不同人群降压目标值的探讨

高血压是严重威胁人类健康的疾病,同时作为心脑血管疾病的高危因素,高血压患者往往合并有一种或多种慢性疾病,由此引起的病死率已升至所有疾病病死率的首位,因此合理的控制血压显得至关重要。近来,关于高血压人群降压目标值的问题引起广泛争议,现将对缺血性心脏病患者、糖尿病患者、脑血管疾病患者、慢性肾病患者和老年人高血压的降压目标值做一综述。     

ASH position paper: Adherence and persistence with taking medication to control high blood pressure

Nonadherence and poor or no persistence in taking antihypertensive medications results in uncontrolled high blood pressure, poor clinical outcomes, and preventable health care costs. Factors associated with nonadherence are multilevel and relate not only to the patient, but also to the provider, health care system, health care organization, and community. National guideline committees have called for more aggressive approaches to implement strategies known to improve adherence and technologies known to enable changes at the systems level, including improved communication among providers and patients. Improvements in adherence and persistence are likely to be achieved by supporting patient self-management, a team approach to patient care, technology-supported office practice systems, better methods to measure adherence, and less clinical inertia. Integrating high blood pressure control into health care policies that emphasize and improve prevention and management of chronic illness remains a challenge. Four strategies are proposed: focusing on clinical outcomes; empowering informed, activated patients; developing prepared proactive practice teams; and advocating for health care policy reform. With hypertension remaining the most common reason for office visits, the time is now.     

Gender disparities in blood pressure control and cardiovascular care in a national sample of ambulatory care visits

The purpose of this study was to provide an analysis of gender-based disparities in hypertension and cardiovascular disease care in ambulatory practices across the United States. Using data from the 2005 National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey, we conducted a cross-sectional analysis of patient visits with their primary care providers and examined the association between gender and blood pressure control, use of any antihypertensive medication or initiation of new therapy for patients with uncontrolled hypertension, and receipt of recommended therapy for select cardiovascular conditions. Multivariable models were estimated to examine the association between gender and each outcome controlling for other variables. A total of 12 064 patient visits were identified (7786 women and 4278 men). Among patients with hypertension, women were less likely than men to meet blood pressure control targets (54.0% versus 58.7%; P<0.02). In multivariate analyses, women aged 65 to 80 years were less likely than men to have controlled hypertension (odds ratio: 0.62; 95% CI: 0.45 to 0.85). There was no association between gender and use of any antihypertensive medication or initiating a new therapy among patients with uncontrolled hypertension. In multivariate analyses, women were less likely than men to receive aspirin (odds ratio: 0.43; 95% CI: 0.27 to 0.67) and beta-blockers (odds ratio: 0.60; 95% CI: 0.36 to 0.99) for secondary prevention of cardiovascular disease. Our study highlights the persistent gender disparities in blood pressure control and cardiovascular disease management and also reveals the inadequate delivery of cardiovascular care to all patients.     

Hypertension in hemodialysis patients

Hypertension is very common and often poorly controlled in patients undergoing chronic hemodialysis. While high blood pressure has been documented to adversely impact several intermediate outcomes of cardiovascular disease, whether hypertension is an independent risk factor for mortality in this population is not clear. Expansion of extracellular fluid volume is the major pathophysiologic mechanism for the development of hypertension in these patients; however, alterations in other humoral mechanisms also play a significant role. Optimization of volume status is, therefore, the cornerstone of therapy with additional use of antihypertensive medications as needed. Good quality prospective studies are urgently needed to define the measurement techniques and blood pressure goals, and to develop therapeutic strategies for more effective management of hypertension in this high-risk population.     

Overcoming barriers to evidence-based diabetes care

Despite evidence-based guidelines that advocate aggressive management of hyperglycemia, hypertension, and hyperlipidemia, patients with diabetes continue to suffer from high rates of cardiovascular and microvascular complications and can expect a lifespan reduction of 10 to 15 years. Our current inability to effectively and widely translate clinical evidence into usual practice represents a major barrier to reducing the burden of diabetes and its complications. Diabetes care represents a complex interaction between patients (and their families and communities), physicians (and other providers), and the health care system. Because multi-drug regimens are typically required to control hyperglycemia and the diabetes-related risk factors of hypertension and hyperlipidemia, polypharmacy is the natural consequence of providing evidence-based medical care to patients with type 2 diabetes. Within this context, we review the current evidence regarding the following three potential barriers to effective care: 1) Medication adherence in the setting of complex medical regimens, 2) Lack of medication adjustment among patients above risk factor goals, and 3) Limitations of currently organized care systems to manage complex chronic diseases such as diabetes. We also describe recent results of controlled trials of population-level, informatics-based interventions to improve diabetes care.     

