倉促翻譯，難免有誤，敬請指正。
1 The 2017 guideline is an update of the “Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure” (JNC 7), published in 2003. The 2017 guideline is a comprehensive guideline incorporating new information from studies regarding blood pressure (BP)-related risk of cardiovascular disease (CVD), ambulatory BP monitoring (ABPM), home BP monitoring (HBPM), BP thresholds to initiate antihypertensive drug treatment, BP goals of treatment, strategies to improve hypertension treatment and control, and various other important issues.
2017版的高血壓指南是對JNC7的更新，是一個(gè)包含了血壓相關(guān)的心血管疾病、動(dòng)態(tài)血壓監(jiān)測、家庭自測血壓的新信息，開始使用降壓藥物的血壓升高的閾值，血壓治療的目標(biāo)值、改善血壓治療和控制的方式等各種高血壓領(lǐng)域的問題。
2 It is critical that health care providers follow the standards for accurate BP measurement. BP should be categorized as normal, elevated, or stages 1 or 2 hypertension to prevent and treat high BP. Normal BP is defined as <120/<80 mm Hg; elevated BP 120-129/<80 mm Hg; hypertension stage 1 is 130-139 or 80-89 mm Hg, and hypertension stage 2 is ≥140 or ≥90 mm Hg. Prior to labeling a person with hypertension, it is important to use an average based on ≥2 readings obtained on ≥2 occasions to estimate the individual’s level of BP. Out-of-office and self-monitoring of BP measurements are recommended to confirm the diagnosis of hypertension and for titration of BP-lowering medication, in conjunction with clinical interventions and telehealth counseling. Corresponding BPs based on site/methods are: office/clinic 140/90, HBPM 135/85, daytime ABPM 135/85, night-time ABPM 120/70, and 24-hour ABPM 130/80 mm Hg. In adults with an untreated systolic BP (SBP) >130 but <160 mm Hg or diastolic BP (DBP) >80 but <100 mm Hg, it is reasonable to screen for the presence of white coat hypertension using either daytime ABPM or HBPM prior to diagnosis of hypertension. In adults with elevated office BP (120-129/<80) but not meeting the criteria for hypertension, screening for masked hypertension with daytime ABPM or HBPM is reasonable.
健康管理者必須遵循嚴(yán)格的血壓測量標(biāo)準(zhǔn)。根據(jù)血壓的值可以分為正常、血壓高值、1級或2級高血壓。正常血壓被定義為<120/<80 mm Hg, 120-129/<80 mm Hg為血壓升高， 1級高血壓為130-139 /80-89 mm Hg, 2級高血壓為 ≥140 or ≥90 mm Hg。必須在不同時(shí)間測量2次，血壓均升高才能診斷高血壓。建議使用診所外和家庭自測血壓診斷高血壓，并作為開始降壓治療的依據(jù)，并和診所保持電話聯(lián)系，并接受指導(dǎo)。血壓測量的方式和標(biāo)準(zhǔn)參照以下的值：診所血壓140/90mm Hg， 家庭自測血壓135/85mm Hg，白天動(dòng)態(tài)血壓平均值135/85mm Hg， 夜間動(dòng)態(tài)血壓平均值120/70mm Hg，24小時(shí)動(dòng)態(tài)血壓平均值130/80 mm Hg。未經(jīng)治療的成年人，如果收縮壓>130mm Hg但 <160 mm Hg 或者 舒張壓 BP >80mm Hg但 <100 mm Hg，在診斷高血壓前，有必要用白天家庭自測血壓或動(dòng)態(tài)血壓排除白大衣高血壓的可能。而成年人如果診所血壓在120-129mm Hg<80mm Hg未達(dá)到高血壓診斷標(biāo)準(zhǔn)者，也有必要使用白天家庭自測血壓或動(dòng)態(tài)血壓排除隱匿性高血壓的可能。
3 For an adult 45 years of age without hypertension, the 40-year risk for developing hypertension is 93% for African Americans, 92% for Hispanics, 86% for whites, and 84% for Chinese adults. In 2010, hypertension was the leading cause of death and disability-adjusted life-years worldwide, and a greater contributor to events in women and African Americans compared with whites. Often overlooked, the risk for CVD increases in a log-linear fashion; from SBP levels <115 mm Hg to >180 mm Hg, and from DBP levels <75 mm Hg to >105 mm Hg. A 20 mm Hg higher SBP and 10 mm Hg higher DBP are each associated with a doubling in the risk of death from stroke, heart disease, or other vascular disease. In persons ≥30 years of age, higher SBP and DBP are associated with increased risk for CVD, angina, myocardial infarction (MI), heart failure (HF), stroke,
peripheral arterial disease, and abdominal aortic aneurysm. SBP has consistently been associated with increased CVD risk after adjustment for, or within strata of, SBP; this is not true for DBP.
