增龄而增加，老年高血压患者占所有高血压人群的60%以上。
已成为我国老年人群心脑血管疾病发病、死亡最重要的危险因素。
老年高血压在发病机制、临床表现及诊断治疗等方面均与非老年人不同，如收缩压增高、脉压增大、血压波动大、昼夜节律异常、易发生直立性低血压和餐后低血压等；常与多种疾病并存，并发症多，如冠心病、心力衰竭、脑血管疾病、肾功能不全、糖尿病等；并且难治性高血压的比率高于非老年人群。
制定适合老年高血压患者降压治疗的目标值和低限值对指导降压治疗、降低高血压导致的致残率和病死率、改善生活质量和提高老年患者的预期寿命具有重要的临床意义。
但目前对老年人群最佳降压目标值和低限值仍存在较大的争议，缺乏更多的循证医学证据。
老年高血压患者降压治疗不宜矫枉过正，血压水平与心血管危险性间可能存在着J型曲线关系，过低的血压可以增加老年患者不良心脑血管事件的发生。
所以探索老年高血压人群降压治疗适宜的目标值和低限值，以制定个体化的降压治疗方案，一直以来受到人们的关注。
一、老年高血压患者积极降压治疗获益的循证证据高血压在老年人群中较为普遍，60岁以后收缩压继续升高而舒张压逐渐降低、脉压增大，这与老年高血压的病理、生理特点有关。
随增龄大动脉弹性回缩能力和顺应性降低、弹性贮备血管中存留的血量减少，导致单纯收缩期高血压。
单纯收缩期高血压是老年人高血压的主要表现形式，控制单纯收缩期高血压，可有效降低卒中、心血管事件和死亡的风险。
一项老年收缩期高血压的临床试验研究中，使用利尿剂和β受体阻滞剂阶梯疗法长期治疗，卒中的发生率较安慰剂下降36%，冠心病事件下降27%，使每1 000人中心血管事件减少55人次。
欧洲收缩期高血压的临床研究中，与安慰剂组患者比较，降压药物治疗组患者收缩压显著下降，卒中发生率下降42%(P＝0.003)，非致死性卒中的危险下降44%(P＝0.007)。
所有心血管疾病的危险下降31%(P<0.001)。
最新中国高血压指南—《高血压的治疗》
最新中国高血压指南—《高血压的治疗》5.1. 治疗目标：目前，全国统一的医疗服务与保障体系尚未完全建成，而各省、市、自治区之间的经济与社会发展水平又存在很大差异，因此，本指南设定标准与基本两个治疗目标。
标准目标：对检出的高血压患者，在非药物治疗的基础上，使用本指南推荐的起始与维持抗高血压药物，特别是那些每日1次使用能够控制24小时血压的降压药物，使血压达到治疗目标，同时，控制其他的可逆性危险因素，并对检出的亚临床靶器官损害和临床疾病进行有效干预。
基本目标：对检出的高血压患者，在非药物治疗的基础上，使用国家食品与药品监督管理局审核批准的任何安全有效的抗高血压药物，包括短效药物每日2-3次使用，使血压达到治疗目标，同时，尽可能控制其它的可逆性危险因素，并对检出的亚临床靶器官损害和临床疾病进行有效干预。
高血压治疗的基本原则：l 高血压是一种以动脉血压持续升高为特征的进行性“心血管综合征”，常伴有其它危险因素、靶器官损害或临床疾患，需要进行综合干预。
l 抗高血压治疗包括非药物和药物两种方法，大多数患者需长期、甚至终身坚持治疗。
l 定期测量血压；规范治疗，改善治疗依从性，尽可能实现降压达标；坚持长期平稳有效地控制血压。
治疗高血压的主要目的是最大程度地降低心脑血管并发症发生和死亡的总体危险，因此，应在治疗高血压的同时，干预所有其它的可逆性心血管危险因素（如吸烟、高胆固醇血症或糖尿病等），并适当处理同时存在的各种临床情况。
危险因素越多，其程度越严重，若还兼有临床情况，则心血管病的绝对危险就越高，对这些危险因素的干预力度也应越大。
心血管危险与血压之间的关系在很大范围内呈连续性，即便在低于140/90mmHg的所谓正常血压范围内也没有明显的最低危险阈值。
因此，应尽可能实现降压达标。
最近，对既往的抗高血压临床试验进行汇总分析后发现，在高危患者中，虽然经过降压、调脂及其他危险因素的干预，患者的心血管“残余危险”仍然很高，长期预后难以根本改善。