Blood pressure control and perceived health status in African Americans with subclinical hypertensive heart disease

The role of antihypertensive therapy in reducing the risk of cardiovascular complications such as heart failure is well established, but the effects of different blood pressure goals on patient-perceived health status has not been well defined. We sought to determine if adverse effects on perceived health status will occur with lower blood pressure goals or more intensive antihypertensive therapy. Data were prospectively collected as a part of a single center, randomized controlled trial designed to evaluate standard (Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure-compliant) versus intense (<120/80 mm Hg) blood pressure goals for patients with uncontrolled hypertension and subclinical hypertensive heart disease. Blood pressure management was open label, and health status was measured at 3-month intervals over 1 year of follow-up using the short-form (SF)-36. Mixed linear models were constructed for each of the SF-36 summary scores. One hundred twenty-three (mean age 49.4 ± 8.2; 65% female; 95.1% African American) patients were randomized, 88 of whom completed the protocol. With the exception of a decrease in perceived health transition, health status did not change significantly on repeat measurement. Lower blood pressure goals and more intensive antihypertensive therapy appear to be well tolerated with limited effects on patients' perception of health status.     

2009 Canadian Hypertension Education Program recommendations: The scientific summary – an annual update

The present report highlights the key messages of the 2009 Canadian Hypertension Education Program (CHEP) recommendations for the management of hypertension and the supporting clinical evidence. In 2009, the CHEP emphasizes the need to improve the control of hypertension in people with diabetes. Intensive reduction in blood pressure (to less than 130/80 mmHg) in people with diabetes leads to significant reductions in mortality rates, disability rates and overall health care system costs, and may lead to improved quality of life. The CHEP recommendations continue to emphasize the important role of patient self-efficacy by promoting lifestyle changes to prevent and control hypertension, and encouraging home measurement of blood pressure. Unfortunately, most Canadians make only minor changes in lifestyle after a diagnosis of hypertension. Routine blood pressure measurement at all appropriate visits, and screening for and management of all cardiovascular risks are key to blood pressure management. Many young hypertensive Canadians with multiple cardiovascular risks are not treated with antihypertensive drugs. This is despite the evidence that individuals with multiple cardiovascular risks and hypertension should be strongly considered for antihypertensive drug therapy regardless of age. In 2009, the CHEP specifically recommends not to combine an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker in people with uncomplicated hypertension, diabetes (without micro- or macroalbuminuria), chronic kidney disease (without nephropathy [micro- or overt proteinuria]) or ischemic heart disease (without heart failure).     

农村自报高血压患者危险因素及治疗行为分析

目的:了解北京农村自报高血压患者危险因素、高血压相关知识及治疗状况。方法:2002年在北京昌平、顺义、房山、大兴四区随机抽取25～64岁的农村户口居民1605人进行行为危险因素调查。共获得自报高血压患者360人。结果:高血压患者缺乏锻炼率为62.2%,超重和肥胖率为73.3%。高血压患者饮酒、多食盐对血压的影响及高血压可导致冠心病和脑卒中知晓率较高,知晓率超过80%。高血压诊断标准知晓率偏低,仅为29.4%。高血压患者获得健康知识的主要途径为广播和电视(83.9%)。85.3%高血压患者近1个月曾服降压药,高血压患者降压药物80.8%从医生那里获得,就医的主要场所是村医疗点(65.5%),59.2%至少每月测量1次血压。结论:高血压患者主要危险因素为超重、肥胖和缺乏运动,患者有关高血压的相关知识需要普及,提高基层医生对高血压患者的个体治疗和健康教育,发挥大众媒体作用,对改变农村高血压患者行为和血压控制具有重要意义。     

Treatment of Hypertension in the Institutionalized Elderly

The goal of antihypertensive therapy in elderly institutionalized persons is to reduce the blood pressure to <140/90 mm Hg if possible. Elderly persons with diastolic hypertension should have their diastolic blood pressure lowered to 80–85 mm Hg. Elderly persons with stage 2 or 3 hypertension, stage 1 hypertension and target organ damage, evidence of clinical cardiovascular disease, or diabetes mellitus should be treated with antihypertensive drug therapy immediately in addition to lifestyle modification. The initial antihypertensive drug in elderly persons without associated medical conditions should be a diuretic or β-blocker because these drugs have been shown to decrease cardiovascular morbidity and mortality in controlled clinical trials. The initial antihypertensive drug in elderly persons should depend on the associated medical condition. If a second antihypertensive drug is indicated, a drug from another class should be administered. If a diuretic is not the initial drug, it is usually indicated as the second drug. If the antihypertensive response is inadequate after reaching the full dose of two classes of drugs, a third drug from another class should be added. Causes of secondary hypertension should be identified and treated.     

