2014高血压指南：清晨血压管理

两种临床常用CCB类降压药清晨血压控制情况的比较作者：杨洪刚来源：《中国当代医药》2014年第34期[摘要] 目的观察本院目前常用的两种CCB类降压药苯磺酸氨氯地平与硝苯地平控释片在清晨血压控制方面的疗效异同。

方法选取2013年3月～2014年3月在本院门诊就诊的158例轻、中度原发性高血压患者，按照统一设计的观察指标和分析内容，在征得患者同意后，进行初始信息收集。

对资料完整的患者按照服用降压药物的不同分为观察组（n=82）和对照组（n=76），观察组应用苯磺酸氨氯地平片5 mg，1次/d，对照组应用硝苯地平控释片30 mg，1次/d，分别监测用药后1、4、8周的清晨血压，比较两组患者清晨血压达标情况。

结果治疗1周后对照组血压达标率为32.9%，高于观察组的19.5%，差异有统计学意义（P0.05）；治疗8周后观察组血压达标率为65.9%，高于对照组的60.5%，但差异无统计学意义（P>0.05）。

结论苯磺酸氨氯地平和硝苯地平控释片治疗高血压的效果一致，没有明显差异，但是对于清晨时段血压较高的患者，苯磺酸氨氯地平具有一定优势。

[关键词] 原发性高血压；清晨血压；长效降压药；达标率[中图分类号] R972+.4 [文献标识码] A [文章编号] 1674-4721（2014）12（a）-0094-03高血压是一种以动脉血压持续升高为主要表现的慢性疾病，可导致心、脑、肾等重要脏器损害等严重并发症，致残、致死率高，给患者造成极大痛苦，并给家庭造成沉重负担。

高血压的防治已成为全球最大的公共社会问题[1]。

人们推测清晨血压的骤升是发生恶性心脑血管事件的危险因素之一[2]，因此，清晨血压达标成为高血压控制疗效的重要监测指标。

近几年，我国高血压的患病率明显增高。

估算2012年全国高血压患者约2.66亿[3]。

有效地控制血压能明显减少严重并发症。

本研究观察本院目前常用的两种CCB类降压药苯磺酸氨氯地平与硝苯地平控释片在清晨血压控制方面的疗效异同。

高血压指南回顾和解读在中国，30％的成年人患有高血压，而50％~75％的脑卒中和40％~50％的心肌梗死发生与血压升高有关。

全国每年由于血压升高而导致的过早死亡人数高达200万，直接医疗费用每年至少达366亿元[1]。

中国疾病预防控制中心周脉耕研究员等[2]在《柳叶刀》杂志在线发表了1990~2013年中国的死因变化。

研究显示，1990年我国年龄校正的心血管病死亡为389.3/10万人，2013年则为307.18，降幅达到21％。

总体上看，我国年龄标化心血管死亡已出现下降拐点，这与我国高血压的防控是密不可分的。

纵观对所有疾病的管理，高血压的管理堪称典范，最早写出了指南，进行规范化管理；最先提出定量的治疗目标（140/90mmHg 或130/80mmHg），定期对降压药物进行评价等。

2015年又有哪些新的高血压指南发表？这些指南对血压目标设定和对各种降压药物地位的评价？已引起人们的关注和期待。

本文将按2015年新指南发表时间的顺序，逐一进行简要的回顾和解读，并就2015年最新发表高血压治疗临床证据对即将修改的高血压指南的影响进行展望。

1 2015年新发布的3项高血压指南简要回顾1.1 2015中国台湾地区高血压管理指南2014年12月中国台湾心脏病学会（TSOC）和高血压学会（THS）联合出台2015年高血压管理指南（以下简称新指南），在线发表于JAMA 杂志[3]。

该指南强调家庭血压监测（HBPM）和动态血压监测（ABPM）的重要性，以便更好地检出夜间高血压、晨起高血压、白大衣高血压和隐性高血压；该指南未采纳欧洲与美国降压目标宽松化的观点，认为糖尿病、冠心病、合并蛋白尿的慢性肾脏病以及接受抗栓治疗预防卒中的患者，血压靶目标值＜130/80mmHg，其他患者血压目标值＜140/90mmHg，80岁以上老年人血压目标值＜150/90mmHg；生活方式调整是所有高血压治疗的基础，包括S-ABCDE（限盐、限酒、减轻体重、戒烟、饮食、锻炼）几方面。