對于年齡大于45歲沒有高血壓者，非洲裔美國人40歲得高血壓的比例為93%，西班牙裔人為92%，白種人為86%，黃種人為84%。在2010年，全世界范圍內(nèi)高血壓作為導(dǎo)致死亡或致殘的首要原因，非洲裔女性比白種人的貢獻(xiàn)大。容易忽視的一點(diǎn)是，心血管疾病的危險(xiǎn)成線性增長。收縮壓從 <115 mm Hg 到>180 mm Hg, 和舒張壓 DBP 從 <75 mm Hg 到 >105 mm Hg，收縮壓每升高 20 mm Hg 和舒張壓每升高10 mm Hg ,卒中、心臟病和其他血管病的死亡風(fēng)險(xiǎn)增加2倍。大于30歲的成年人，高收縮壓和舒張壓增加心血管疾病、心絞痛、心肌梗死、心力衰竭、外周動(dòng)脈疾病和腹主動(dòng)脈瘤的風(fēng)險(xiǎn)。收縮壓升高不同于舒張壓升高，收縮壓升高在調(diào)整了其他危險(xiǎn)因素后，仍然增加心血管疾病的風(fēng)險(xiǎn)。
4 It is important to screen for and manage other CVD risk factors in adults with hypertension: smoking, diabetes, dyslipidemia, excessive weight, low fitness, unhealthy diet, psychosocial stress, and sleep apnea. Basic testing for primary hypertension includes fasting blood glucose, complete blood cell count, lipids, basic metabolic panel, thyroid stimulating hormone, urinalysis, electrocardiogram with optional echocardiogram, uric acid, and urinary albumin-to-creatinine ratio.
對于血壓升高的成年人，還要篩查出現(xiàn)其他心血管疾病的危險(xiǎn)因素，比如吸煙、糖尿病、血脂異常、超重、不健康飲食、精神壓力和睡眠呼吸暫停等。原發(fā)性高血壓基礎(chǔ)的檢測應(yīng)該包括空腹血糖、全血細(xì)胞計(jì)數(shù)、血脂、基礎(chǔ)代謝狀態(tài)、甲狀腺激素水平、尿液檢查、心電圖、心臟超聲、尿酸和尿白蛋白/肌酐比值。
5 Screening for secondary causes of hypertension is necessary for new-onset or uncontrolled hypertension in adults including drug-resistant (≥3 drugs), abrupt onset, age <30 years, excessive target organ damage (cerebral vascular disease, retinopathy, left ventricular hypertrophy, HF with preserved ejection fraction [HFpEF] and HF with reserved EF [HFrEF], coronary artery disease [CAD], chronic kidney disease [CKD], peripheral artery disease, albuminuria) or for onset of diastolic hypertension in older adults or in the presence of unprovoked or excessive hypokalemia. Screening includes testing for CKD, renovascular disease, primary aldosteronism, obstructive sleep apnea, drug-induced hypertension (nonsteroidal anti-inflammatory drugs, steroids/androgens, decongestants, caffeine, monoamine oxidase inhibitors), and alcohol-induced hypertension. If more specific clinical characteristics are present, screening for uncommon causes of secondary hypertension is indicated (pheochromocytoma, Cushing’s syndrome, congenital adrenal hyperplasia, hypothyroidism, hyperthyroidism, and aortic coarctation). Physicians are advised to refer patients screening positive for these conditions to a clinician with specific expertise in the condition.