2023年中国老年高血压管理指南
2023年中国老年高血压管理指南导言：高血压是一种常见的慢性疾病，尤其在老年人中发病率较高。
为了更好地管理老年人的高血压病情，中国老年高血压管理指南于2023年正式发布。
本文将介绍该指南的主要内容，以及对老年高血压患者的管理建议。
一、定义与诊断根据指南，高血压的定义为：收缩压≥140mmHg和/或舒张压≥90mmHg。
老年人的高血压分类以及诊断要点与年轻人有所不同，应根据年龄、血压水平和合并症情况综合评估。
二、评估与风险分层老年高血压患者的评估与风险分层是指南的重要内容。
根据患者的年龄、性别、血压水平、合并症等因素进行风险评估，以确定适当的治疗目标和管理策略。
三、非药物治疗除了药物治疗外，非药物治疗在老年高血压管理中占据重要地位。
指南建议老年人应积极改变不良生活方式，包括戒烟、限制饮酒、合理饮食、增加体力活动等。
此外，控制体重、减少钠盐摄入以及避免过度紧张和焦虑也是非药物治疗的重要措施。
四、药物治疗老年高血压患者的药物治疗需根据患者的具体情况来确定。
指南根据患者的血压水平、年龄、合并症等因素，提出了不同药物的首选和替代方案。
同时也强调了药物治疗的个体化原则，因为老年人的生理特点和耐受性与年轻人存在差异。
五、合并症的处理老年高血压患者常常伴随着多种合并症，如糖尿病、冠心病、慢性肾脏病等。
指南明确了老年高血压患者合并症的处理原则，建议将合并症的治疗纳入整体管理计划中，并与专科医生进行密切合作。
六、随访和复查老年高血压患者的随访和复查是确保治疗效果的关键。
指南建议定期随访患者，评估治疗效果和不良反应，并根据需要进行相关检查和调整治疗方案。
同时，也强调了老年高血压患者的自我管理和定期复查的重要性。
七、预防与健康教育老年高血压的预防和健康教育是指南的重要内容之一。
通过宣传健康生活方式、合理饮食和药物治疗的必要性，可以有效降低老年人的高血压发病率和并发症风险。
结语：中国老年高血压管理指南的发布为老年高血压患者的管理提供了科学的依据。
《中国老年高血压管理指南(2023版)》解读PPT课件
老年高血压特点
指南制定意义
强调《中国老年高血压管理指南（ 2023版）》对于规范老年高血压管理 、提高治疗效果和改善患者生活质量 的重要意义。
介绍老年高血压的临床特点，如收缩 压升高、脉压增大、血压波动大等。
指南制定过程
01
02
03
制定团队
介绍指南制定团队的组成 ，包括心血管、老年医学 、全科医学等多学科专家 。
合并心力衰竭
首选血管紧张素转换酶抑制剂、血管 紧张素Ⅱ受体拮抗剂、β受体阻滞剂 和醛固酮受体拮抗剂等。
07 随访管理与效果评价
定期随访内容及频率安排
随访内容
包括血压测量、心血管风险评估、生活方式指导、用药情况评估等。
频率安排
根据患者具体情况制定个体化随访计划，一般建议至少每3个月随访一次，病情不稳定或需要调整治 疗方案的患者应增加随访频率。
β受体阻滞剂
通过抑制中枢和周围RAAS，抑制心肌收缩力和减 慢心率，发挥降压作用。
血管紧张素转换酶抑制剂
通过抑制循环和组织ACE，使ATⅡ生成减少，同 时抑制激肽酶使缓激肽降解减少，从而达到降压 效果。
联合用药方案优化选择
自由联合
根据患者具体情况和耐受性，选择不 同作用机制的降压药物进行联合应用 。
降低心血管事件风险是老年高血压治疗的重要目标，包括减少心肌梗死、脑卒中等严重心血管事件的发生。
个体化治疗原则
根据患者特点制定治疗方案
老年高血压患者具有独特的生理和病理特点，治疗方案应综合考 虑患者的年龄、性别、合并症、靶器官损害等因素。
生活方式干预
生活方式的调整是老年高血压治疗的基础，包括限盐、戒烟、限酒 、合理饮食、适量运动等。
临床后果
老年高血压可增加心血管事件和死亡风险，严重影响患者生 活质量。
