高血压诊疗“三部曲”

2015-10-09 佚名 心在线

2015年伊始,中国台湾心脏病学会(TSOC)和高血压学会(THS)联合出台了2015年高血压管理指南。该指南充分考虑了亚洲高血压的流行病学特点,以简单易懂的流程图体现了高血压的防治理念和管理要求,临床实用性强。其所提出的3大流程(诊断流程、治疗流程和未达标后的调整流程)简便可行,值得关注和借鉴。 一、诊断流程 1.一般患者诊室血压≥140/90 mmHg(特殊人群,如合并

2015年伊始,中国台湾心脏病学会(TSOC)和高血压学会(THS)联合出台了2015年高血压管理指南。该指南充分考虑了亚洲高血压的流行病学特点,以简单易懂的流程图体现了高血压的防治理念和管理要求,临床实用性强。其所提出的3大流程(诊断流程、治疗流程和未达标后的调整流程)简便可行,值得关注和借鉴。


一、诊断流程



1.一般患者诊室血压≥140/90 mmHg(特殊人群,如合并糖尿病、冠心病、慢性肾脏病蛋白尿的患者诊室血压≥130/80 mmHg),应进行常规实验室检查,并了解必要的病史。


常规检查包括:血红蛋白和血细胞比容;血清肌酐、肌酐清除率、肾小球滤过率;血钠、钾、钙;空腹血糖;总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇和甘油三酯;血尿酸;尿常规;心电图;X线胸片。


推荐检查:口服糖耐量试验或糖化血红蛋白;超敏C反应蛋白;微量白蛋白定量或蛋白尿;眼底检查;超声心动图;颈动脉超声;家庭血压监测(HBPM)/动态血压监测(ABPM);踝臂指数;脉搏波传导速度。


对于存在并发症的高血压患者应进一步寻找脑、心、肾和血管损害,根据既往史、体格检查或常规检查寻找继发性高血压。


2.2周至1个月间复测诊室血压。如血压<140/90 mmHg(特殊人群<130/80 mmHg),则继续随访。如患者血压为正常高值(120~139/80~89 mmHg,特殊人群120~129/70~79 mmHg),应在3~6个月内行ABPM或HBPM以除外隐匿性高血压。


3.复查血压仍≥140/90 mmHg者,应寻找靶器官损害的证据[包括左室肥厚、微量白蛋白尿、无症状动脉粥样硬化(颈动脉内中膜增厚或主动脉斑块)、踝臂指数<0.9或脉搏波传导速度加快]。如存在靶器官损害,应启动治疗流程。若无靶器官损害,行ABPM或HBPM除外白大衣高血压的可能。


4.如HBPM≥135/85 mmHg或ABPM≥130/80 mmHg,应启动治疗流程。HBPM和ABPM<13585 mmHg者,应给予生活方式干预,并随访3~6个月。


二、治疗流程



1.生活方式调整


指南强调生活方式调整(S-ABCDE)干预高血压。具体措施包括:S(限盐)、A(限酒)、B(减轻体重)、C(戒烟)、D(饮食)、E(锻炼)。


2.药物治疗


药物治疗遵循“PROCEED”原则。P:患者既往用药经验,应仔细考量服药后的不适体验;R:明确患者个体的危险因素,如代谢综合征和糖耐量异常的患者不应首选利尿剂和β受体阻滞剂;O:器官损害;C:禁忌证或不适;E:任何指南仅供参考,专家或医生的判断最为重要;E:需考虑费用或成本,;D:治疗依从性。


对80岁以上老年人,当基线血压≥150/90 mmHg时才考虑药物治疗,目标血压<150/90 mmHg。基线血压≥170/100 mmHg时考虑初始两药联合治疗。3种药物联合不建议作为初始治疗。