對于成年人新發(fā)的或者難以控制的高血壓，包括使用三種降壓藥物的頑固性高血壓、突然升高的高血壓、年齡小于30歲，嚴(yán)重的靶器官受損（包括腦血管疾病、視網(wǎng)膜病變、左心室肥厚、左室射血分?jǐn)?shù)保留的心衰、冠心病、慢性腎臟病、外周血管疾病、蛋白尿）或者年齡大的患者，以舒張壓升高為主要表現(xiàn)或嚴(yán)重低血鉀的患者，需要進(jìn)一步排除繼發(fā)性高血壓的可能。包括慢性腎臟病的檢測、腎血管疾病、原發(fā)性醛固酮升高、睡眠呼吸暫停綜合征、藥物相關(guān)性高血壓（包括非甾體類消炎藥、激素、減充血?jiǎng)?、咖啡因、單氨氧化酶抑制劑）和酒精誘導(dǎo)的高血壓。如果有其他特殊的臨床表現(xiàn)，對于一些非常見的原因也需要排除（比如嗜鉻細(xì)胞瘤、庫欣綜合征、先天性腎上腺增生、甲狀腺功能減退和甲狀腺功能亢進(jìn)和主動(dòng)脈夾層）。全科醫(yī)生應(yīng)該建議此類患者在高血壓?？漆t(yī)生的指導(dǎo)下做相應(yīng)疾病的篩查。
6 Nonpharmacologic interventions to reduce BP include: weight loss for overweight or obese patients with a heart healthy diet, sodium restriction, and potassium supplementation within the diet; and increased physical activity with a structured exercise program. Men should be limited to no more than 2 and women no more than 1 standard alcohol drink(s) per day. The usual impact of each lifestyle change is a 4-5 mm Hg decrease in SBP and 2-4 mm Hg decrease in DBP; but diet low in sodium, saturated fat, and total fat and increase in fruits, vegetables, and grains may decrease SBP by approximately 11 mm Hg.
非藥物干預(yù)降低血壓的方法有：超重或肥胖患者通過健康飲食、限鹽、富鉀食物來減體重；有計(jì)劃地增加運(yùn)動(dòng)量。應(yīng)該限制每天飲酒量，男性不超過2個(gè)標(biāo)準(zhǔn)的酒精量，女性不超過1個(gè)標(biāo)準(zhǔn)的酒精量。常規(guī)的每一項(xiàng)改善生活方式的舉措可以降低收縮壓4-5mmHg，舒張壓2-4mmHg。但是如果低鹽飲食、低飽和脂肪酸和全脂肪飲食、增加蔬菜、水果和谷物可以降低收縮壓大約11mmHg。
7 The benefit of pharmacologic treatment for BP reduction is related to atherosclerotic CVD (ASCVD) risk. For a given magnitude reduction of BP, fewer individuals with high ASCVD risk would need to be treated to prevent a CVD event (i.e., lower number needed to treat) such as in older persons, those with coronary disease, diabetes, hyperlipidemia, smokers, and CKD. Use of BP-lowering medications is recommended for secondary prevention of recurrent CVD events in patients with clinical CVD and an average SBP ≥130 mm Hg or a DBP ≥80 mm Hg, or for primary prevention in adults with no history of CVD but with an estimated 10-year ASCVD risk of ≥10% and SBP ≥130 mm Hg or DBP ≥80 mm Hg. Use of BP-lowering medication is also recommended for primary prevention of CVD in adults with no history of CVD and with an estimated 10-year ASCVD risk <10% and a SBP ≥140 mm Hg or a DBP ≥90 mm Hg.
藥物降低血壓的益處在于降低動(dòng)脈粥樣硬化性心血管疾病的發(fā)生。如果血壓能在指定范圍內(nèi)大幅度下降，動(dòng)脈粥樣硬化性心臟病高危的患者很少需要其他的治療來預(yù)防心血管事件（也就是更少的心血管疾病高?；颊咝枰委煟?，尤其是老年有冠心病、糖尿病、血脂異常、吸煙和慢性腎臟疾病的患者。有臨床心血管疾病的患者如果平均收縮壓≥130 mm Hg 或舒張壓 ≥80 mm Hg需要使用降壓藥物作為預(yù)防心血管疾病的二級預(yù)防，對于沒有心血管疾病但動(dòng)脈粥樣硬化心血管疾病的10年風(fēng)險(xiǎn)≥10%的患者，如果平均收縮壓≥130 mm Hg 或舒張壓 ≥80 mm Hg，需要使用降壓藥物作為心血管疾病的一級預(yù)防。在沒有心血管疾病，但動(dòng)脈粥樣硬化心血管疾病的10年風(fēng)險(xiǎn)≥10%的患者，如果平均收縮壓≥140 mm Hg 或舒張壓 ≥90 mm Hg，推薦使用降壓藥物作為一級預(yù)防。
The prevalence of hypertension is lower in women compared with men until about the fifth decade, but is higher later in life. While no randomized controlled trials have been powered to assess outcome specifically in women (e.g., SPRINT), other than special recommendations for management of hypertension during pregnancy, there is no evidence that the BP threshold for initiating drug treatment, the treatment target, the choice of initial antihypertensive medication, or the combination of medications for lowering BP differs for women compared with men. For adults with confirmed hypertension and known CVD or 10-year ASCVD event risk of 10% or higher, a BP target of <130/80 mm Hg is recommended. For adults with confirmed hypertension, but without additional markers of increased CVD risk, a BP target of <130/80 mm Hg is recommended as reasonable.
