中国高血压联盟专家热议:高血压患者的心率管理-不宜操之过急

2016-05-09 UMED UMED

导语: 4月初,Journal of Hypertension杂志在线发表了ESH关于心率增快的高血压患者管理的第二次共识会议的声明,引起了对高血压患者心率管理的关注。昨天晚上,一篇文不对题的媒体报道更是在高血压联盟理事群中引起了各位专家对高血压患者的心率管理的热议。现将各位专家的观点整理如下与读者分享。 张宇清  阜外心血管病医院 “高血压患者应常规测量心率,

导语:
4月初,Journal of Hypertension杂志在线发表了ESH关于心率增快的高血压患者管理的第二次共识会议的声明,引起了对高血压患者心率管理的关注。昨天晚上,一篇文不对题的媒体报道更是在高血压联盟理事群中引起了各位专家对高血压患者的心率管理的热议。现将各位专家的观点整理如下与读者分享。

张宇清  阜外心血管病医院

“高血压患者应常规测量心率,但心率的目标值仍然无解。ESH关于心率增快的高血压患者管理第二次共识最终的建议是需要进行深入研究。”

冯颖青  广东省人民医院

“有流行病学资料支持心率增快与预后相关,然而在高血压人群中没有以控制心率为目标的临床研究, 因此只能提出应关注,但无法提出“度”在哪? 但这份共识确实很好地提出了规范的静息心率监测。”

孙宁玲  北京大学人民医院

“应当规范静息心率的监测。”

牟建军  西安交通大学医学院第一附属医院

“关键是缺乏独立于降低血压之外减慢心率带来临床获益的证据!此外,健康成人心率偏快者,除建议其运动锻炼以外,是否需用β受体阻断剂?能否获益?也是很值得探究的问题!”

陈鲁原  广东省人民医院

“@牟建军 言之有理。还有实践中遇到的一些具体问题:β阻滞剂联合降压受限,心率达标血压不达标时就会遇上,抑或血压十分理想但心率未控制,此时调整降压方案是否会血压波动?”

刘靖 北京大学人民医院

“这个问题几年前曾与Williams教授 和Parati教授沟通过,大家的看法其实基本一致,观点在文中有所体现,值得关注。感谢宇清提供最新文献,使我们得以了解国际同行的观点和领袖的意见,使我们看得更清,更远。总之,高血压患者的心率管理:悬而未决,不宜操之过急。”

王文  阜外心血管病医院

“高血压伴心率增快是心血管危险增加,需要关注。减慢心率是否可降低心血管风险需要临床试验的评估。”

郭艺芳  河北省人民医院

“心率与血压是最为重要的生命体征之一,伴有心率增快的高血压患者其整体心血管危险水平进一步升高。关于心率增快与高血压之间的内在关联尚未完全清楚,因此可否应用降低心率的药物(特别是选择性β-1-受体阻滞剂)进行治疗尚存争议。

回顾近年来循证医学所走过的历程,我们曾遇到过很多“悖论”:对于存在严重器质性心脏病的患者,室性心律失常可以显著增高死亡率,然而CAST试验发现,应用Ic类抗心律失常药虽能显著减少心律失常数量,却进一步增高了患者死亡率;高密度脂蛋白胆固醇水平降低与不良心血管结局密切相关,但HPS2与AIM-HIGH等研究却显示,应用药物升高高密度脂蛋白胆固醇未能使患者获益;稳定性冠心病患者心率增快与不良预后密切相关,但SIGNIFY研究显示,应用伊伐布雷定降低心率也未能改善患者预后。

人体的生命活动是非常复杂的,目前我们所能了解的只是浮在水面上的冰山一角。流行病学研究对于临床实践具有重要指导意义,但流行病学研究只可为临床研究提供初步线索与方向,而不能做为制定临床决策的直接依据。