清晨血压临床管理中国专家指导建议高血压是一种常见疾病，会给人体各个器官造成损伤。

而清晨血压特别重要，它与心血管疾病和脑卒中的风险密切相关。

中国专家制定了一些指导建议，以帮助医生和患者更好地管理高血压。

高血压的临床管理高血压有许多治疗方法，其中包括药物治疗、非药物治疗和手术治疗。

治疗的目标是使患者的血压降至正常水平，并预防心血管事件的发生。

对于大多数高血压患者来说，清晨血压的管理尤为重要。

清晨血压的意义清晨血压指的是在早晨醒来前和进食前的血压。

清晨血压的升高与心血管疾病和脑卒中的风险密切相关。

事实上，多项研究显示，清晨血压升高是心血管事件发生的独立危险因素。

此外，清晨血压升高与全天血压水平的升高和高血压病程的恶化也有关系。

指导建议以下是国内专家对清晨血压管理的一些指导建议：1.监测清晨血压，并在早晨醒来前和进食前测量血压。

2.对于诊断为高血压的患者，建议使用长效药物控制清晨血压。

3.对于永久性起搏器患者，清晨血压监测更为困难，在排除反复刺激或疾病恶化后，建议加强治疗以控制血压。

4.对于伴有睡眠呼吸暂停综合征的患者，建议采取有效的非药物治疗和药物治疗以控制清晨血压。

5.对于中年和老年人，建议注意保持规律作息时间，减少压力，积极进行体育锻炼，白天充分活动，睡觉前不饮酒、不吸烟，同时进行药物治疗。

对于老年患者，应当尽量减小药物的剂量，避免发生低血压。

6.对于年轻人，建议减少不良生活习惯，积极参加锻炼和休闲活动，保持心态平和，养成规律的作息习惯，在医生的指导下进行适当的药物治疗。

清晨血压是评估高血压患者临床管理效果的重要指标。

对于高血压患者和医护人员来说，掌握清晨血压的监测方法和有效控制方法非常有必要。

建议患者定期检查和治疗，积极采取非药物治疗和药物治疗控制高血压。

同时，医生应注意制定个性化的治疗方案，以最大程度满足患者的需求，达到优质医疗的目标。

为什么清晨是高血压管理的重要时机！如何做好清晨血压管理“我们如果能够每天早睡，清晨睡到自然醒，然后在懒洋洋的起来，之后，才开始一天工作的话，那简直就是太幸福了。

但事实却是，工作的压力和生活的压力再加上不良的作息习惯，每天晚上都会睡的很晚，第二天为了上班，也是有早早地爬起来。

如果单纯只是这些还要好一些，由于长期的这种习惯，很多人在不知不觉中就让身体患上了疾病，就比如现在人们都非常熟悉的高血压。

这种疾病的可怕性相信大部分接触过的人都是有所了解的。

特别是对于有熬夜早起习惯的人来说，身体的危害就更加的厉害了。

因为，一般在清晨的时候，血压是最高的，很多高血压并发症也都是在这个时候发作的。

所以，患有高血压的人们，如果不改变以前不好的习惯的话，是很有可能造成无法挽回的结果的。

不过，由于很多人都没有这种认识，所以，最近几年因清晨高血压问题而导致患者病情加重的人，就变得越来越多了。

由此，中国药科教育协会发起、辉瑞企业基金资助的“北京早安，共护血压-高血压管理改善项目”近日在京启动。

该项目的主要目的就是为了加强高血压患者对高血压疾病的认知。

通过对大医院和社区医院门诊护士进行一对一的病人教育，通过病人就诊间隙，传递正确的血压测量和高血压病知识，从而帮助更多的病人知道自己的血压情况，了解自己的血压，实现高血压早发现和早治疗，进而降低因高血压加重病情和引发并发症的发病几率。

清晨血压与血压管理的“把握”清晨血压异常升高与心脑血管事件是密切相关的。

以早晨血压为“重点”，对提高高血压综合管理水平是具有非常重要意义的。

所以，无论对医生还是患者来说，控制清晨血压，对于稳定控制一天24小时的血压都是非常重要的。

不过，要管理好早晨的血压，第一步就是：要有效地监测早晨的血压。

高血压最重要的一个特点就是24小时的血压是不断变化的。

一般来说，从早上6:00到10:00的时候，血压会在短时间内从相对较低的水平迅速上升到较高的水平，大多数人的血压这个时间段是一天内会达到的最高水平。

·讲　座·２０１４欧洲高血压学会动态血压监测指南简介邹花一阳，卢新政南京医科大学第一附属医院心内科，江苏南京２１００２９通信作者：卢新政，Ｅ－ｍａｉｌ：ｘｚｌｕ＠ｎｊｍｕ．ｅｄｕ．ｃｎ ２０１４年８月，欧洲高血压学会（Ｅｕｒｏｐｅａｎ　Ｓｏｃｉｅｔｙｏｆ　Ｈｙｐｅｒｔｅｎｓｉｏｎ，ＥＳＨ）发布了动态血压监测（ａｍｂｕｌａ－ｔｏｒｙ　ｂｌｏｏｄ　ｐｒｅｓｓｕｒｅ　ｍｏｎｉｔｏｒｉｎｇ，ＡＢＰＭ）指南［１］。

近年，关于ＡＢＰＭ的研究成为热点，２０１２年底，相关文献超过１万篇。

２０１１年，英国临床健康与优化研究所（ｔｈｅ　ｎａｔｉｏｎａｌ　ｉｎｓｔｉｔｕｔｅ　ｆｏｒ　ｈｅａｌｔｈ　ａｎｄ　ｃｌｉｎｉｃａｌ　ｅｘｃｅｌ－ｌｅｎｃｅ，ＮＩＣＥ）推荐，ＡＢＰＭ可作为拟诊高血压患者的经济实用筛查手段。

