小结
高血压是一种影响大部分社区人群的常见疾病。它一般无明显临床表现，通常在常规检查及心脏病或脑卒中等并发症发作后被发现，[1]Lip GY. Hypertension, platelets, and the endothelium: the "thrombotic paradox" of hypertension (or "Birmingham paradox") revisited. Hypertension. 2003 Feb;41(2):199-200. http://hyper.ahajournals.org/cgi/content/full/41/2/199 http://www.ncbi.nlm.nih.gov/pubmed/12574081?tool=bestpractice.com
美国多家学术团体（美国心脏病学会 [American College of Cardiology, ACC] 和美国心脏协会 [American Heart Association, AHA] 以及其他团体）、英国高血压学会（British Society of Hypertension）和欧洲高血压学会（European Society of Hypertension）联合指南已对高血压进行定义。[2]Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol. 2018 May 15;71(19):e127-248. http://www.ncbi.nlm.nih.gov/pubmed/29146535?tool=bestpractice.com [3]Williams B, Poulter NR, Brown MJ, et al. Guidelines for management of hypertension: report of the fourth working party of the British Hypertension Society, 2004-BHS IV. J Hum Hypertens. 2004 Mar;18(3):139-85. https://www.nature.com/articles/1001683 http://www.ncbi.nlm.nih.gov/pubmed/14973512?tool=bestpractice.com [4]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 http://www.ncbi.nlm.nih.gov/pubmed/30165516?tool=bestpractice.com 不同指南对高血压的定义存在差异。
2017 年 ACC/AHA 成人高血压预防、识别、评估和管理指南将高血压定义为收缩压测量值 ≥130 mmHg 或舒张压测量值 ≥80 mmHg。[2]Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. J Am Coll Cardiol. 2018 May 15;71(19):e127-248. http://www.ncbi.nlm.nih.gov/pubmed/29146535?tool=bestpractice.com ACC/AHA 血压类别的定义如下：
血压升高：收缩压 120-129 mmHg 且舒张压 <80 mmHg
1 期高血压：收缩压 130-139 mmHg 和/或舒张压 80-89 mmHg
2 期高血压：收缩压≥140 mmHg 和/或舒张压≥90 mmHg。
与美国第 7 届和第 8 届全国联合委员会（Joint National Committee, JNC）的建议相比，2017 年 ACC/AHA 指南定义给出了更激进的高血压诊断和治疗方法，即 120-139 mmHg/80-89 mmHg 的血压被认定为是高血压前期，＞140/90 mmHg 的血压被认定为是高血压。[5]Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. JAMA. 2003 May 21;289(19):2560-72. http://www.ncbi.nlm.nih.gov/pubmed/12748199?tool=bestpractice.com [6]James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pressure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014 Feb 5;311(5):507-20. http://jama.jamanetwork.com/article.aspx?articleid=1791497 http://www.ncbi.nlm.nih.gov/pubmed/24352797?tool=bestpractice.com
2017 年 ACC/AHA 指南的发表引起了广泛的争议，有人呼吁重新讨论这些建议。实施这些指南会使美国的高血压患病率增加 26.8%。批评者担心，将更多患者标记为高血压可能会增加心理并发症发生率，并使低风险患者暴露于降压药物的潜在危害。[7]Khera R, Lu Y, Lu J, et al. Impact of 2017 ACC/AHA guidelines on prevalence of hypertension and eligibility for antihypertensive treatment in United States and China: nationally representative cross sectional study. BMJ. 2018 Jul 11;362:k2357. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039831 http://www.ncbi.nlm.nih.gov/pubmed/29997129?tool=bestpractice.com
2017 年 ACC/AHA 指南主要基于 SPRINT 试验的结果，该试验在收缩压≥130 mmHg、心血管风险增加（但没有糖尿病）的人群中研究了强化或标准降压治疗。[8]SPRINT Research Group; Wright JT Jr, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015 Nov 26;373(22):2103-16. https://www.nejm.org/doi/10.1056/NEJMoa1511939 http://www.ncbi.nlm.nih.gov/pubmed/26551272?tool=bestpractice.com 欲获取关于争议的更多信息，请收听我们的播客。 BMJ Best Practice Podcast: hypertension Opens in new window
欧洲指南对高血压的分类如下：[4]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 http://www.ncbi.nlm.nih.gov/pubmed/30165516?tool=bestpractice.com
正常血压高值：收缩压 130-139 mmHg 和/或舒张压 85-89 mmHg
1 级：收缩压 140-159 mmHg 和/或舒张压 90-99 mmHg
2 级：收缩压 160-179 mmHg 和/或舒张压 100-109 mmHg
3 级：收缩压 ≥180 mmHg 和/或舒张压 ≥110 mmHg。
英国国家卫生与临床优化研究所 (National Institute for Health and Care Excellence ) 指南使用的高血压定义与欧洲指南类似。[9]National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. March 2022 [internet publication]. https://www.nice.org.uk/guidance/ng136