女性在50歲前高血壓的發(fā)生率低于男性，但50歲以后高血壓的發(fā)生率增加。目前沒有隨機(jī)對照的研究來有力評估預(yù)后，尤其是女性，除了妊娠高血壓的管理有特殊建議外，目前仍然沒有證據(jù)確定開始藥物治療的血壓閾值、血壓的目標(biāo)值、選擇什么藥物作為初始的降壓方案或聯(lián)合使用降壓藥物在男性和女性之間的區(qū)別。對于成年人如果有明確的心血管疾病或沒有心血管疾病但10年的動(dòng)脈粥樣硬化性心血管疾病的風(fēng)險(xiǎn)≥10%，把血壓的目標(biāo)值確定為<130/80 mm Hg是合理的。對于確認(rèn)高血壓的病人，但沒有增加心血管疾病危險(xiǎn)的其他因素，血壓目標(biāo)值定義為<130/80 mm Hg也是合理的。
8 Follow-up: In low-risk adults with elevated BP or stage 1 hypertension with low ASCVD risk, BP should be repeated after 3-6 months of nonpharmacologic therapy. Adults with stage 1 hypertension and high ASCVD risk (≥10% 10-year ASCVD risk) should be managed with both nonpharmacologic and antihypertensive drug therapy with repeat BP in 1 month. Adults with stage 2 hypertension should be evaluated by a primary care provider within 1 month of initial diagnosis, and be treated with a combination of nonpharmacologic therapy and 2 antihypertensive drugs of different classes with repeat BP evaluation in 1 month. For adults with a very high average BP (e.g., ≥160 mm Hg or DBP ≥100 mm Hg), prompt evaluation and drug treatment followed by careful monitoring and upward dose adjustment is recommended.
關(guān)于隨訪，在血壓升高的低危患者或1級高血壓且動(dòng)脈粥樣硬化性心血管疾病低危的患者，可以非藥物治療3-6月后重新測量血壓。如果1級高血壓但動(dòng)脈粥樣硬化性心血管疾病高危的患者（10年動(dòng)脈粥樣硬化心血管疾病風(fēng)險(xiǎn)≥10%）應(yīng)該在非藥物治療的同時(shí)使用降壓藥物，并且1個(gè)月后重新測量血壓。2級高血壓由初級醫(yī)療服務(wù)中心在最初診斷的1個(gè)月內(nèi)重新評估，而且應(yīng)該在非藥物治療同時(shí)使用2種不同種類的降壓藥物，并1個(gè)月后重新測量。收縮壓超過≥160 mm Hg 或舒張壓≥100 mm Hg的重度高血壓患者，及時(shí)全面評估并嚴(yán)密監(jiān)測血壓的情況下先調(diào)整降壓藥物，必要時(shí)增加劑量。
Part 2: Principles of Drug Therapy and Special Populations
第二部分：特殊人群使用降壓藥物的原則
9 Principles of drug therapy: Chlorthalidone (12.5-25 mg) is the preferred diuretic because of long half-life and proven reduction of CVD risk. Angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARBs), and direct renin inhibitors should not be used in combination. ACE inhibitors and ARBs increase the risk of hyperkalemia in CKD and with supplemental K+ or K+-sparing drugs. ACE inhibitors and ARBs should be discontinued during pregnancy. Calcium channel blocker (CCB) dihydropyridines cause edema. Non-dihydropyridine CCBs are associated with bradycardia and heart block and should be avoided in HFrEF. Loop diuretics are preferred in HF and when glomerular filtration rate (GFR) is <30 ml/min. Amiloride and triamterene can be used with thiazides in adults with low serum K+, but should be avoided with GFR <45 ml/min.