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.。
中国老年高血压管理指南
中国老年高血压管理指南一、本文概述《中国老年高血压管理指南》旨在提供全面、科学的指导，帮助医疗工作者更有效地管理老年高血压患者的健康。
高血压是老年人最常见的慢性疾病之一，严重影响了患者的生活质量和预期寿命。
因此，制定和实施一份专门针对老年高血压患者的管理指南，对于提高老年人的健康水平，降低高血压相关并发症的风险，具有重要的现实意义和深远的社会影响。
本指南基于国内外最新的临床研究和实践经验，结合中国老年人的实际情况，从诊断、治疗、预防、康复等多个方面，对老年高血压的管理进行了详细阐述。
我们期望通过这份指南，帮助医生、护士和其他医疗工作者更好地理解和应对老年高血压的挑战，为老年患者提供更为精准和个性化的医疗服务。
我们也希望通过这份指南，提高公众对老年高血压的认识和理解，鼓励老年患者积极参与到自我管理中来，与医疗工作者共同努力，实现高血压的有效控制，享受更高质量的晚年生活。
在未来的工作中，我们将持续关注老年高血压的最新研究进展和临床实践，不断更新和完善本指南，以期为中国老年高血压的管理提供更为科学、全面的指导。
二、定义与分类高血压，也被称为“血压升高”或“高压”，是指血液在血管中流动时对血管壁产生的压力持续高于正常水平。
这是一种常见的慢性疾病，通常没有明显的症状，但却是心脏病、中风、肾脏疾病等多种健康问题的主要风险因素。
在老年人群中，高血压的发病率尤其高，因此对其进行有效的管理至关重要。
在中国，我们根据高血压的严重程度和临床表现，将其分为几个不同的类别。
首先是正常血压，这是指收缩压（SBP）在90-119mmHg 之间，舒张压（DBP）在60-79mmHg之间。
当SBP在120-139mmHg或DBP在80-89mmHg时，我们称之为正常高值血压，这是高血压的前期阶段，需要密切关注。
一旦SBP达到或超过140mmHg，或DBP达到或超过90mmHg，即可诊断为高血压。
高血压再根据SBP和DBP的水平，分为1级、2级和3级。
2024老年高血压管理详细用药方案
2024老年高血压管理详细用药方案高血压是脑卒中、心肌梗死以及心血管死亡的首要危险因素。
我国老年人高血压患病率高且呈增高趋势，但血压控制率较低。
老年高血压具有收缩压升高为主、血压波动大、多重用药、存在假性高血压等特点，其预防、诊断、评估和治疗策略与一般人群显著不同。
我国发布《中国老年高血压管理指南（2023）》,针对老年人血压测量、降压目标、老年高血压特点、功能保存、多重用药、特定人群的治疗及血压管理等问题做了详细阐述。
与2019版指南相比，新版指南更加强调老年高血压诊治过程中的安全性与有效性平衡，突出了诊室外血压测量在老年高血压诊疗中的重要性，更新了老年高血压及其伴随疾病的药物治疗推荐，扩展了老年高血压特殊人群的范围，进一步优化了老年高血压的管理策略。
老年高血压的定义和分级老年高血压的定义与分级与一般成年人相同。
年龄≥65岁，在未使用降压药物的情况下非同日3次测量血压，收缩压≥140mmHg和/或舒张压≥90mmHg,即可诊断为老年高血压。
曾明确诊断高血压且正在接受降压药物治疗的老年人，虽然血压<140/90mmHg也应诊断为老年高血压。
表1老年人血压水平的定义与分级（mmHg）家庭自测血压与动态血压监测也可作为高血压诊断与疗效评估的依据。
表2诊室血压与诊室外血压测量的高血压诊断标准（mmHg）降压原则.药物治疗时机与血压控制目标新版指南指出，老年高血压患者多以收缩压升高为主，舒张压正常甚至偏低，老年高血压的降压治疗应强调收缩压达标，同时也应避免舒张压过度降低。
对于老年高血压，需从小剂量开始应用降压药物并加强监测，根据患者耐受情况逐渐、缓慢地增加治疗强度，直到血压达标。
在积极控制血压的同时，还应筛查并控制各种可逆性危险因素（如血脂异常、糖代谢异常、吸烟、肥胖等），同时关注和治疗相关靶器官损害与临床疾患。