如果舒张压<90 mmHg，还可根据收缩压数值的范围对单纯收缩期高血压进行分级。[4]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 http://www.ncbi.nlm.nih.gov/pubmed/30165516?tool=bestpractice.com
尽管不同研究在社区诊断高血压采用了不同的临界值，但是收缩压> 120 mmHg 与心血管事件风险增加有关。高血压的重要性在于它与其他心血管危险因素的相互作用以及由此导致的心血管风险。
AHA 将难治性高血压定义为：[10]Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018 Nov;72(5):e53-90. https://www.ahajournals.org/doi/full/10.1161/HYP.0000000000000084 http://www.ncbi.nlm.nih.gov/pubmed/30354828?tool=bestpractice.com
尽管联合使用至少 3 种最大剂量或最大可耐受剂量的降压药（包括 ACE 抑制剂或血管紧张素受体拮抗剂、长效钙离子通道阻滞剂和利尿剂），但临床血压仍 ＞130/80 mmHg。
需要 4 种或更多种降压药才能达到目标血压的患者也被认定为有难治性高血压。该诊断需要排除白大衣高血压以及对降压药的依从性不佳。
本专题讨论了成人高血压的评估。
流行病学
根据 2013-2016 年的国家健康与营养调查（National Health and Nutrition Survey, NHANES）数据，估计在年龄 ≥20 岁的美国成年人中有 1.164 亿人患有高血压（临界值为 140/90 mmHg）。[11]Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020 Mar 3;141(9):e139-e596. https://www.doi.org/10.1161/CIR.0000000000000757 http://www.ncbi.nlm.nih.gov/pubmed/31992061?tool=bestpractice.com 在此期间，20-44 岁人群中的高血压患病率为 26.1%，45-64 岁人群中为 59.2%，≥65 岁人群中为 78.2%。[11]Virani SS, Alonso A, Benjamin EJ, et al. Heart disease and stroke statistics-2020 update: a report from the American Heart Association. Circulation. 2020 Mar 3;141(9):e139-e596. https://www.doi.org/10.1161/CIR.0000000000000757 http://www.ncbi.nlm.nih.gov/pubmed/31992061?tool=bestpractice.com 在西欧，患病率相近或更高一些。[12]Falaschetti E, Mindell J, Knott C, et al. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet. 2014 May 31;383(9932):1912-9. http://www.ncbi.nlm.nih.gov/pubmed/24881995?tool=bestpractice.com [13]Lacruz ME, Kluttig A, Hartwig S, et al. Prevalence and incidence of hypertension in the general adult population: results of the CARLA-cohort study. Medicine (Baltimore). 2015 Jun;94(22):e952. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4616348 http://www.ncbi.nlm.nih.gov/pubmed/26039136?tool=bestpractice.com
根据欧洲指南，在全球范围内，成人高血压的整体患病率为 30%-45%，其中男性的患病率高于女性（分别为 24% 和 20%）。[4]Williams B, Mancia G, Spiering W, et al. 2018 ESC/ESH guidelines for the management of arterial hypertension. Eur Heart J. 2018 Sep 1;39(33):3021-104. https://academic.oup.com/eurheartj/article/39/33/3021/5079119 http://www.ncbi.nlm.nih.gov/pubmed/30165516?tool=bestpractice.com
从儿童期开始，高血压在黑人中就比在白人中更常见，到 55 岁时，有 76% 的黑人男性和女性患有高血压，而白人男性和白人女性中，这一比例分别为 55% 和 40%。[14]Thomas SJ, Booth JN 3rd, Dai C, et al. Cumulative incidence of hypertension by 55 years of age in blacks and whites: the CARDIA study. J Am Heart Assoc. 2018 Jul 11;7(14). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6064834 http://www.ncbi.nlm.nih.gov/pubmed/29997132?tool=bestpractice.com
确切的高血压患病率很难评估，因为它通常无症状。如果重新将高血压的“临界值”重新定义在较低水平，预计患病率会增高。
大约 15% 的高血压患者有难治性高血压。[10]Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018 Nov;72(5):e53-90. https://www.ahajournals.org/doi/full/10.1161/HYP.0000000000000084 http://www.ncbi.nlm.nih.gov/pubmed/30354828?tool=bestpractice.com
并发症和高血压介导的器官损伤
多项研究表明，治疗高血压可以降低未来心脑血管事件的发生率。[15]Ogden LG, He J, Lydick E, et al. Long-term absolute benefit of lowering blood pressure in hypertensive patients according to the JNC VI risk stratification. Hypertension. 2000 Feb;35(2):539-43. http://hyper.ahajournals.org/cgi/content/full/35/2/539 http://www.ncbi.nlm.nih.gov/pubmed/10679494?tool=bestpractice.com 早期诊断和治疗高血压的目的是降低整体心血管危险和预防脑血管事件。
慢性高血压对器官系统的影响被称为高血压介导的器官损伤。
