[2016高血压年会] 陈伟伟:药物治疗时间学思考——基于动态血压监测的个性化治疗

2016-09-28 MedSci MedSci原创

动态血压监测是高血压诊断技术发展史上的重大创新,它可以测量一个人日常生活状态下的血压,因而可以更准确、更全面地反映血压的整体情况,动态血压连续监测的平均值应该作为金标准。在2016年中国高血压年会暨第18届国际高血压及相关疾病学会研讨会关于“血压测量”的专题会上,国家心血管病中心、阜外医院的陈伟伟教授报告了基于动态血压监测的个性化治疗。血压测量与动态血压监测血压测量是了解血压水平、诊断高血压和评估



动态血压监测是高血压诊断技术发展史上的重大创新,它可以测量一个人日常生活状态下的血压,因而可以更准确、更全面地反映血压的整体情况,动态血压连续监测的平均值应该作为金标准。在2016年中国高血压年会暨第18届国际高血压及相关疾病学会研讨会关于“血压测量”的专题会上,国家心血管病中心、阜外医院的陈伟伟教授报告了基于动态血压监测的个性化治疗。

血压测量与动态血压监测

血压测量是了解血压水平、诊断高血压和评估降压疗效的主要手段,是高血压防治的基础性工作。在临床诊疗和人群防治及科学研究工作中,通常采用诊室血压、动态血压和家庭血压3种方法测量血压,其高血压诊断的切点分别为≥140/90 mmHg、≥135/85 mmHg和≥130/80 mmHg(24 h),这其中,动态血压监测是高血压诊断技术发展史上的重大创新,它可以测量一个人日常生活状态下的血压,因而可以更准确、更全面地反映血压的整体情况,发现“隐蔽性高血压”。



血压测量值的即时波动现象与多次测量

从日常临床工作中可以看出,血压的测量值存在一些即时波动现象,血压波动的个体特征包括:杓型/非杓型血压、单纯夜间高血压、单纯晨间高血压、双峰血压、单峰血压和晨峰现象。因此进行多次测量是准确测定血压值的根本途径,多次测量取稳定值更为准确,也更适用于临床。在1190人中开展的“心健康”专项行动进行了10196人-次连续多次血压测量,结果显示,采用二次测量,48.85%的人可得到稳定血压值,而采用三次测量,75.55%的人能得到稳定血压值。 

血压的晨峰现象及其危害

血压的晨峰现象是指起床后2 h内的平均SBP减夜间睡眠时的最低SBP(1 h平均值)≥35 mmHg。晨峰现象有可能导致心脏性猝死、心肌梗死、不稳定性心绞痛和出血性/缺血性脑卒中,这些不良事件特别容易发生在清晨和上午时段,约40%的心肌梗死和29%的心脏性猝死发生在此时段,脑卒中的发生率是其他时段的3~4倍。 

高血压控制情况的评价

目前对高血压控制情况的评价分为诊室达标、全面达标和未达标。其中关键的评价技术即是动态血压测量,动态血压连续监测的平均值应该作为金标准。我们需要做到全面控制高血压,预防高血压引起的心脑血管疾病。因而,控制血压变异度和减少晨峰血压程度成为降压治疗的新目标。在药物治疗方面,应选择长效降压药物(高谷峰比值)和平稳的降压药物(高平滑指数),并注意调整给药时间。 

高血压药物时间治疗学

睡前服用长效平稳的抗高血压药物可以较好地纠正非杓型血压状态,对凌晨高血压的控制疗效明显。对夜间(非杓型)、晨峰及清晨高血压患者的治疗有重要意义。
相关研究表明,与晨起服药相比,睡前服药能更有效地控制高血压。2015年中国高血压杂志上发表的一项研究显示,采用相同的降压药物——硝苯地平控释片30 mg,夜间服药组24 h的平均收缩压低于清晨服药组。夜间服药组清晨收缩压上升的速度低于清晨服药组。回归分析示清晨收缩压上升的速度及白天的收缩压水平是心脑血管事件发生的危险因素。
高血压患者睡前服用降压药物的优势在于,它能够有效地控制晨峰现象、夜间高血压、清晨高血压,实现全面达标,减少体位性低血压和心血管事件(J型曲线)。




基于动态血压监测的个性化治疗

但更重要的是对高血压患者进行个性化治疗。首先,要掌握血压波动的类型,然后在血压高峰前服药,最后实现全天平稳达标。要实现个体化精准治疗,需要通过动态血压了解个体的血压波动特征及节律,从而做到根据个体调整给药时间,实现全面达标。睡前服药是个体化治疗不可忽视的方法。动态血压测量的基本指标包括:24小时平均血压<130/80 mmHg、日间平均血压<135/85 mmHg、夜间平均血压<120/70 mmHg。动态血压更大的价值是监测夜间高血压、晨峰现象和清晨高血压。

因此我们要意识到,动态血压连续监测的平均值作为金标准应该尽早纳入相关指南,还应鼓励有条件的地区尽早开展,以实现全面达标。

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encodeId=a43113e1698b, content=谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:05 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137133, encodeId=679e13e13311, content=学习啦,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=127, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:04:35 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137132, encodeId=7e8313e1322d, content=动态血压监测是高血压诊断技术发展史上的重大创新,, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:03:27 CST 2016, time=2016-09-28, status=1, ipAttribution=)]
    2016-09-28 知难而进

    继续关注!