指南推荐利尿剂、β受体阻滞剂、钙通道阻滞剂、ACEI、ARB五类降压药作为一线用药。推荐的联合用药方式包括:①ARB+钙通道阻滞剂(A+C);②ACEI+钙通道阻滞剂(A+C);③ARB+噻嗪类利尿剂(A+D);④ACEI+噻嗪类利尿剂(A+D);⑤β受体阻滞剂+钙通道阻滞剂(B+C)。不推荐或禁止的两药联合方式包括:①β受体阻滞剂+利尿剂(心力衰竭除外);②ACEI+ARB;③(ACEI或ARB)+直接肾素抑制剂。


同时指南鼓励使用单片固定复方制剂,一般人群、年龄<80岁、血压≥160/100 mmHg或特殊人群,且年龄<80岁、血压≥150/90 mmHg时,单片固定复方制剂可以作为初始治疗。


三、血压未达标的调整治疗流程



降压药物一般在1~2周达到最大效应的50%~80%,因此,调整治疗的周期应在2~4周。若治疗4周后血压仍未达标,推荐“AT GOALs”法调整治疗。调整治疗首先需再次确定服药的依从性;其次,根据HBPM或ABPM夜间血压情况调整服药时间。采用的调整方案包括:同种药物增大剂量;更换药物或采用联合用药;或单片固定复方制剂;并同时进行生活方式调整及实验室检查评估。


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    2017-06-26 医望无涯

    综合全身,因人而定。

    0

  2. [GetPortalCommentsPageByObjectIdResponse(id=215743, encodeId=7f20215e43ec, content=综合全身,因人而定。, beContent=null, objectType=article, channel=null, level=null, likeNumber=99, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/ajNVdqHZLLDicUw7yoAI4gptl6B3VGw6WZrBwAOwx2SfiafGGQAR5HcSI6IZVGvkthHYWlxfSGeSMz7KiablPqmJhCFP8wLMk7JFEkIFg7iaveU/0, createdBy=4bd02015384, createdName=医望无涯, createdTime=Mon Jun 26 23:55:06 CST 2017, time=2017-06-26, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=156567, encodeId=c9d815656ec7, content=总结的全面,学习了!, beContent=null, objectType=article, channel=null, level=null, likeNumber=106, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20200816/e4675a86ea694f12b82202b320dc2654/12f6b900498349e994ce8f516a584d6a.jpg, createdBy=09431951290, createdName=大爰, createdTime=Fri Nov 18 10:27:39 CST 2016, time=2016-11-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=38782, encodeId=f5b738e8261, content=靶器官损害包括了左室肥厚、微量白蛋白尿、无症状动脉粥样硬化(颈动脉内中膜增厚或主动脉斑块,学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=134, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=a1a01625167, createdName=zhouxue1990, createdTime=Mon Oct 12 19:22:00 CST 2015, time=2015-10-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=38779, encodeId=138938e7999, content=血压要达标, beContent=null, objectType=article, channel=null, level=null, likeNumber=146, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160806/IMG57A5698BDB0244113.jpg, createdBy=32a91358059, createdName=jyzxjiangqin, createdTime=Mon Oct 12 17:49:00 CST 2015, time=2015-10-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=38777, encodeId=3db838e7761, content=降压很重要, beContent=null, objectType=article, channel=null, level=null, likeNumber=129, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTJPXDw7FHXZf9ounibcIkI3fbic3dlp798gIhH5kDDJeJZ4LANiaujtG5m3tbxhE81eZmsR42I0IFFZw/132, createdBy=e2cc1654754, createdName=Sophia2058, createdTime=Mon Oct 12 16:07:00 CST 2015, time=2015-10-12, status=1, ipAttribution=)]
    2016-11-18 大爰

    总结的全面,学习了!

    0

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    2015-10-12 zhouxue1990

    靶器官损害包括了左室肥厚、微量白蛋白尿、无症状动脉粥样硬化(颈动脉内中膜增厚或主动脉斑块,学习了

    0

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    2015-10-12 jyzxjiangqin

    血压要达标

    0

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    2015-10-12 Sophia2058

    降压很重要

    0

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