Dietary supplements and hypertension: potential benefits and precautions

Dietary supplements (DSs) are used extensively in the general population and many are promoted for the natural treatment and management of hypertension. Patients with hypertension often choose to use these products either in addition to or instead of pharmacologic antihypertensive agents. Because of the frequent use of DS, both consumers and health care providers should be aware of the considerable issues surrounding these products and factors influencing both efficacy and safety. In this review of the many DSs promoted for the management of hypertension, 4 products with evidence of possible benefits (coenzyme Q10, fish oil, garlic, vitamin C) and 4 that were consistently associated with increasing blood pressure were found (ephedra, Siberian ginseng, bitter orange, licorice). The goals and objectives of this review are to discuss the regulation of DS, evaluate the efficacy of particular DS in the treatment of hypertension, and highlight DS that may potentially increase blood pressure.     

Managing Hypertension: State of the Science

Hypertension management is both routine and a challenge. Updated guidelines emphasize the need to achieve increasingly stringent blood pressure goals to reduce cardiovascular morbidity and mortality; however, the blood pressure of many patients who have been diagnosed with hypertension is not well controlled. Treating prehypertension nonpharmacologically may preempt the progression to hypertension, whereas early and aggressive management of hypertension with antihypertensive agents reduces short- and long-term cardiovascular risk. Treatment decisions should follow current guidelines while evaluating recently published clinical studies. When choosing between agents from different therapeutic classes or combining agents, physicians should consider current and targeted blood pressure levels, the patient's demographic profile, the presence or absence of compelling cardiovascular and metabolic indications, other comorbidities, and concurrent medication(s).     

家庭血压监测的临床应用

血压测量是诊断高血压病的基本手段,目前主要有三种方法评价血压：诊所偶测血压、动态血压监测和家庭血压监测。家庭血压监测方便、经济,已有大量数据表明：与诊所偶测血压相比,家庭血压监测是评估心血管疾病风险的一个更好的预测因子。同时它能改善高血压患者的治疗依从性,有利于血压控制,监测降压药物疗效,减少医疗费用。另外对鉴别白大衣高血压和隐性高血压也很有帮助。     

Prospective surveillance of hypertension in firefighters

The authors evaluated blood pressure and antihypertensive medication use in 334 firefighters in an occupational medical surveillance program. Firefighters received written summaries of their examination results, including blood pressures, and were encouraged to see their personal physicians for any abnormal results. The mean age of the participants was 39 years, and the vast majority were men (n=330). The prevalence of hypertension was 20% at baseline (1996), 23% in 1998, and 23% in 2000. Among firefighters with high blood pressure readings, only 17%, 25%, and 22% were taking antihypertensive medications at the baseline, 1998, and 2000 examinations, respectively. Medical surveillance was effective in detecting hypertension in firefighters; however, after 4 years of follow-up, only 42% of hypertensives were receiving treatment with medications, including only 22% of firefighters with hypertensive readings. Overall, 74% of hypertensives were not adequately controlled. Possible reasons for low treatment rates may be the inadequate recognition among primary care physicians that mild hypertension is a significant risk factor for cardiovascular disease.     

Management of Hypertension Following Hurricane Katrina: A Review of Issues in Management of Chronic Health Conditions Following a Disaster

Following Hurricane Katrina many residents of the Gulf Coast had difficulties managing their cardiovascular risk factors especially hypertension. Care for patients with chronic diseases can be an enormous challenge after any disaster. The difficulties are compounded if the population prior to the disaster was already experiencing major health disparities. Focusing on hypertension we review the issues confronted by residents of the Gulf Coast following Hurricane Katrina in managing their health care. In addition, we address possible solutions to these problems. Pre-disaster preparedness is essential and requires multidisciplinary efforts including patient education. Being certain that patients with chronic diseases have enough medical supplies to last through the immediate disaster period and for portability of medical records are essential interventions in maintaining control of blood pressure in the post-disaster period.     

Prevention of arteriosclerosis. Importance of the treatment of arterial hypertension