基于ＡＢＰＭ的重要性，２０１１年ＥＳＨ血压监测与心血管疾病工作组在米兰举行了有关ＡＢＰＭ的专家共识会。

由３４位高血压专家，参考６００篇文献基础上于２０１３年发表立场观点。

围绕３个问题：①哪些患者需行ＡＢＰＭ？②如何规范实施ＡＢＰＭ？③如何在临床中推广ＡＢＰＭ？现对其主要内容作一简介。

１　哪些患者需行ＡＢＰＭ？１．１　ＡＢＰＭ的优缺点　近年有数据显示，夜间血压能更好地预测心血管事件。

经过４０年不断发展和完善，目前ＡＢＰＭ逐渐渗透到临床工作中。

ＡＢＰＭ不仅真实提供各时间点的血压情况，也反映了高血压患者的血压波动特点及昼夜变化规律。

有助于鉴别白大衣性高血压、隐蔽性高血压等，并预示靶器官损害，更好地评价降压药疗效，指导合理降压。

指南强调，白大衣性高血压的诊断仅限于未治疗高血压人群。

与诊室血压相比，ＡＢＰＭ具有以下优势：①提供更多的血压读数；②提供２４ｈ、白天、夜间血压值，对未治疗高血压患者明确白大衣性高血压、隐蔽性高血压；③明确血压变化趋势；④提供夜间高血压、血压变化曲线；⑤评估２４ｈ血压变异性；⑥评估降压疗效；⑦明确２４ｈ内降压值，对心血管疾病的发生率、死亡率具有独立预测价值。