对于高血压患者,心率增快是危险因素还是伴随现象仍有待探讨,不应因为心率增快的高血压患者具有更高的危险性就简单地认为应该使用减慢心率的药物进行干预。正是由于这种原因,欧洲高血压协会的专家共识声明对于选择性β1受体阻滞剂在高血压患者中的应用做出了谨慎但灵活的建议,而未简单的推荐为所有伴心率增快的高血压患者使用此类药物。部分高血压患者存在心率增快相关的临床症状,应用β-受体阻滞剂控制心率当然是合理的。但对于大多数高血压患者,还是应该将降低血压作为第一要务,根据现行指南原则应用一线降压药物积极控制血压并使之持久达标。

对于高血压患者,将心率作为干预目标尚缺乏充分证据。过分强调高血压患者的心率控制,可能不利于整个人群的血压管理。”

祝之明  第三军医大学大坪医院

“在有心血管病基础上的心率增快可升高心血管风险,目前对此质疑相对较少。问题是普通无心血管病人群,这一假设是否还存立?β受体阻断剂的效应较为广泛,在心率不快时使用对心率影响有限,可能产生其他效益。如同对血压不高的心衰与心梗患者使用ACEI不是为了降压。”

李勇  上海华山医院

“什么是药?没有病的人为什么要服药呢?体检未确诊有心血管疾病或其它基础疾病,但心率快,自觉无不适,是否需要服药?如果自觉时有心悸,是否应服药?服药的目的是减轻心悸症状,还是减慢心率?减慢到什么水平?如果心率减慢了仍感心悸,而未见心律失常或其它疾病,那么减慢心率有临床意义吗?”

陈鲁原  广东省人民医院

“准确的讲是伴有“高交感”的高血压患者心血管风险增高,但是心率不能完全代表交感激活。某些白大衣高血压心率并不快。“

牟建军  西安交通大学医学院第一附属医院

“这个很有意思,人们都很关注,希望有研究探索!但目前沒证据!个人认为目前只能建议运动控制心率。美国运动医学会强调:中等强度、有氧运动更有效!”

周晓芳  四川省人民医院

“高血压患者的心率管理,确实是临床上一道尚未解决的难题。欧洲专家共识为临床医生提供了决策的建议,但仍然有很多问题悬而未决……。郭教授提到的“悖论”,这些年学界经历不少。我们的患者为医学研究贡献出了他们的健康,以至生命。理论研究与临床实践之间的差距,可能部分源于人体的复杂性。而对此,也许我们还知之甚少。简单的用药物将病人、健康人的心率“统一”管理,也许又是一个悖论。”

张承宗  天津医科大学第二医院

“病因检查是重要的。但是高血压伴有心率增快,β受体阻滞剂如果没有禁忌症,作为降压治疗的药物同时控制心率应该是有益的。在注意个体化的前提下,一般来说窦性节律脉搏和心率清晨醒来安静状态≥50次/分的正常窦性节律,没有心排血量降低表现,应该是非常合适的,至少没有反作用。对高血压当然没有一致的改善预后的试验结果,个体化还是主要的,首先是降压!然而,收缩功能衰竭患者降低心率大于或等于55次/分是有循证医学根据的。当然应该强调,一是逐渐下降,二是个体化,能够耐受!冠心病心绞痛患者降低心率也有益。当然没有心脏病者主要是保持健康的生活方式,没有必要服药降心率,如果是快速性心律失常则另当别论!”

张新军    四川大学华西医院

“交感异常激活是高血压患者心血管事件风险增加的重要原因,而心率增快仅仅是交感活化状态的标记。将心率指标作为高血压患者预后的预测指标是适宜的,但作为干预靶点缺乏依据。现有研究证据支持抑制高血压患者长期、慢性、过度的交感激活是控制血压、减少心血管事件的重要干预靶点,通过抑制交感神经过度激活(通常伴随心率减慢)能够显著降低心血管事件风险,而仅仅减慢心率本身并不能改善患者预后。”

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    2018-12-16 12177770m58暂无昵称

    学习了

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    2016-05-13 QQ6709219e

    好好学习',希望多一些这样的文章

    0

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    2016-05-11 zexyw04
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    2016-05-09 stead

    很不错,学习了

    0