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=2022159, encodeId=50a4202215922, content=<a href='/topic/show?id=348a3311836' target=_blank style='color:#2F92EE;'>#动态血压监#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33118, encryptionId=348a3311836, topicName=动态血压监)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=85df2500173, createdName=654699882_84926986, createdTime=Mon Jan 23 12:40:00 CST 2017, time=2017-01-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1992648, encodeId=7f5019926486a, content=<a href='/topic/show?id=f68c6465315' target=_blank style='color:#2F92EE;'>#治疗时间#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=105, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=64653, encryptionId=f68c6465315, topicName=治疗时间)], attachment=null, authenticateStatus=null, 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objectType=article, channel=null, level=null, likeNumber=81, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33119, encryptionId=e7543311913, topicName=动态血压监测)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=d7096025384, createdName=lsndxfj, createdTime=Fri Sep 30 07:40:00 CST 2016, time=2016-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1508987, encodeId=9ed1150898e09, content=<a href='/topic/show?id=a7c83311e88' target=_blank style='color:#2F92EE;'>#动态血压#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=33117, encryptionId=a7c83311e88, topicName=动态血压)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=2c1e10025437, createdName=limedical1977, createdTime=Fri Sep 30 07:40:00 CST 2016, time=2016-09-30, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137171, encodeId=29fe13e171e4, content=继续关注!, beContent=null, objectType=article, channel=null, level=null, likeNumber=94, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:28:33 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137170, encodeId=c7cb13e1701b, content=动态血压更大的价值是监测夜间高血压、晨峰现象和清晨高血压。, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:55 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137169, encodeId=a43113e1698b, content=谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:05 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137133, encodeId=679e13e13311, content=学习啦,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=127, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:04:35 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137132, encodeId=7e8313e1322d, content=动态血压监测是高血压诊断技术发展史上的重大创新,, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:03:27 CST 2016, time=2016-09-28, status=1, ipAttribution=)]
    2016-09-28 知难而进

    动态血压更大的价值是监测夜间高血压、晨峰现象和清晨高血压。

    0

  8. 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encodeId=a43113e1698b, content=谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:05 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137133, encodeId=679e13e13311, content=学习啦,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=127, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:04:35 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137132, encodeId=7e8313e1322d, content=动态血压监测是高血压诊断技术发展史上的重大创新,, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:03:27 CST 2016, time=2016-09-28, status=1, ipAttribution=)]
    2016-09-28 知难而进

    谢谢分享!

    0

  9. 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encodeId=29fe13e171e4, content=继续关注!, beContent=null, objectType=article, channel=null, level=null, likeNumber=94, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:28:33 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137170, encodeId=c7cb13e1701b, content=动态血压更大的价值是监测夜间高血压、晨峰现象和清晨高血压。, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:55 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137169, encodeId=a43113e1698b, content=谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=88, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:05 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137133, encodeId=679e13e13311, content=学习啦,,, beContent=null, objectType=article, channel=null, level=null, likeNumber=127, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:04:35 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137132, encodeId=7e8313e1322d, content=动态血压监测是高血压诊断技术发展史上的重大创新,, beContent=null, objectType=article, channel=null, level=null, likeNumber=103, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/mStl88fu4NfdY7yem1P7bRvOP6z0jKsBoYR8ezfAricY7meQWcte7LRJsWHVn0CnPJg2JuQmevR0DoFmmEib5QLD2kNESBESQT/0, createdBy=59191706502, createdName=医路开来, createdTime=Wed Sep 28 19:03:27 CST 2016, time=2016-09-28, status=1, ipAttribution=)]
    2016-09-28 医路开来

    学习啦,,

    0

  10. 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encodeId=29fe13e171e4, content=继续关注!, beContent=null, objectType=article, channel=null, level=null, likeNumber=94, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:28:33 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137170, encodeId=c7cb13e1701b, content=动态血压更大的价值是监测夜间高血压、晨峰现象和清晨高血压。, beContent=null, objectType=article, channel=null, level=null, likeNumber=147, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160811/IMG57AC91915ACA64463.jpg, createdBy=9c351934462, createdName=知难而进, createdTime=Wed Sep 28 19:27:55 CST 2016, time=2016-09-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=137169, 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    2016-09-28 医路开来

    动态血压监测是高血压诊断技术发展史上的重大创新,

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