2014Evidence-Based Guideline for the Management of High Blood Pressure in AdultsReport From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8)Paul A.James,MD;Suzanne Oparil,MD;Barry L.Carter,PharmD;William C.Cushman,MD;Cheryl Dennison-Himmelfarb,RN,ANP,PhD;Joel Handler,MD;Daniel ckland,DrPH;Michael L.LeFevre,MD,MSPH;Thomas D.MacKenzie,MD,MSPH;Olugbenga Ogedegbe,MD,MPH,MS;SidneyC.Smith Jr,MD;Laura P.Svetkey,MD,MHS;Sandra J.Taler,MD;Raymond R.Townsend,MD;Jackson T.Wright Jr,MD,PhD;Andrew S.Narva,MD;Eduardo Ortiz,MD,MPHEditorialsAuthor Audio Interview at Supplemental content at Author Affiliations:Authoraffiliations are listed at the end of this article.Corresponding Author:Paul A.James,MD,University of Iowa,200Hawkins Dr,01286-D PFP,Iowa City,IA 52242-1097(paul-james@uiowa .edu).Clinical Review &EducationSpecial CommunicationE1H ypertension remains one of the most important prevent-able contributors to disease and death.Abundant evi-dencefromrandomizedcontrolledtrials(RCTs)hasshown benefit of antihypertensive drug treatment in reducing important health outcomes in persons with hypertension.1-3Clinical guide-lines are at the intersection between research evidence and clinical actions that can improve patient outcomes.The Institute of Medi-cine Report Clinical Practice Guidelines We Can Trust outlined a path-way to guideline development and is the approach that this panel aspired to in the creation of this report.4The panel members appointed to the Eighth Joint National Committee(JNC8)used rigorous evidence-based methods, developing Evidence Statements and recommendations for blood pressure(BP)treatment based on a systematic review of the lit-erature to meet user needs,especially the needs of theprimary care clinician.Thisreport is an executive sum-mary of the evidence and isdesigned to provide clearrecommendations for allclinicians.Major differ-ences from the previousJNC report are summarizedin Table1.The completeevidence summary and detailed description of the evidence review and methods are pro-vided online(see Supplement).The ProcessThe panel members appointed to JNC8were selected from more than400nominees based on expertise in hypertension(n=14), primary care(n=6),including geriatrics(n=2),cardiology(n=2), nephrology(n=3),nursing(n=1),pharmacology(n=2),clinical trials(n=6),evidence-based medicine(n=3),epidemiology (n=1),informatics(n=4),and the development and implementa-tion of clinical guidelines in systems of care(n=4).The panel also included a senior scientist from the National In-stitute of Diabetes and Digestive and Kidney Diseases(NIDDK),a se-nior medical officer from the National Heart,Lung,and Blood Insti-tute(NHLBI),and a senior scientist from NHLBI,who withdrew from authorship prior to publication.Two members left the panel early in the process before the evidence review because of new job com-mitmentsthatpreventedthemfromcontinuingtoserve.Panelmem-bers disclosed any potential conflicts of interest including studies evaluated in this report and relationships with industry.Those with conflicts were allowed to participate in discussions as long as they declared their relationships,but they recused themselves from vot-ing on evidence statements and recommendations relevant to their relationships or conflicts.Four panel members(24%)had relation-ships with industry or potential conflicts to disclose at the outset of the process.In January2013,the guideline was submitted for external peer review by NHLBI to20reviewers,all of whom had expertise in hypertension,and to16federal agencies.Reviewers also had expertise in cardiology,nephrology,primary care,pharmacology,research(including clinical trials),biostatistics,and other impor-tant related fields.Sixteen individual reviewers and5federal agencies responded.Reviewers’comments were collected,col-lated,and ments were reviewed and discussed by the panel from March through June2013and incorporated into a revised document.(Reviewers’comments and suggestions, and responses and disposition by the panel are available on request from the authors.)Questions Guiding the Evidence ReviewThis evidence-based hypertension guideline focuses on the pan-el’s3highest-ranked questions related to high BP management iden-tified through a modified Delphi technique.5Nine recommenda-tions are made reflecting these questions.These questions address thresholds and goals for pharmacologic treatment of hypertension and whether particular antihypertensive drugs or drug classes im-proveimportanthealthoutcomescomparedwithotherdrugclasses.1.Inadultswithhypertension,doesinitiatingantihypertensivephar-macologic therapy at specific BP thresholds improve health out-comes?2.In adults with hypertension,does treatment with antihyperten-sive pharmacologic therapy to a specified BP goal lead to im-provements in health outcomes?3.In adults with hypertension,do various antihypertensive drugsor drug classes differ in comparative benefits and harms on spe-cific health outcomes?The Evidence ReviewThe evidence review focused on adults aged18years or older with hypertension and included studies with the following prespecified subgroups:diabetes,coronary artery disease,peripheral artery dis-ease,heart failure,previous stroke,chronic kidney disease(CKD), proteinuria,older adults,men and women,racial and ethnic groups, and smokers.Studies with sample sizes smaller than100were ex-cluded,as were studies with a follow-up period of less than1year, because small studies of brief duration are unlikely to yield enough health-relatedoutcomeinformationtopermitinterpretationoftreat-ment effects.Studies were included in the evidence review only if theyreportedtheeffectsofthestudiedinterventionsonanyofthese important health outcomes:•Overall mortality,cardiovascular disease(CVD)–related mortality, CKD-related mortality•Myocardial infarction,heart failure,hospitalization for heart fail-ure,stroke•Coronary revascularization(includes coronary artery bypass sur-gery,coronary angioplasty and coronary stent placement),other revascularization(includes carotid,renal,and lower extremity re-vascularization)•End-stage renal disease(ESRD)(ie,kidney failure resulting in di-alysis or transplantation),doubling of creatinine level,halving of glomerular filtration rate(GFR).The panel limited its evidence review to RCTs because they are less subject to bias than other study designs and represent the gold standard for determining efficacy and effectiveness.6The studiesACEI angiotensin-converting enzymeinhibitorARB angiotensin receptor blockerBP blood pressureCCB calcium channel blockerCKD chronic kidney diseaseCVD cardiovascular diseaseESRD end-stage renal diseaseGFR glomerular filtration rateHF heart failureClinical Review&Education Special Communication2014Guideline for Management of High Blood PressureE2JAMA Published online December18,Copyright 2013 American Medical Association. All rights reserved.in the evidence review were from original publications of eligible RCTs.These studies were used to create evidence tables and sum-mary tables that were used by the panel for their deliberations (see Supplement).Because the panel conducted its own systematic re-view using original studies,systematic reviews and meta-analyses of RCTs conducted and published by other groups were not in-cluded in the formal evidence review.InitialsearchdatesfortheliteraturereviewwereJanuary1,1966,through December 31,2009.The search strategy and PRISMA dia-gram for each question is in the online Supplement.To ensure that no major relevant studies published after December 31,2009,were excluded from consideration,2independent searches of PubMed and CINAHL between December 2009and August 2013were con-ducted with the same MeSH terms as the original search.Three panel members reviewed the results.The panel limited the inclusion cri-teria of this second search to the following.