In most European countries and Northern America, cardiovascular diseases induced by atherosclerosis are the most common cause of death in older people. People surviving acute myocardial infarction or stroke suffer often by disabilities or handicaps. The lifelong care of such patients is expensive and plays a major role for increment of costs in public health systems. Prevention of atherosclerosis will reduce cardiovascular morbidity and mortality, enhance quality of life and prolong lifetime of patients. Therefore the worldwide accepted risk factors of atherosclerosis have to be treated consequently and early enough within the meaning of primary prevention. Hypertension is one of the six major cardiovascular risk factors and is defined as elevated blood pressure above 140/90 mmHg. In case of hypertension, diagnostic efforts has to be focussed on detection of additional cardiovascular risk factors, secondary forms of hypertension, end organ damage or associated diseases. All therapeutic strategies are based on life style changes, which cover weight reduction, sodium restriction, controlled alcohol consumption and increment in physical activity. Pharmacotherapy will be added in regard to the global risk of the patient and the success of the life style changes. Selection of antihypertensives and their optimal combination will be determined by associated diseases (compelling indication), side effects and individual response in blood pressure. Goal of treatment is the normalization of blood pressure below 140/90 mmHg independent of age or sex. In diabetics and in case of nephropathy the goal is set lower (below 130/80 mmHg).There is strong evidence that reduction in blood pressure is followed by a decrease in the incidence of myocardial infarction, stroke, heart failure, nephropathy, and even in cardiovascular mortality. The success of antihypertensive therapy is greater in high risk patients like older people, patients with isolated systolic hypertension or diabetics. Risk reduction correlates well with the degree in blood pressure reduction. However, to minimize cardiovascular risk in hypertensives all additional risk factors have to be treated too.     

Moving beyond guidelines: Are report cards the answer to high rates of uncontrolled hypertension?

Hypertension control rates remain alarmingly low worldwide despite the extensive evidence for decreased rates of cardiovascular, cerebrovascular, and renal events in response to blood pressure (BP) lowering to recommended targets. Several classes of antihypertensive drugs are available, which in combination can produce major decreases in BP, with minimal side effects. Moreover, most patients only have mild hypertension and, in general, can be controlled to < 140/90 mm Hg by proper combinations of two antihypertensive drugs. Although patient-related factors clearly contribute to poor control of hypertension, physician-related factors, particularly “passive” therapeutic inertia, are as responsible if not more so. Recent studies clearly indicate that monitoring performance of individual physicians and providing feedback on the care delivered by them can move treatment of hypertension to BP control rates in the 60% to 70% range. If health care organizations would implement this approach, enormous benefits could be expected for the prevention of cardiovascular and cerebrovascular disease.     

Characteristics of inner-city African-Americans with uncontrolled hypertension

Hypertension control rates are low in inner-city African-Americans. This article describes the demographic and clinical characteristics of uncontrolled hypertension in this population. During a single outpatient visit, normotensive and hypertensive African-American volunteers (age 18 to 55) completed a questionnaire, and the following measurements were obtained: blood pressure (BP), anthropometric measures, and blood chemistries. Volunteers received a gift for participating. Of the 3,943 volunteers, 52% were hypertensive. Among the hypertensives, 75% were aware of hypertension, and of those aware, 76% were on antihypertensive drug therapy. BP was uncontrolled in 78% of all hypertensives and in 60% of those on drug therapy. Males were two times more likely than females to have uncontrolled hypertension. Compared to participants with controlled hypertension, those with uncontrolled hypertension were younger, had lower body mass index, and were more likely to report smoking cigarettes, drinking alcohol, and less likely to report restricting dietary salt. Lack of hypertension control was primarily related to the lack of antihypertensive drug therapy rather than to inadequate drug therapy. Uncontrolled hypertension was associated with several self-reported aversive health behaviors, including not taking antihypertensive medications. Strategies to improve hypertension control should be directed to patients and to health care providers.     

Physician-nurse team approaches to improve blood pressure control

Hypertension is an asymptomatic chronic disease that contributes to the development of serious health problems including coronary artery disease, chronic renal failure, and stroke. Despite published guidelines addressing goals for the treatment of hypertension, control rates (defined as a blood pressure <140/90 mm Hg) have not increased in recent years, and uncontrolled hypertension remains a serious public health issue. Both patient- and provider-related factors contribute to these poor control rates, and new approaches to the management of hypertension must be sought. In this review, we describe unique physician-nurse team approaches to improve the control of hypertension both in a subspecialty hypertension practice and in a primary care clinic setting. By implementing practice models that result in sustainable improvements in blood pressure control rates, the morbidity and mortality resulting from target organ damage and ensuing costs to society may be expected to decline as well.     

糖尿病患者血压控制目标的争论

我国糖尿病患病率和患者数量正逐年增长,已成为我国主要公共健康问题之一,心血管疾病是导致糖尿病患者发病和死亡的主要原因。糖尿病、高血压均为心血管疾病危险因素,常相互伴发,研究表明对糖尿病患者进行降压治疗可降低其心血管事件风险。既往诸多学术组织建议糖尿病合并高血压患者血压值应〈130／80mmHg（1mmHg=0．1333kPa）,但近几年相关试验研究及Meta分析结果对此提出质疑,2013版ADA指南及ESH／ESC高血压指南对糖尿病患者血压目标值也进行了修订。