降壓藥物使用的原則：氫氯噻嗪（12.5-25mg）因?yàn)槠浒胨テ陂L且證實(shí)可以降低心血管的風(fēng)險(xiǎn)可以作為合適的利尿劑來降低血壓。血管緊張素轉(zhuǎn)換酶抑制劑（ACEI）、血管緊張素受體拮抗劑(ARB)和直接腎素抑制劑不能聯(lián)合使用。ACEI和ARB聯(lián)合使用，如果同時(shí)補(bǔ)充氯化鉀或服含鉀豐富的食物時(shí)，有升高血鉀的風(fēng)險(xiǎn)。二氫吡啶類鈣離子拮抗劑可以引起水腫。非二氫吡啶類鈣離子拮抗劑可能導(dǎo)致心動(dòng)過緩和心臟傳導(dǎo)阻滯，并應(yīng)避免在射血分?jǐn)?shù)下降的心力衰竭病人中使用。袢利尿劑在心力衰竭和腎小球?yàn)V過率<30 ml/min的患者中使用。氨氯地平和氨苯蝶啶可以和噻嗪類利尿劑合用，尤其是低血鉀的患者，但在腎小球?yàn)V過率<45 ml/min的患者中避免使用。
Spironolactone or eplerenone is preferred for the treatment of primary aldosteronism and in resistant hypertension. Beta-blockers are not first-line therapy except in CAD and HFrEF. Abrupt cessation of beta-blockers should be avoided. Bisoprolol and metoprolol succinate are preferred in hypertension with HFrEF and bisoprolol when needed for hypertension in the setting of bronchospastic airway disease. Beta-blockers with both alpha- and beta-receptor activity such as carvedilol are preferred in HFrEF.
安體舒通和依普利同在原發(fā)性醛固酮增多癥和頑固性高血壓的患者中建議使用。倍他受體阻滯劑除了在冠心病和左室射血分?jǐn)?shù)下降的心衰中作為一線藥物使用，其他情況不作為一線降壓藥物。應(yīng)該避免突然停用倍他受體阻滯劑。比索洛爾和琥珀酸美托洛爾在左心室射血分?jǐn)?shù)下降的心力衰竭中使用，但比索洛爾可以用于氣道痙攣性的高血壓患者。同時(shí)阻斷α和β受體的倍他受體阻滯劑比如卡維地洛爾在左心室射血分?jǐn)?shù)下降的心衰患者中可以使用。
10 Alpha-1 blockers are associated with orthostatic hypotension; this drug class may be considered in men with symptoms of benign prostatic hyperplasia. Central acting alpha-1 agonists should be avoided, and are reserved as last-line due to side effects and the need to avoid sudden discontinuation. Direct-acting vasodilators are associated with sodium and water retention and must be used with a diuretic and beta-blocker.
α1受體阻滯劑與體位性低血壓相關(guān)，這類藥物可以用于男性有良性前列腺增生癥狀的患者。中樞α1受體阻滯劑應(yīng)該避免使用，因副作用大作為最后考慮使用的藥物，且應(yīng)避免突然停藥。直接血管擴(kuò)張劑因可導(dǎo)致水鈉潴留，必須和利尿劑和倍他受體阻滯劑合用。
11 Initial first-line therapy for stage 1 hypertension includes thiazide diuretics, CCBs, and ACE inhibitors or ARBs. Two first-line drugs of different classes are recommended with stage 2 hypertension and average BP of 20/10 mm Hg above the BP target. Improved adherence can be achieved with once-daily drug dosing, rather than multiple dosing, and with combination therapy rather than administration of the free individual components.
噻嗪類利尿劑、鈣離子拮抗劑、ACEI或ARB都可以作為1級高血壓的初始治療藥物。2級高血壓和血壓超過目標(biāo)值20/10 mm Hg的患者可以初始合用兩種不同的降壓藥物。建議長效的降壓藥物，一天一次使用，而不是多次使用，以提高患者的依從性，建議固定復(fù)方制劑而不是自由聯(lián)合方案以提高依從性。
12 For adults with confirmed hypertension and known stable CVD or ≥10% 10-year ASCVD risk, a BP target of <130/80 mm Hg is recommended. The strategy is to first follow standard treatment guidelines for CAD, HFrEF, previous MI, and stable angina, with the addition of other drugs as needed to further control BP. In HFpEF with symptoms of volume overload, diuretics should be used to control hypertension, following which ACE inhibitors or ARBs and beta-blockers should be titrated to SBP <130 mm Hg. Treatment of hypertension with an ARB can be useful for prevention of recurrence of atrial fibrillation.