生活方式干预是降压治疗的基本措施。
在生活方式干预的基础上，多数老年高血压患者需要接受降压药物治疗以保证血压达标。
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
2014 中国高血压患者教育指南(简明版)
131中国循环杂志 2014年11月 第29卷 Chinese Circulation Journal，November，2014，Vol. 29 Supplment 2014年中国高血压患者教育指南（简明版）高血压联盟（中国），国家心血管病中心，中华医学会心血管病学分会，中国医师协会高血压专业委员会通讯作者：王文 主任医师 教授 主要从事高血压防治研究 Email： wangwen5588@中图分类号： R54 文献标识码：C 文章编号：1000-3614（2014）增刊-0131-010 doi：10.3969/j.issn.1000-3614.2014.增刊.029关键词 高血压；患者教育；指南1 前言1.1 制定《指南》是慢性病防治的需要2011年9月，联合国举行了由国家元首或政府首脑参加的预防和控制慢性非传染性疾病高级别会议，提出加强非传染性疾病（通常指心血管病、癌症、糖尿病、等常见慢性病）的防控任务和要求。
2012年5月，原卫生部等15个部委联合制定了《中国慢性病防治工作规划2012~2015年》，慢性病已成为我国重要的公共卫生问题。
1.2 是提高高血压治疗率和控制率的重要措施当前我国心血管病死亡占总死亡的41%，每年死亡350万，其中70%的脑卒中和50%的心肌梗死与高血压有关。
降低高血压患者的血压水平可减少40%~50% 的脑卒中危险和15%~30%的心肌梗死危险。
因此，控制高血压是心血管病防治的切入点。
估算2012年我国有高血压患者2.66亿，但治疗率和控制率分别低于40%和10%，原因是多方面的，重要原因之一是患者对高血压的认识不足，治疗的依从性差。
调查表明，初诊高血压治疗一年的依从性仅为30%，严重影响了高血压的治疗率和血压控制率的改善。
因此，对高血压患者进行教育，提高患者对高血压的危害及长期治疗重要性的认识很有必要，高血压患者教育指南是将成为提高高血压治疗率和控制率的重要措施和助推器。
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家庭自测血压）有助于提高血压评估的准确性；
首次应测量双侧上肢血压； 监测立位血压，观察有无体位性低血压。
知晓率、治疗率和控制率
Framingham 心脏研究显示，随着年龄增长，接受
降压治疗的高血压患者血压控制率逐渐下降。年
龄 <60 岁、 60-79 岁和≥ 80 岁的人群中，血压控制
• • • • • • • • • •
老年高血压的治疗策略
小剂量开始，平稳降压；
慎重选药，严密观察；
多药联合，逐步达标；
因人而异，个体化治疗 监测立位血压，避免低血压； 重视家庭自测血压及24小时血压测量
老年高血压的药物治疗
合理选择降压药物不仅有利于提高老年高血压患者血压达标率，更重
治疗策略和降压药物选择的建议
SBP ≥160 mmHg 的老年人，很强的证据支持SBP降低到 150 -140 mmHg
推荐级别 证据等级
I A
对于<80岁的合适的老年人，SBP ≥140 mmHg时可考虑药物 治疗，如果能够耐受，目标SBP <140 mmHg 对于初始SBP ≥160 mmHg 的80岁以上的老年人，只要身体 和精神状态允许，建议SBP降低到 150 -140 mmHg 对于体弱的老年人，建议根据临床治疗的监测结果，由医生 决定是否采取降压药物 如果患者到了80岁，且对降压药物耐受良好，可以考虑继续 坚持治疗 所有类别降压药物对老年患者都适用，尽管利尿剂和钙拮抗 剂对ISH患者更为推荐