(1)The study was a ma-jor study in hypertension (eg,ACCORD-BP,SPS3;however,SPS3did not meet strict inclusion criteria because it included nonhyperten-sive participants.SPS3would not have changed our conclusions/recommendations because the only significant finding supporting a lower goal for BP occurred in an infrequent secondary outcome).7,8(2)The study had at least 2000participants.(3)The study was mul-ticentered.(4)The study met all the other inclusion/exclusion cri-teria.The relatively high threshold of 2000participants was used because of the markedly lower event rates observed in recent RCTs such as ACCORD,suggesting that larger study populations are needed to obtain interpretable results.Additionally,all panel mem-bers were asked to identify newly published studies for consider-ation if they met the above criteria.No additional clinical trials met the previously described inclusion criteria.Studies selected wererated for quality using NHLBI’s standardized quality rating tool (see Supplement)and were only included if rated as good or fair.An external methodology team performed the literature re-view,summarized data from selected papers into evidence tables,and provided a summary of the evidence.From this evidence re-view,the panel crafted evidence statements and voted on agree-ment or disagreement with each statement.For approved evi-dence statements,the panel then voted on the quality of the evidence (Table 2).Once all evidence statements for each critical question were identified,the panel reviewed the evidence state-ments to craft the clinical recommendations,voting on each rec-ommendationandonthestrengthoftherecommendation(Table3).For both evidence statements and recommendations,a record of the vote count (for,against,or recusal)was made without attribu-tion.The panel attempted to achieve 100%consensus whenever possible,but a two-thirds majority was considered acceptable,with the exception of recommendations based on expert opinion,which required a 75%majority agreement to approve.Results (Recommendations)The following recommendations are based on the systematic evi-dence review described above (Box ).Recommendations 1through 5address questions 1and 2concerning thresholds and goals for BP treatment.Recommendations 6,7,and 8address question 3con-cerning selection of antihypertensive drugs.Recommendation 9is asummaryofstrategiesbasedonexpertopinionforstartingandadd-ing antihypertensive drugs.The evidence statements supporting the recommendations are in the onlineSupplement.Abbreviations:ACEI,angiotensin-converting enzyme inhibitor;ARB,angiotensin receptor blocker;CCB,calcium channel blocker;CKD,chronic kidney disease;CVD,cardiovascular disease;JNC,Joint National Committee;RCT,randomized controlled trial2014Guideline for Management of High Blood Pressure Special Communication Clinical Review &EducationJAMA Published online December 18,2013E3Copyright 2013 American Medical Association. All rights reserved.Recommendation 1In the general population aged 60years or older,initiate pharma-cologic treatment to lower BP at systolic blood pressure (SBP)of 150mm Hg or higher or diastolic blood pressure (DBP)of 90mm Hg or higher and treat to a goal SBP lower than 150mm Hg and goal DBP lower than 90mm Hg.Strong Recommendation –Grade ACorollary RecommendationIn the general population aged 60years or older,if pharmacologic treatment for high BP results in lower achieved SBP (for example,<140mm Hg)and treatment is not associated with adverse effects on health or quality of life,treatment does not need to be adjusted.Expert Opinion –Grade ERecommendation 1is based on evidence statements 1through 3from question 2in which there is moderate-to high-quality evi-dence from RCTs that in the general population aged 60years or older,treating high BP to a goal of lower than 150/90mm Hg re-duces stroke,heart failure,and coronary heart disease (CHD).There isalsoevidence(albeitlowquality)fromevidencestatement6,ques-tion 2that setting a goal SBP of lower than 140mm Hg in this age group provides no additional benefit compared with a higher goal SBP of 140to 160mm Hg or 140to 149mm Hg.9,10To answer question 2about goal BP,the panel reviewed all RCTs thatmettheeligibilitycriteriaandthateithercomparedtreatmentwith a particular goal vs no treatment or placebo or compared treatment with one BP goal with treatment to another BP goal.The trials on whichtheseevidencestatementsandthisrecommendationarebased includeHYVET,Syst-Eur,SHEP ,JATOS,VALISH,andCARDIO-SIS.1-3,9-11Strengths,limitations,andotherconsiderationsrelatedtothisevidence reviewarepresentedintheevidencestatementnarrativesandclearly support the benefit of treating to a BP lower than 150mm Hg.The corollary to recommendation 1reflects that there are many treated hypertensive patients aged 60years or older in whom SBP is currently lower than 140mm Hg,based on implementation of pre-vious guideline recommendations.12The panel’s opinion is that in these patients,it is not necessary to adjust medication to allowBPThe strength of recommendation grading system used in this guideline was developed by the National Heart,Lung,and Blood Institute’s (NHLBI’s)Evidence-Based Methodology Lead (with input from NHLBI staff,external methodology team,and guideline panels and work groups)for use by all the NHLBI CVD guideline panels and work groups during this project.Additional details regarding thestrength of recommendation grading system are available in the online Supplement.aNet benefit is defined as benefits minus the risks/harms of theservice/intervention.Abbreviations:RCT,randomized controlled trialaThe evidence quality rating system used in this guideline was developed by the National Heart,Lung,and Blood Institute’s (NHLBI’s)Evidence-BasedMethodology Lead (with input from NHLBI staff,external methodology team,and guideline panels and work groups)for use by all the NHLBI CVD guidelinepanels and work groups during this project.As a result,it includes the evidence quality rating for many types of studies,including studies that were not used in this guideline.Additional details regarding the evidence quality rating system are available in the online Supplement.Clinical Review &Education Special Communication 2014Guideline for Management of High Blood PressureE4JAMA Published online December 18,2013Copyright 2013 American Medical Association. All rights reserved.to increase.In 2of the trials that provide evidence supporting an SBP goal lower than 150mm Hg,the average treated SBP was 143to 144mm Hg.2,3Many participants in those studies achieved an SBP lower than 140mm Hg with treatment that was generally well tolerated.Twoothertrials 9,10suggesttherewasnobenefitforanSBPgoallower than 140mm Hg,but the confidence intervals around the effect sizes were wide and did not exclude the possibility of a clinically impor-tant benefit.Therefore,the panel included a corollary recommen-dationbasedonexpertopinionthattreatmentforhypertensiondoes not need to be adjusted if treatment results in SBP lower than 140mm Hg and is not associated with adverse effects on health or qual-ity of life.While all panel members agreed that the evidence supporting recommendation 1is very strong,the panel was unable to reach una-nimity on the recommendation of a goal SBP of lower than 150mm Hg.Some members recommended continuing the JNC 7SBP goal of lower than 140mm Hg for individuals older than 60years based on expert opinion.12These members concluded that the evidence was insufficient to raise the SBP target from lower than 140to lower than 150mm Hg in high-risk groups,such as black persons,those with CVD including stroke,and those with multiple risk factors.The panel agreed that more research is needed to identify optimal goals of SBP for patients with high BP.Recommendation 2In the general population younger