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1、 高血压合理用药高血压合理用药最新要点讨论及处方分析最新要点讨论及处方分析 我国高血压患病率愈来愈高我国高血压患病率愈来愈高百分比*(%)04812162019591814106219791991200218.8%全国患病人数已超过2.0亿中国居民营养与健康现状调查。卫生部、科技部、统计局，2004、10、12我国18岁及以上居民高血压患病率为18.8%6.1 8%24.7 30.2 1.6亿亿18.8 2004年全国营养年全国营养与健康综合调查与健康综合调查（18岁）岁）2.9 12.2 26.6 9400万万11.26 1991年全国抽样年全国抽样调查调查(15岁以上岁以上)控制率控制率服
2、药率服药率知晓率知晓率患病人数患病人数患病率患病率中国中国高血压控制率高血压控制率降压本身的益处降压本身的益处 平均降低平均降低 卒中发生率卒中发生率 3540%心肌梗死心肌梗死 2025%心力衰竭心力衰竭 50%JNC 7收缩压降低1012mmHg或舒张压降低5-6mmHg1、高血压治疗四大目标、高血压治疗四大目标 长期、有效、平稳控制血压水平长期、有效、平稳控制血压水平预防预防(逆转逆转)心、脑、肾等靶器官的损害心、脑、肾等靶器官的损害减少心、脑血管疾病的发病和死亡减少心、脑血管疾病的发病和死亡循证循证医学医学改善生活质量改善生活质量亚临床靶器官损害之保护亚临床靶器官损害之保护(2009,
3、oct ESH Reappraisal)Evidence on the important prognostic role of subclinical organ damage continues to grow.In both hypertensive patients and the general population,the presence of electrocardiographic and echocardiographic LVH,a carotid plaque or thickening,an increased arterial stiffness,a reduced
4、 eGFR(assessed by the MDRD formula),or microalbuminuria or proteinuria substantially increases the total cardiovascular risk,usually moving hypertensive patients into the high absolute risk range.合并亚临床靶器官损害常为高危者：合并亚临床靶器官损害常为高危者：LVH,颈动脉颈动脉斑块、增厚硬化，斑块、增厚硬化，eGFR下降，微量下降，微量/蛋白尿。蛋白尿。-Journal of Hypertensio
5、n 2009,27:21212158血压目标血压目标 所有患者所有患者 140/90 140/90DM/肾病肾病 130/80(DM)130/80冠心病：冠心病：130/80 mm Hg(2007/2009年欧洲高血压指南年欧洲高血压指南)*老年老年SBP难于难于140可适当灵活些可适当灵活些(尤低危者尤低危者)，老年收缩压老年收缩压可可降至降至150 mm Hg以下以下血压目标血压目标 低限？低限？(ESH June,2009)Key among the changes will be the recommendation of a lower threshold level-around
6、120 mm Hg systolic and 70 mm Hg diastolic-below which it could be dangerous to reduce blood pressure in high-risk individuals,representing the so-called J-curve phenomenon,Mancia said.J-Curve:A Narrow Window of Optimum BP for High-Risk Individuals“J形曲线形曲线”可能存在，有些特定高危患者血可能存在，有些特定高危患者血压不宜过低（压不宜过低（50%，
7、Qd，提，提高顺从、平稳降压高顺从、平稳降压据血压水平、据血压水平、RF、TOD、ACC,选单或多药联合选单或多药联合制定个性化方案：制定个性化方案：2级以上高血压常需联合用药，配级以上高血压常需联合用药，配合非药物疗法合非药物疗法 达标快慢：达标快慢：(2009,June ESH)In 2007,we took a strong stance in favor of combination treatment.This has been shown again-trials such as ACCOMPLISH,ADVANCE,HYVET,ASCOT and ONTARGET are cha
8、nging the picture.We have to lower BP rather quickly in these patients to try to prevent a catastrophe,and more recently,studies have shown there is less discontinuation of treatment in this patient population if treatment is started with combination therapy,Mancia said.对高危患者更倾向于：联合用药、尽快达标、预防事件对高危患者