冠心病、慢性心力衰竭老年患者首选药物。
β - 受体阻滞剂禁用于病窦综合征、 II 度及
II度
以上房室传导阻滞、支气管哮喘的患者，长期大 量使用可引起糖脂代谢紊乱。
α -受体阻滞剂
一般不作为老年高血压患者的一线用药。
合并症状性前列腺增生症的老年患者可选用α-受
体阻滞剂。
最主要的不良反应是体位性低血压，治疗时应从
此类药物降压疗效好，作用平稳，无绝对禁忌证，与其他4类基本降 压药物均可联合使用。
CCB 对心肌、窦房结功能、房室传导、外周动脉和冠脉循环作用存在 明显差异。
ACEI与ARB
ACEI 对于高肾素活性的高血压患者具有良好的降压疗效及明确肾脏
保护作用，适用于伴有冠状动脉疾病、心肌梗死、心绞痛、左心功能 不全、糖尿病、慢性肾脏疾病或蛋白尿的老年高血压患者。
推荐将收缩压<150/90mmHg
作为老年高血压患者 的血压控制目标值，若患者能够耐受可将血压进 一步降低至140/90mmHg以下。
老年高血压的治疗目标
高血压合并心、脑、肾等靶器官损害的老年患者，
建议采取个体化治疗、分级达标治疗策略：
首先将血压降低至<150/90mmHg ，如果患者能够
主要内容
老年高血压的特点
指南更新为老年高血压治疗带来的启示
老年高血压相关临床研究及治疗
2013年多个高血压指南相继发布
6月15日 11月15日 12月17日 12月18日
ESH高血压指南
AHA/ACC/CDC 高血压控制有效途 径科学建议
ASH/ISH社区 高血压管理临床实践 指南
JNC 8
2013ESH老年人的治疗策略
-
利尿剂(噻嗪类/氯噻酮/吲哒帕胺)
- Beta阻滞剂 - 钙拮抗剂
- ACEI
- ARB
Journal of Hypertension 2013, 31:1281 –1357
2013美国新指南 对血压目标值的不同要求
SBP
AHA/ACC/CDC
DBP
＜90mmg Hg
＜140mmg Hg
JNC 8
ARB的降压及肾脏保护作用与ACEI相似，尤其适用于不能耐受ACEI
咳嗽等副作用的患者。
老年患者常存在动脉粥样硬化性肾血管疾病或其他肾脏病变，使用 ACEI或ARB时需除外双侧重度肾动脉狭窄。用药过程中需要密切监 测血钾及血肌酐水平的变化。
β-受体阻滞剂
虽有争议，如无禁忌症，仍推荐作为高血压合并
IIb
I
C
B
I IIa I
C C A
Journal of Hypertension 2013, 31:1281–1357
2013ESH降压药物的选择
• 降压治疗的主要收益来自于血压降低本身，并且在很 大程度上是独立于所选择的药物 • 目前的指南进一步确认一下五大类降压药物，无论是 单独使用还是某种情况下与其他药物联合使用，都适 合于高血压的初始和维持治疗
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JNC8指南对老年患者降压治疗的推荐
• 对于60岁及以上的普通人群，起始接受降压药物治疗的 SBP≥150mmHg或DBP≥90mmHg，治疗血压目标值为＜ 150/90mmHg（强烈推荐-A级） • 基于推荐1的推论推荐 • 年龄≥60岁的患者，如果药物治疗使达标的SBP更低(比 如＜140mmHg)且耐受性较好、对健康和生活质量无不 良事件发生，治疗无需进行调整（专家意见-E级）
老年高血压降压目标值的推荐
最新欧美高血压指南对于老年高血压的治疗均强调基于 已有临床试验证据，推荐老年人的血压控制目标为
140-150/90mmHg
老年高血压的非药物治疗
非药物治疗是高血压治疗的基本措施，包括：改善生活方式、消除不 利于心理和身体健康的行为和习惯 减少钠盐的摄入 调整膳食结构 减少脂肪及饱和脂肪酸摄入 增加不饱和脂肪酸摄入 增加膳食纤维摄入 戒烟、避免吸二手烟 限制饮酒 适当减轻体重 规律适度的运动 减轻精神压力，保持心理平衡