than 60years,initiate pharma-cologic treatment to lower BP at DBP of 90mm Hg or higher and treat to a goal DBP of lower than 90mm Hg.For ages 30through 59years,Strong Recommendation –Grade A For ages 18through 29years,Expert Opinion –Grade ERecommendation 2is based on high-quality evidence from 5DBPtrials(HDFP ,Hypertension-StrokeCooperative,MRC,ANBP ,and VA Cooperative)that demonstrate improvements in health out-comes among adults aged 30through 69years with elevated BP.13-18Initiation of antihypertensive treatment at a DBP threshold of 90mm Hg or higher and treatment to a DBP goal of lower than 90mm Hg reduces cerebrovascular events,heart failure,and overall mor-tality (question 1,evidence statements 10,11,13;question 2,evi-dence statement 10).In further support for a DBP goal of lower than 90mm Hg,the panel found evidence that there is no benefit in treat-ing patients to a goal of either 80mm Hg or lower or 85mm Hg or lower compared with 90mm Hg or lower based on the HOT trial,in which patients were randomized to these 3goals without statisti-cally significant differences between treatment groups in the pri-mary or secondary outcomes (question 2,evidence statement 14).19In adults younger than 30years,there are no good-or fair-quality RCTs that assessed the benefits of treating elevated DBP on health outcomes (question 1,evidence statement 14).In the ab-senceofsuchevidence,itisthepanel’sopinionthatinadultsyounger than 30years,the DBP threshold and goal should be the same as in adults 30through 59years of age.Recommendation 3In the general population younger than 60years,initiate pharma-cologic treatment to lower BP at SBP of 140mm Hg or higher and treat to a goal SBP of lower than 140mm Hg.Expert Opinion –Grade E2014Guideline for Management of High Blood Pressure Special Communication Clinical Review &EducationJAMA Published online December 18,2013E5Copyright 2013 American Medical Association. All rights reserved.Recommendation3is based on expert opinion.While there is high-quality evidence to support a specific SBP threshold and goal forpersonsaged60yearsorolder(Seerecommendation1),thepanel found insufficient evidence from good-or fair-quality RCTs to sup-port a specific SBP threshold or goal for persons younger than60 years.In the absence of such evidence,the panel recommends an SBP treatment threshold of140mm Hg or higher and an SBP treat-ment goal of lower than140mm Hg based on several factors.First,in the absence of any RCTs that compared the current SBP standard of140mm Hg with another higher or lower standard in this age group,there was no compelling reason to change current rec-ommendations.Second,intheDBPtrialsthatdemonstratedtheben-efit of treating DBP to lower than90mm Hg,many of the study par-ticipants who achieved DBP of lower than90mm Hg were also likely to have achieved SBPs of lower than140mm Hg with treatment.It is not possible to determine whether the outcome benefits in these trials were due to lowering DBP,SBP,or both.Third,given the rec-ommended SBP goal of lower than140mm Hg in adults with dia-betes or CKD(recommendations4and5),a similar SBP goal for the general population younger than60years may facilitate guideline implementation.Recommendation4In the population aged18years or older with CKD,initiate pharma-cologic treatment to lower BP at SBP of140mm Hg or higher or DBP of90mm Hg or higher and treat to goal SBP of lower than140mm Hg and goal DBP lower than90mm Hg.Expert Opinion–Grade EBased on the inclusion criteria used in the RCTs reviewed by the panel,this recommendation applies to individuals younger than70years with an estimated GFR or measured GFR less than 60mL/min/1.73m2and in people of any age with albuminuria defined as greater than30mg of albumin/g of creatinine at any level of GFR.Recommendation4is based on evidence statements15-17from question2.In adults younger than70years with CKD,the evidence is insufficient to determine if there is a benefit in mortality,or car-diovascular or cerebrovascular health outcomes with antihyperten-sive drug therapy to a lower BP goal(for example,<130/80mm Hg) compared with a goal of lower than140/90mm Hg(question2,evi-dence statement15).There is evidence of moderate quality dem-onstrating no benefit in slowing the progression of kidney disease from treatment with antihypertensive drug therapy to a lower BP goal(for example,<130/80mm Hg)compared with a goal of lower than140/90mm Hg(question2,evidence statement16).Three trials that met our criteria for review addressed the effect of antihypertensive drug therapy on change in GFR or time to development of ESRD,but only one trial addressed cardiovas-cular disease end points.Blood pressure goals differed across the trials,with2trials(AASK and MDRD)using mean arterial pressure and different targets by age,and1trial(REIN-2)using only DBP goals.20-22None of the trials showed that treatment to a lower BP goal(for example,<130/80mm Hg)significantly lowered kidney or cardiovascular disease end points compared with a goal of lower than140/90mm Hg.For patients with proteinuria(>3g/24hours),post hoc analy-sis from only1study(MDRD)indicated benefit from treatment to a lower BP goal(<130/80mm Hg),and this related to kidney out-comes only.22Although post hoc observational analyses of data from this trial and others suggested benefit from the lower goal at lower levels of proteinuria,this result was not seen in the primary analyses or in AASK or REIN-2(question2,evidence statement 17).20,21Based on available evidence the panel cannot make a recom-mendation for a BP goal for people aged70years or older with GFR less than60mL/min/1.73m2.The commonly used estimating equations for GFR were not developed in populations with signifi-cant numbers of people older than70years and have not been validated in older adults.No outcome trials reviewed by the panel included large numbers of adults older than70years with CKD. Further,the diagnostic criteria for CKD do not consider age-related decline in kidney function as reflected in estimated GFR.Thus, when weighing the risks and benefits of a lower BP goal for people aged70years or older with estimated GFR less than60mL/min/ 1.73m2,antihypertensive treatment should be individualized,tak-ing into consideration factors such as frailty,comorbidities,and albuminuria.Recommendation5In the population aged18years or older with diabetes,initiate phar-macologic treatment to lower BP at SBP of140mm Hg or higher or DBP of90mm Hg or higher and treat to a goal SBP of lower than 140mm Hg and goal DBP lower than90mm Hg.Expert Opinion–Grade ERecommendation5is based on evidence statements18-21from question2,which address BP goals in adults with both diabetes and hypertension.Thereismoderate-qualityevidencefrom3trials(SHEP, Syst-Eur,and UKPDS)that treatment to an SBP goal of lower than 150mm Hg improves cardiovascular and cerebrovascular health out-comes and lowers mortality(see question2,evidence statement18) in adults with diabetes and hypertension.23-25No RCTs addressed whether treatment to an SBP goal of lower than140mm Hg com-pared with a higher goal(for example,<150mm Hg)improves health outcomes in adults with diabetes and hypertension.In the absence of such evidence,the panel recommends an SBP goal of lower than 140mm Hg and a DBP goal lower than90mm Hg in this population based on expert opinion,consistent with the BP goals in recom-mendation3for the general population younger than60years with e of a consistent BP goal in the general population younger than60years and in adults with diabetes of any age may facilitateguidelineimplementation.ThisrecommendationforanSBP goal of lower than140mm Hg in patients with diabetes is also sup-ported by the ACCORD-BP trial,in which the control group used this goal and had similar outcomes compared with a lower goal.7 The panel recognizes