9、更倾向于：联合用药、尽快达标、预防事件-June 16,2009(Milan,Italy)The European Society of Hypertension(ESH)3、药物治疗战略理念、药物治疗战略理念3-1用药模式用药模式：1）套餐）套餐模式：模式：195060s2）席餐）席餐模式模式:197080s3）自助餐）自助餐模式模式:19902000s 3-2常用五类药物及其配方：常用五类药物及其配方：RAS拮抗剂：拮抗剂：ACEI(普利普利)ARB(沙坦沙坦)钙拮抗剂：钙拮抗剂：CCB(地平等地平等)利尿剂利尿剂 (噻嗪等噻嗪等)Beta阻滞剂：阻滞剂：BB(洛尔等洛尔等)2009 ES
10、C/ESH 专家意见利尿剂利尿剂CCBCCBARBARBACEIACEI3-3 2007ESC/ESH指南推荐联合指南推荐联合:噻嗪类利尿剂与噻嗪类利尿剂与ACEI，噻嗪类利尿剂与噻嗪类利尿剂与ARB，钙拮抗剂与钙拮抗剂与ACEI，钙拮抗剂与钙拮抗剂与ARB，钙拮抗剂与噻嗪类利尿剂，钙拮抗剂与噻嗪类利尿剂，-受体阻滞剂与二氢吡啶类钙拮抗剂。受体阻滞剂与二氢吡啶类钙拮抗剂。保护心脑肾作用突出：保护心脑肾作用突出：(2009,oct ESH)In no less than 1520%of hypertensive patients,BP control cannot be achieved by
11、a two-drug combination.When three drugs are required,the most rational combination appears to be a blocker of the reninangiotensin system,a calcium antagonist,and a diuretic at effective doses.至少至少1520%高血压患者，需要三联用药：高血压患者，需要三联用药：最合理方案：最合理方案：RAS拮抗剂拮抗剂+CCB+利尿剂利尿剂-Journal of Hypertension 2009,27:2121215
12、8合理联合用药方案：合理联合用药方案：(2009,oct ESH)The combination of two antihypertensive drugs may offer advantages also for treatment initiation,particularly in patients at high cardiovascular risk in which early BP control may be desirable.Whenever possible,use of fixed dose(or single pill)combinations should be
13、preferred,because simplification of treatment carries advantages for compliance to treatment.在高危病人，两药联合还可尽快达标在高危病人，两药联合还可尽快达标应优先应用固定剂量的应优先应用固定剂量的单片剂复方单片剂复方：使治疗简化、顺应性提高使治疗简化、顺应性提高4-2、2007欧洲高血压指南欧洲高血压指南:长效钙通道阻滞剂：长效钙通道阻滞剂：没有强制禁忌证。没有强制禁忌证。推荐用于推荐用于:脑卒中、脑卒中、老年单纯收缩期高血压、老年单纯收缩期高血压、心绞痛、心绞痛、左室肥厚、左室肥厚、颈动脉或冠状动脉
14、粥样硬化、颈动脉或冠状动脉粥样硬化、妊娠妇女、妊娠妇女、黑人高血压等。黑人高血压等。ACEI/ARB类药物的绝对禁类药物的绝对禁忌证忌证 妊娠妊娠血管神经性水肿血管神经性水肿高钾血症高钾血症双侧肾动脉狭窄双侧肾动脉狭窄4-2、2007欧洲高血压指南欧洲高血压指南:ACEI：ACEI优先适应证共优先适应证共10项：项：心力衰竭、左室肥厚、左室功能异常、心力衰竭、左室肥厚、左室功能异常、心肌梗死后、心肌梗死后、糖尿病肾病、非糖尿病肾病、糖尿病肾病、非糖尿病肾病、颈动脉粥样硬化、颈动脉粥样硬化、蛋白尿或微量蛋白尿、蛋白尿或微量蛋白尿、心房颤动心房颤动和和 代谢综合征等代谢综合征等4-2、2007欧洲
15、高血压指南欧洲高血压指南:ARB优先适应证：优先适应证：1.老年患者老年患者2.糖尿病糖尿病3.肾功能不全肾功能不全4.脑卒中脑卒中5.冠心病和心衰冠心病和心衰6.房颤房颤7.代谢综合征代谢综合征Beta阻滞剂：阻滞剂：(2009,June ESH)The totality of evidence now shows different conclusions for different patient populations,he said.For example,for stroke prevention,beta blockers are inferior to calcium anta
16、gonists,but for congestive heart failure prevention,beta blockers are superior to calcium antagonists and similar to other drugs,对脑卒中预防，对脑卒中预防，BB弱于弱于CCB;对心衰，对心衰，BB强于强于CCB-June 16,2009(Milan,Italy)The European Society of Hypertension(ESH)Beta阻滞剂：阻滞剂：(2009,oct ESH)a recent meta-analysis of 147 randomized trials(the largest meta-analysis so far available)reports only a slight inferiority of b-blockers in preventing stroke(17%reduction rather than 29%reduction with other agents),but a similar effect