＜60岁患者 ＜140mmg Hg ≥ 60岁患者 ＜150mmg Hg
＜90mmg Hg
ASH/ISH
＜80岁患者 ＜140mmg Hg ≥ 80岁患者 ＜150mmg Hg ＜90mmg Hg （如合并CKD或DM等高危因素， 则＜140mmg Hg）
美国新指南对一线降压药的推荐
AHA/ACC/CDC • 1级高血压（SBP140-159或DBP90-99）：在生活方式干预基础上可采用噻 嗪类利尿剂
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主要内容
老年高血压的特点
指南更新为老年高血压治疗带来的启示
老年高血压相关临床研究及治疗
老年人降压治疗临床试验
老年收缩期高血压研究(Systolic Hypertension in the Elderly Program, SHEP）
瑞典老年高血压研究（Swedish Trial in Old Patients with Hypertension, STOP-H）
欧洲收缩期高血压试验（Systolic Hypertension in Europe, Syst-Eur）
中国收缩期高血压试验（Systolic Hypertension in China, Syst-China） 老年人认知功能和预后研究（The Study on Cognition and Prognosis in the Elderly, SCOPE） 高龄老年人高血压试验（ Hypertension in the Very Elderly Trial, HYVET） 日本老年高血压患者最佳收缩压研究（Japanese Trial to Assess Optimal Systolic Blood Pressure in Elderly Hypertensive Patients, JATOS）
利尿剂应作为老年高血压联合用药的基本药物，可用于治疗老年单纯 收缩期高血压，尤其适用于合并心力衰竭、水肿的老年高血压患者。
使用利尿剂时应从小剂量开始；肌酐清除率<30ml/ min/1.73 m2者应使
用袢利尿剂如托拉塞米或呋塞米等。
钙拮抗剂（CCB）
推荐长效二氢吡啶类CCB作为老年高血压患者降压治疗的基本药物。
达标率分别为男性： 38% 、 36% 和 28% ，女性： 38% 、 28%和23%。
在我国，老年高血压患者治疗率仅 32.2%
，控制
率仅7.6%。
老年高血压的流行病学与防治现状
Framingham心脏研究显示，年龄<60岁的人群中，
27% 的人患有高血压； 80 岁左右的人群中， 75% 患 有高血压；年龄≥ 80 岁的人群中，高血压的患病 率>90%。
2002
年卫生部全国居民营养与健康状况调查资料 显示，我国≥60岁人群高血压的患病率为49%，显 著高于中青年人群。
老年高血压的临床特点
收缩压增高为主
脉压增大 血压波动大 易发生体位性低血压 常见血压昼夜节律异常 常与多种疾病并存，并发症多 诊室高血压 继发性高血压容易漏诊
良好的耐受，可继续降低到<140/90mmHg。
降压治疗J形曲线现象
血压过高可增加心脑肾等靶器官损害的危险，但过度降低血压也可影 响各重要脏器的血流灌注，同样对患者产生不利影响。
冠心病患者舒张压水平低于 65~70mmHg 时可能会增加不良心脏事件 的危险，对于伴有缺血性心脏病的老年 ISH患者，在强调收缩压达标 的同时应避免过度降低舒张压。 卒中与J形曲线的关系并不明显。而降压达标对老年高血压患者预防 卒中尤为重要。 应用降压药物后收缩压下降幅度往往较大，而舒张压降低较少。因此 不应因为担心舒张压过低而放弃对老年人ISH的治疗。
利尿剂和长效钙拮抗剂降压疗效好、副作用较少，推
荐用于无明显并发症的老年高血压患者的初始治疗。
若患者已存在靶器官损害，或并存其他疾病和 / 或心