that the ADVANCE trial tested the ef-fects of treatment to lower BP on major macrovascular and micro-vascular events in adults with diabetes who were at increased risk of CVD,but the study did not meet the panel’s inclusion criteria be-cause participants were eligible irrespective of baseline BP,and there were no randomized BP treatment thresholds or goals.26 The panel also recognizes that an SBP goal of lower than130 mm Hg is commonly recommended for adults with diabetes and hy-pertension.However,this lower SBP goal is not supported by any RCT that randomized participants into2or more groups in whichClinical Review&Education Special Communication2014Guideline for Management of High Blood PressureE6JAMA Published online December18,Copyright 2013 American Medical Association. All rights reserved.treatment was initiated at a lower SBP threshold than140mm Hg or into treatment groups in which the SBP goal was lower than140 mm Hg and that assessed the effects of a lower SBP threshold or goal on important health outcomes.The only RCT that compared an SBP treatment goal of lower than140mm Hg with a lower SBP goal and assessed the effects on important health outcomes is ACCORD-BP, which compared an SBP treatment goal of lower than120mm Hg with a goal lower than140mm Hg.7There was no difference in the primary outcome,a composite of cardiovascular death,nonfatal myocardial infarction,and nonfatal stroke.There were also no dif-ferences in any of the secondary outcomes except for a reduction in stroke.However,the incidence of stroke in the group treated to lower than140mm Hg was much lower than expected,so the ab-solute difference in fatal and nonfatal stroke between the2groups was only0.21%per year.The panel concluded that the results from ACCORD-BP did not provide sufficient evidence to recommend an SBP goal of lower than120mm Hg in adults with diabetes and hy-pertension.The panel similarly recommends the same goal DBP in adults with diabetes and hypertension as in the general population(<90 mm Hg).Despite some existing recommendations that adults with diabetes and hypertension should be treated to a DBP goal of lower than80mm Hg,the panel did not find sufficient evidence to sup-port such a recommendation.For example,there are no good-or fair-quality RCTs with mortality as a primary or secondary prespeci-fied outcome that compared a DBP goal of lower than90mm Hg with a lower goal(evidence statement21).In the HOT trial,which is frequently cited to support a lower DBP goal,investigators compared a DBP goal of90mm Hg or lower vs a goal of80mm Hg or lower.19The lower goal was associated with a reduction in a composite CVD outcome(question2,evidence state-ment20),but this was a post hoc analysis of a small subgroup(8%) of the study population that was not prespecified.As a result,the evidence was graded as low quality.Another commonly cited study to support a lower DBP goal is UKPDS,25which had a BP goal of lower than150/85mm Hg in the more-intensively treated group compared with a goal of lower than 180/105mm Hg in the less-intensively treated PDS did show that treatment in the lower goal BP group was associated with a significantly lower rate of stroke,heart failure,diabetes-related end points,and deaths related to diabetes.However,the comparison in UKPDS was a DBP goal of lower than85mm Hg vs lower than105 mm Hg;therefore,it is not possible to determine whether treat-ment to a DBP goal of lower than85mm Hg improves outcomes compared with treatment to a DBP goal of lower than90mm Hg. In addition,UKPDS was a mixed systolic and diastolic BP goal study (combined SBP and DBP goals),so it cannot be determined if the benefits were due to lowering SBP,DBP,or both.Recommendation6In the general nonblack population,including those with diabetes, initial antihypertensive treatment should include a thiazide-type di-uretic,calcium channel blocker(CCB),angiotensin-converting en-zyme inhibitor(ACEI),or angiotensin receptor blocker(ARB). Moderate Recommendation–Grade BFor this recommendation,only RCTs that compared one class of antihypertensive medication to another and assessed the effects on health outcomes were reviewed;placebo-controlledRCTs were not included.However,the evidence review was informed by major placebo-controlled hypertension trials,includ-ing3federally funded trials(VA Cooperative Trial,HDFP,and SHEP),that were pivotal in demonstrating that treatment of hypertension with antihypertensive medications reduces cardio-vascular or cerebrovascular events and/or mortality.3,13,18These trials all used thiazide-type diuretics compared with placebo or usual care as the basis of therapy.Additional evidence that BP lowering reduces risk comes from trials ofβ-blocker vs placebo16,27and CCB vs placebo.1Each of the4drug classes recommended by the panel in rec-ommendation6yielded comparable effects on overall mortality and cardiovascular,cerebrovascular,and kidney outcomes,with one ex-ception:heart failure.Initial treatment with a thiazide-type di-uretic was more effective than a CCB or ACEI(question3,evidence statements14and15),and an ACEI was more effective than a CCB (question3,evidence statement1)in improving heart failure out-comes.While the panel recognized that improved heart failure out-comes was an important finding that should be considered when se-lecting a drug for initial therapy for hypertension,the panel did not conclude that it was compelling enough within the context of the overall body of evidence to preclude the use of the other drug classes for initial therapy.The panel also acknowledged that the evidence supported BP control,rather than a specific agent used to achieve that control,as the most relevant consideration for this recommen-dation.The panel did not recommendβ-blockers for the initial treat-ment of hypertension because in one study use ofβ-blockers re-sulted in a higher rate of the primary composite outcome of cardio-vascular death,myocardial infarction,or stroke compared to use of an ARB,a finding that was driven largely by an increase in stroke (question3,evidence statement22).28In the other studies that com-pared aβ-blocker to the4recommended drug classes,theβ-blocker performed similarly to the other drugs(question3,evidence state-ment8)or the evidence was insufficient to make a determination (question3,evidence statements7,12,21,23,and24).α-Blockers were not recommended as first-line therapy be-cause in one study initial treatment with anα-blocker resulted in worse cerebrovascular,heart failure,and combined cardiovascular outcomes than initial treatment with a diuretic(question3,evi-dence statement13).29There were no RCTs of good or fair quality comparing the following drug classes to the4recommended classes: dualα1-+β-blocking agents(eg,carvedilol),vasodilatingβ-block-ers(eg,nebivolol),centralα2-adrenergic agonists(eg,clonidine),di-rect vasodilators(eg,hydralazine),aldosterone receptor antago-nists(eg,spironolactone),peripherally acting adrenergic antagonists (reserpine),and loop diuretics(eg,furosemide)(question3,evi-dence statement30).Therefore,these drug classes are not recom-mended as first-line therapy.In addition,no eligible RCTs were iden-tified that compared a diuretic vs an ARB,or an ACEI vs an ARB. ONTARGET was not eligible because hypertension was not re-quired for inclusion in the study.30Similar to those for the general population,this recommenda-tion applies to those with diabetes because trials including partici-pants with diabetes showed no differences in major cardiovascular or cerebrovascular outcomes from those in the general population (question3,evidence statements36-48).2014Guideline for Management of High Blood Pressure Special Communication Clinical Review&Education JAMA Published online December18,2013E7 Copyright 2013 American Medical Association. All rights reserved.。