如果高血壓且動(dòng)脈粥樣硬化性心血管疾病高危的患者（10年動(dòng)脈粥樣硬化心血管疾病風(fēng)險(xiǎn)≥10%），建議血壓控制的目標(biāo)在<130/80 mm Hg。治療的策略首先是按照標(biāo)準(zhǔn)的冠心病、左心室射血分?jǐn)?shù)下降心力衰竭、陳舊性心肌梗死和穩(wěn)定性心絞痛的治療指南，同時(shí)加用其他的藥物進(jìn)一步控制血壓。在左心室射血分?jǐn)?shù)保留的心力衰竭，有容量負(fù)荷過重的癥狀，利尿劑可以用來控制血壓，同時(shí)使用ACEI或ARB及倍他受體阻滯劑，逐漸調(diào)整劑量，控制血壓目標(biāo)在<130/80 mm Hg。使用ARB治療高血壓可以預(yù)防心房顫動(dòng)的復(fù)發(fā)。
13 CKD: BP goal should be <130/80 mm Hg. In those with stage 3 or higher CKD or stage 1 or 2 CKD with albuminuria (>300 mg/day), treatment with an ACE inhibitor is reasonable to slow progression of kidney disease. An ARB is reasonable if an ACE inhibitor is not tolerated.
慢性腎臟?。貉獕耗繕?biāo)值在<130/80 mm Hg。在慢性腎臟病3級以上的病人或慢性腎臟病1級或2級蛋白尿(>300 mg/day)，使用ACEI可以延緩腎臟病的進(jìn)展。如果ACEI不能耐受可以使用ARB。
14 Adults with stroke and cerebral vascular disease are complex. To accommodate the variety of important issues pertaining to BP management in the stroke patient, treatment recommendations require recognition of stroke acuity, stroke type, and therapeutic objectives, which along with ideal antihypertensive therapeutic class have not been fully studied in clinical trials. In adults with acute intracranial hemorrhage and SBP >220 mm Hg, it may be reasonable to use continuous intravenous drug infusion with close BP monitoring to lower SBP. Immediate lowering of SBP to <140 mm Hg from 150-220 mm Hg is not of benefit to reduce death, and may cause harm. In acute ischemic stroke, BP should be lowered slowly to <185/110 mm Hg prior to thrombolytic therapy and maintained to <180/105 mm Hg for at least the first 24 hours after initiating drug therapy. Starting or restarting antihypertensive therapy during the hospitalization when patients with ischemic stroke are stable with BP >140/90 mm Hg is reasonable. In those who do not undergo reperfusion therapy with thrombolytics or endovascular treatment, if the BP is ≥220/120 mm Hg, the benefit of lowering BP is not clear, but it is reasonable to consider lowering BP by 15% during the first 24 hours post onset of stroke. However, initiating or restarting treatment when BP is <220/120 mm Hg within the first 48-72 hours post-acute ischemic stroke is not effective.
有卒中和腦血疾病的患者情況比較復(fù)雜，因卒中的類型、卒中的程度和治療目標(biāo)不同，在臨床上目前尚無針對不同情況的理想降壓藥物。急性顱內(nèi)出血的患者，收縮壓>220 mm Hg，需要在密切監(jiān)測血壓的情況下，使用靜脈降壓藥物來降低血壓。血壓直接從150-220mmHg下降到<140 mm Hg并不能降低死亡的風(fēng)險(xiǎn)，反而有害。在急性缺血性卒中，血壓應(yīng)該在使用降壓藥物24小時(shí)內(nèi)慢慢降低到<180/105 mm Hg。在缺血性卒中患者住院期間如果血壓>140/90 mm Hg，開始或重新開始使用降壓藥物是合理的。如果沒有用溶栓藥物治療或血管內(nèi)治療的患者，血壓≥220/120 mm Hg，降低血壓是否能獲益目前并不明確，但是在卒中發(fā)生最初的24小時(shí)內(nèi)血壓降低15%是合理的。然而急性缺血性卒中的48-72小時(shí)內(nèi)，血壓在<220/120 mm Hg，開始或重新開始降壓治療并不有效。
15 Secondary prevention following a stroke or transient ischemic attack (TIA) should begin by restarting treatment after the first few days of the index event to reduce recurrence. Treatment with ACE inhibitor or ARB with thiazide diuretic is useful. Those not previously treated for hypertension and who have a BP ≥140/90 mm Hg should begin antihypertensive therapy a few days after the index event. Selection of drugs should be based on comorbidities. A goal of <130/80 mm Hg may be reasonable for those with a stroke, TIA, or lacunar stroke. For those with an ischemic stroke and no previous treatment for hypertension, there is no evidence of treatment benefit if the BP is <140/90 mm Hg.
