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2013ESH/ESC高血压指南更新要点和启迪2013ESH/ESCHypertensionGuidelineClassesofrecommendationsClassesofrecommendationsDefinitionSuggestedwordingtouseClassIEvidenceand/orgeneralagreementthatagiventreatmentorprocedureisbeneficial,useful,effective.Isrecommended/isindicatedClassIIConflictingevidenceand/oradivergenceofopinionabouttheusefulness/efficacyofthegiventreatmentorprocedureClassIIaWeightofevidence/opinionisinfavourofusefulness/efficacyShouldbeconsideredClassIIbUsefulness/efficacyislesswellestablishedbyevidence/opinionMaybeconsideredClassIIIEvidenceorgeneralagreementthatthegiventreatmentorprocedureisnotuseful/effective,andinsomecasesmaybeharmfulIsnotrecommended2013ESH/ESCHypertensionGuidelineLevelofevidenceADataderivedfrommultiplerandomizedclinicaltrialsormeta-analyses.LevelofevidenceBDataderivedfromasinglerandomizedclinicaltrialorlargenon-randomizedstudiesLevelofevidenceCConsensusofopinionoftheexpertsand/orsmallstudies,retrospectivestudies,registriesLevelsofEvidence更新要点(一):心血管风险分层★细化了分层标准，将RFs、TOD和DM、CKD不同阶段分属于不同的层面。★将隐蔽性高血压或白大衣性高血压列入心血管风险分层，分别提高或降低一个风险层次。★以患者心血管风险程度作为高血压患者启动治疗和治疗路径的主要决定因素。2013ESH/ESCHypertensionGuidelineOtherriskfactors(RF),asymptomaticorgandamage(OD)ordiseaseBloodPressure(mmHg)HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NOotherRFLowriskModerateriskHighrisk1-2RFLowriskModerateriskModeratetoHighriskHighrisk≥3RFLowtoModerateriskModeratetoHighriskHighriskHighriskOD,CKDstage3ordiabetesModeratetoHighriskHighriskHighriskHightoVeryhighriskSymptomaticCVD,CKDstage≥4ordiabeteswithOD/RFsVeryhighriskVeryhighriskVeryhighriskVeryhighriskStratificationoftotalCVriskZanchettiandMancia,JHypertens2012;30:660-668.PAMELAStudy:PredictionofCVEventsByDifferentSBPsandSBPCombinationsClinicClinic+HomeClinic+24hClinic+Home+24hAUC0.80.780.760.740.72Psignificantvs:**‡0.700.742*0.762*‡0.7640.7530.80.91.00.70.60.50.40.30.20.1000.10.20.30.40.50.60.70.80.91.01-SpecificitySensitivityClinic0.742Cinic+24h0.753Clinic+Home0.762Allthree0.764RefAUC**DefinitionsaccordingtoofficeBPandout-of-officeBP(daytimeambulatoryorhomeBP)OfficeBP(mmHg)SBP140andDBP90SBP≥140orDBP≥90DaytimeABPorhomeBP(mmHg)SBP135andDBP85Truenormotension(NT)White-coathypertension(WCHT)SBP≥135orDBP≥85Maskedhypertension(MHT)Sustainedhypertension(SHT)PrevalenceofmaskedHTinPAMELASega,etal.Ciralation2005;111:17-18.OfficeBP→/24hBP↑OfficeBP→/HomeBP↑MaskedHTHTNMaskedHTHTN49.524.58.528.649.38.96050403020100%6050403020100%TheprognosisofmaskedhypertensionChronicetal,JAmCollCardiong,2005;46:508-515Prevalenceisapproximately10%ingeneralpopulationCVeventsper1000patientsyear35251530201050CVEventsNormal23/685Whitecoat24/656masked236/3125Uncontrolled41/462更新要点(二):启动药物治疗★将2-3级和1级高危患者列为药物治疗强指征推荐。★将老年人高血压患者SBP≥160mmHg列为药物治疗强指征推荐。★对血压水平在正常高值，即使高危或很高危患者，不推荐实施降压干预治疗。InitiationofantihypertensivedrugtreatmentGrade2-3Recommended(Promptly)IAGrade1/HighCVriskRecommendedIBGrade1/LowCVriskShouldbeconsideredIIaBElderlyRecommendedifSBP≥160mmHgIA(also80ysofage)MaybeconsideredifSBP140-159IIbCmmHgHighnormalBPNodrugtreatmentrecommendedIIIA2013ESH/ESCHypertensionGuidelineZhangetal.EurHeartJ2011;32:1500.FEVERTrial:BeneficialEffectsofTreatmentInLow-moderateRiskGrade1HypertensivesNoDMOrCVD(n=4850)Women(n=3791)SBP153mmHg(n=4855)NoDMOrCVD(n=4850)Women(n=3791)SBP153mmHg(n=4855)0-10-20-30-40-50-60-55-39-17-11-58-39-29-48-3-53-39-21-9-34-29-46-70-10-20-30-40-50-60P0.0020.010.030.01-520.010.001△Riskofstroke(%)△RiskofCVevents(%)10-yearrisk13.6%13.9%13.8%2013ESH/ESCHypertensionGuidelineOtherriskfactors(RF),asymptomaticorgandamage(OD)ordiseaseBloodPressure(mmHg)HighnormalSBP130-139orDBP85-89Grade1HTSBP140-159orDBP90-99Grade2HTSBP160-179orDBP100-109Grade3HTSBP≥180orDBP≥110NOotherRFNoBPInterventionLifestylechangesforseveralmonthsThenaddBPdrugstargeting140/90LifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/901-2RFLifestylechangesNoBPInterventionLifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90≥3RFLifestylechangesNoBPInterventionLifestylechangesforseveralweeksThenaddBPdrugstargeting140/90LifestylechangesBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90OD,CKDstage3ordiabetesLifestylechangesNoBPInterventionLifestylechangesBPdrugstargeting140/90LifestylechangesBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90SymptomaticCVD,CKDstage≥4ordiabeteswithOD/RFsLifestylechangesNoBPInterventionLifestylechangesBPdrugstargeting140/90LifestylechangesBPdrugstargeting140/90LifestylechangesImmediateBPdrugstargeting140/90Initiationoflifestylechangesandantihypertensivedrugtreatment更新要点(三):治疗目标★调整很高危患者的血压控制目标值。★调整老年人高血压的血压控制目标值。★确定舒张压80-85mmHg是合适安全的控制目标范围。2013ESH/ESCHypertensionGuidelineRecommendationsClassLevelASBPgoal140mmHga)isrecommendedinpatientsatlow-moderateCVrisk;IBb)isrecommendedinpatientswithdiabetes;IAc)shouldbeconsideredinpatientswithprevi