左心室肥厚、心血管疾病、脑血管疾病、高血压性视网膜病变和肾病是最常见的表现。[16]Nadar SK, Tayebjee MH, Meserelli F, et al. Target organ damage in hypertension: pathophysiology and implications for drug therapy. Curr Pharm Des. 2006;12(13):1581-92. http://www.ncbi.nlm.nih.gov/pubmed/16729871?tool=bestpractice.com 其中左心室肥厚是预后不佳的体征，逆转左心室肥厚可以改善预后。[17]Lewington S, Clarke R, Qizilbash N, et al. Age-specific relevance of usual blood pressure to vascular mortality: a meta-analysis of individual data for one million adults in 61 prospective studies. Lancet. 2002 Dec 14;360(9349):1903-13. http://www.ncbi.nlm.nih.gov/pubmed/12493255?tool=bestpractice.com 难治性高血压患者经历心血管和脑血管事件以及发生慢性肾病的风险更高。[10]Carey RM, Calhoun DA, Bakris GL, et al. Resistant hypertension: detection, evaluation, and management: a scientific statement from the American Heart Association. Hypertension. 2018 Nov;72(5):e53-90. https://www.ahajournals.org/doi/full/10.1161/HYP.0000000000000084 http://www.ncbi.nlm.nih.gov/pubmed/30354828?tool=bestpractice.com
心血管风险
高血压管理指南强调计算和管理患者总体心血管风险的重要性，而不是仅仅关注血压读数。ACC 和 AHA 已发布一种在线工具，可以计算出患者 10 年和终身患动脉粥样硬化性心血管疾病的风险。 ACC: ASCVD Risk Estimator Plus Opens in new window 对于 40-70 岁的人群而言，当血压在 115/75-185/115 范围内时，收缩压每增加 20 mmHg 或舒张压每增加 10 mmHg，发生心血管疾病的风险将加倍。[18]Blair SN, Goodyear NN, Gibbons LW, et al. Physical fitness and incidence of hypertension in healthy normotensive men and women. JAMA. 1984 Jul 27;252(4):487-90. http://www.ncbi.nlm.nih.gov/pubmed/6737638?tool=bestpractice.com 在降低总体心血管风险方面，处理相关的心血管危险因素（例如肥胖、糖尿病、高胆固醇血症和吸烟）与治疗高血压一样重要。
一项荟萃分析已经证实，在基线收缩压≥140 mmHg 的人群中，降低血压可减少心血管疾病和死亡。[19]Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018 Jan 1;178(1):28-36. http://www.ncbi.nlm.nih.gov/pubmed/29131895?tool=bestpractice.com 然而，一级预防降压不会使基线血压较低的人群受益（已患有心血管疾病的人群除外）。[19]Brunström M, Carlberg B. Association of blood pressure lowering with mortality and cardiovascular disease across blood pressure levels: a systematic review and meta-analysis. JAMA Intern Med. 2018 Jan 1;178(1):28-36. http://www.ncbi.nlm.nih.gov/pubmed/29131895?tool=bestpractice.com 一项 Cochrane 评价发现，没有足够的证据表明对高血压合并心血管疾病患者采取较低血压目标（≤135/85 mmHg）是合理的做法。[20]Saiz LC, Gorricho J, Garjón J, et al. Blood pressure targets for the treatment of people with hypertension and cardiovascular disease. Cochrane Database Syst Rev. 2018 Jul 20;(7):CD010315. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010315.pub3/full http://www.ncbi.nlm.nih.gov/pubmed/30027631?tool=bestpractice.com
鉴别诊断
撰稿人
作者
Sunil Nadar, MD, FRCP, CCT, FESC
Senior Consultant Cardiologist
Sultan Qaboos University Hospital
Muscat
Oman
利益声明
SN is an author of a number of references cited in this topic.
Gregory Y.H. Lip, MD, FRCP, DFM, FACC, FESC, FEHRA
Price-Evans Professor of Cardiovascular Medicine
University of Liverpool
Senior Investigator
National Institute for Health Research
UK
Distinguished Professor
Faculty of Medicine
Aalborg University
Denmark
Adjunct Professor
Yonsei University
Seoul
South Korea
利益声明
GYHL is a consultant for Bayer/Janssen, BMS/Pfizer, Biotronik, Medtronic, Boehringer Ingelheim, Novartis, Verseon, and Daiichi-Sankyo; he is also a speaker for Bayer, BMS/Pfizer, Medtronic, Boehringer Ingelheim, and Daiichi-Sankyo. No fees are directly received personally. GYHL is an author of a number of references cited in this topic.
同行评议者
Rod Jackson, MD, PhD
Professor of Epidemiology
Head of the Section of Epidemiology & Biostatistics
School of Population Health
University of Auckland
Auckland
New Zealand
利益声明
RJ declares that he has no competing interests.
Alan Wilkinson, MD, FRCP
Professor of Medicine
David Geffen School of Medicine at UCLA
Los Angeles
CA
利益声明
AW declares that he has no competing interests. Unfortunately we have since been made aware that Professor Wilkinson is deceased.
Michael Schachter, MB, BSc, FRCP
Department of Clinical Pharmacology
St Mary’s Hospital
Imperial College
London
UK
利益声明
MS declares that he has no competing interests.
指南
- 成人高血压：诊断和管理
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