JAMA杂志今天发布了2014年成人高血压治疗指南（2014 Evidence-Based Guideline for the Management of High Blood Pressure in Adults），新指南包含9条推荐和一种治疗流JNC8高血压管理流程图：图1. JNC8推荐管理流程图新指南回答了三个常见问题：•何时开始降压治疗专家组对需要开始治疗的血压水平进行明确。

指南推荐，60岁以上老年人，血压达到150/90即应开始降压治疗；治疗目标值如上述。

但是，专家组强调，新指南规定的这一血压界值并不是重新定义高血压，此前由Joint National Committee 7定义的高血压水平（>=140/90 mm Hg ）仍然有效。

血压处于这一范围的人群，均应通过生活方式进行干预。

•血压治疗目标值新指南对以上三个问题的回答总体概括如下：60岁以上老年高血压患者的高血压治疗目标值应为150/90 mm Hg；30-59岁高血压患者舒张压应低于90mmHg。

但是这一年龄段高血压患者收缩压的推荐治疗目标值目前没有充足的证据支持，30岁以下高血压患者舒张压的治疗目标值也没有证据支持。

因此专家组推荐，这类人群的高血压治疗目标应低于140/90 mm Hg。

此外，对于60岁以下罹患高血压合并糖尿病，或高血压合并非糖尿病性慢性肾脏疾病(CKD)患者，指南推荐的治疗目标值和60岁以下普通高血压人群一致。

•高血压治疗起始用药专家点评：•Harold C. Sox, M.D.：新指南证据级别更有说服力Harold C. Sox, M.D.，达特茅斯学院教授Harold C. Sox, M.D.指出，新版指南以及撰写指南的专家小组权威性更高。

他指出，评价指南是否权威，可以从以下四个方面进行考察：1，指南中最可信的部分是什么？2，指南是如何撰写制定的？3，撰写指南的专家小组成员扮演何种角色？4，指南获取公众信任的途径是什么？Harold博士认为，从这四个角度来看，新版指南权威性更高。