16 在卒中發(fā)作最初幾天內(nèi)開始使用降壓藥物，可以作為卒中或短暫腦缺血發(fā)作的二級預(yù)防措施來預(yù)防復(fù)發(fā)。使用ACEI或ARB聯(lián)合噻嗪類利尿劑是有用的。如果血壓≥140/90 mm且以前未使用過降壓藥物的患者，應(yīng)該在卒中事件發(fā)作后的幾天內(nèi)開始使用降壓藥物。藥物的選擇應(yīng)該在評估合并癥后再考慮選擇。卒中、短暫腦缺血發(fā)作或腔隙性卒中的患者，控制血壓在<130/80 mmHg是合理的。但如果沒有缺血性卒中病史、未經(jīng)治療過的高血壓，血壓控制在<140/90 mm Hg是否獲益目前尚無證據(jù)。
17 Diabetes mellitus (DM) and hypertension: Antihypertensive drug treatment should be initiated at a BP ≥130/80 mm Hg with a treatment goal of <130/80 mm Hg. In adults with DM and hypertension, all first-line classes of antihypertensive agents (i.e., diuretics, ACE inhibitors, ARBs, and CCBs) are useful and effective. ACE inhibitors or ARBs may be considered in the presence of albuminuria.
糖尿病和高血壓：糖尿病的患者血壓在≥130/80 mm Hg應(yīng)該開始抗高血壓治療，治療的目標(biāo)值是<130/80 mm Hg。糖尿病合并高血壓的患者，所有的一線降壓藥物（利尿劑、ACEI、ARB和鈣離子拮抗劑）都是可用和有效的。在出現(xiàn)蛋白尿時(shí)首選ACEI或ARB。
18 Metabolic syndrome: Lifestyle modification with an emphasis on improving insulin sensitivity by means of dietary modification, weight reduction, and exercise is the foundation of treatment of the metabolic syndrome. The optimal antihypertensive drug therapy for patients with hypertension in the setting of the metabolic syndrome has not been clearly defined. Chlorthalidone was at least as effective for reducing CV events as the other antihypertensive agents in the ALLHAT study. Traditional beta-blockers should be avoided unless used for ischemic heart disease.
代謝綜合征：生活方式改變是提高胰島素敏感性的重點(diǎn)，飲食結(jié)構(gòu)的改變、減體重和運(yùn)動(dòng)是代謝綜合征治療的基礎(chǔ)。在代謝綜合征背景下的理想的降壓藥物，目前的研究還沒有確定。氯噻酮至少在ALLHAT研究中證實(shí)可以與其他降壓藥物一樣可以減少心血管事件。常規(guī)的倍他受體阻滯劑應(yīng)該避免使用，除非同時(shí)有缺血性心臟病。
19 Valvular heart disease: Asymptomatic aortic stenosis with hypertension should be treated with pharmacotherapy, starting at a low dose, and gradually titrated upward as needed. In patients with chronic aortic insufficiency, treatment of systolic hypertension is reasonable with agents that do not slow the heart rate (e.g., avoid beta-blockers).
瓣膜性心臟?。簾o癥狀的高血壓合并主動(dòng)脈瓣狹窄，應(yīng)該開始使用降壓藥物，從小劑量開始，根據(jù)血壓，慢慢滴定降壓藥物的劑量。慢性主動(dòng)脈瓣關(guān)閉不全的患者，使用降低收縮壓的降壓藥物，同時(shí)避免減慢心率（比如避免使用倍他受體阻滯劑）。
20 Aortic disease: Beta-blockers are recommended as the preferred antihypertensive drug class in patients with hypertension and thoracic aortic disease.
主動(dòng)脈疾?。涸谛刂鲃?dòng)脈疾病合并高血壓的患者中推薦倍他受體阻滯劑。
21 Race/ethnicity: In African American adults with hypertension but without HF or CKD, including those with DM, initial antihypertensive treatment should include a thiazide-type diuretic or CCB. Two or more antihypertensive medications are recommended to achieve a BP target of <130/80 mm Hg in most adults, especially in African American adults, with hypertension.
種族：非洲裔美國人如果沒有心衰或慢性腎臟病，包括糖尿病的患者，初始治療應(yīng)該包括噻嗪類利尿劑或鈣離子拮抗劑。大多數(shù)的高血壓成年人，尤其是非洲裔的美國人，需要2種或2種以上的降壓藥物，控制血壓<130/80 mm Hg。
22 Age-related issues: Treatment of hypertension is recommended for noninstitutionalized ambulatory community-dwelling adults (≥65 years of age), with an average SBP ≥130 mm Hg with SBP treatment goal of <130 mm Hg. For older adults (≥65 years of age) with hypertension and a high burden of comorbidity and/or limited life expectancy, clinical judgment, patient preference, and a team-based approach to assess risk/benefit is reasonable for decisions regarding intensity of BP lowering and choice of antihypertensive drugs. BP lowering is reasonable to prevent cognitive decline and dementia.
年齡相關(guān)的情況：年齡≥65歲，如果一般狀況良好，生活自理的老人，血壓的平均收縮壓≥130 mm Hg需要高血壓的治療，血壓目標(biāo)值<130 mm Hg。年齡≥65歲的高血壓患者，合并很多疾病、預(yù)期壽命有限、病人狀況差，在開始降壓治療前，對于降壓的強(qiáng)度和藥物的選擇，需要權(quán)衡利弊。降壓治療可以預(yù)防認(rèn)知功能的下降和老年癡呆。
23 Preoperative surgical procedures: Beta-blockers should be continued in persons with hypertension undergoing major surgery, as should other antihypertensive drug therapy until surgery. Discontinuation of ACE inhibitors and ARBs perioperatively may be considered. For patients with planned elective major surgery and SBP ≥180 mm Hg or DBP ≥110 mm Hg, deferring surgery may be considered. Abrupt preoperative discontinuation of beta-blockers or clonidine may be harmful. Intraoperative hypertension should be managed with intravenous medication until oral medications can be resumed.
圍外科手術(shù)期降壓：有高血壓的患者在重大手術(shù)前，可以繼續(xù)使用倍他受體阻滯劑，其他降壓藥物可以繼續(xù)使用直到手術(shù)。圍手術(shù)期建議暫停ACEI和ARB。擇期重大手術(shù)如果收縮壓 ≥180 mm Hg 或 舒張壓 ≥110 mm Hg，應(yīng)暫停手術(shù)。手術(shù)前突然停用倍他受體阻滯劑或可樂定是有害的。手術(shù)室內(nèi)血壓升高需要靜脈使用降壓藥物，直到口服藥物可以恢復(fù)使用。
24 For discussion regarding hypertensive crises with and without comorbidities, refer to Section 11.2: Hypertensive Crises–Emergencies and Urgencies in the Guideline.
合并癥或無合并癥的高血壓危象的治療-另外討論
25 Every adult with hypertension should have a clear, detailed, and current evidence-based plan of care that ensures the achievement of treatment and self-management goals; effective management of comorbid conditions; timely follow-up with the healthcare team; and adheres to CVD evidence-based guidelines. Effective behavioral and motivational strategies are recommended to promote lifestyle modification. A structured team-based approach including a physician, nurse, and pharmacist collaborative model is recommended, along with integrating home-based monitoring and telehealth interventions. Outcome may be improved with quality improvement strategies at the health system, provider, and patient level. Financial incentives paid to providers can be useful.
每一個(gè)高血壓患者應(yīng)該有一個(gè)清晰、具體和目前循證證據(jù)為基礎(chǔ)的計(jì)劃，保證血壓治療的達(dá)標(biāo)和自我管理目標(biāo)的實(shí)現(xiàn)；有效管理合并存在的一些疾病，定期隨訪，遵循有心血管疾病證據(jù)支持的指南。通過有效的行為和自我驅(qū)動(dòng)來改善生活方式。嚴(yán)格的以團(tuán)隊(duì)為基礎(chǔ)的隊(duì)伍建設(shè)包括：內(nèi)科，醫(yī)生、護(hù)士和藥劑師合作的模式，聯(lián)合家庭監(jiān)測系統(tǒng)和遠(yuǎn)程管理的介入。提高整個(gè)健康系統(tǒng)、健康系統(tǒng)的提供者和患者本身的血壓管理水平，可以改善預(yù)后。對管理者提供財(cái)力上的獎(jiǎng)勵(lì)是有效的。
說明：本文英文部分來自ACC官方網(wǎng)站，中文部分由@劉燕榮醫(yī)生 翻譯。
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