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/41/2/199http://www.ncbi.nlm.nih.gov/pubmed/12574081?tool=bestpractice.com
阅读更多在美国多家学术团体（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）[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 、英国高血压学会 (British Society of Hypertension)[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.http://www.nature.com/jhh/journal/v18/n3/full/1001683a.htmlhttp://www.ncbi.nlm.nih.gov/pubmed/14973512?tool=bestpractice.com 和欧洲高血压学会 (European Society of Hypertension) 的联合指南已经定义了高血压。[4]Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013 Jul;34(28):2159-219.http://eurheartj.oxfordjournals.org/content/34/28/2159.longhttp://www.ncbi.nlm.nih.gov/pubmed/23771844?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、检测、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.comACC/AHA 血压类别的定义如下：
血压升高：收缩压 120 至 129 mmHg 且舒张压 <80 mmHg
1 期高血压：收缩压 130 至 139 mmHg 和/或舒张压 80 至 89 mmHg
2 期高血压：收缩压≥140 mmHg 和/或舒张压≥90 mmHg。
与美国全国联合委员会 (Joint National Committee, JNC) 第 7 次和第 8 次报告建议相比，2017 年 ACC/AHA 指南定义给出了更积极的高血压诊断和治疗方法，在 JNC 建议中，在 120 至 139 mmHg/80 至 89 mmHg 范围内的血压被认为是高血压前期，超过 140/90 mmHg 的血压被认为是升高。[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=1791497http://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论。并非所有人都完全接受 2017 ACC/AHA 指南，有人呼吁重新审议这些建议。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。[7]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/NEJMoa1511939http://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
欧洲指南对高血压的分类如下：[4]Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013 Jul;34(28):2159-219.http://eurheartj.oxfordjournals.org/content/34/28/2159.longhttp://www.ncbi.nlm.nih.gov/pubmed/23771844?tool=bestpractice.com[8]National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Nov 2016 [internet publication].https://www.nice.org.uk/guidance/cg127
1 级：收缩压 140 至 159 mmHg 和/或舒张压 90 至 99 mmHg
2 级：收缩压 160 至 179 mmHg 和/或舒张压 100 至 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。[8]National Institute for Health and Care Excellence. Hypertension in adults: diagnosis and management. Nov 2016 [internet publication].https://www.nice.org.uk/guidance/cg127
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]Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC guidelines for the management of arterial hypertension: the Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Eur Heart J. 2013 Jul;34(28):2159-219.http://eurheartj.oxfordjournals.org/content/34/28/2159.longhttp://www.ncbi.nlm.nih.gov/pubmed/23771844?tool=bestpractice.com
尽管不同研究采用了不同的临界值在社区诊断高血压，但是收缩压超过 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。
本专题讨论了成人高血压的评估。
流行病学
在美国，国家健康与营养检查调查 (National Health and Nutrition Survey, NHANES) 数据提示，29% 的成人（>18 岁）患有高血压（临界值 140/90 mmHg）。患病率从 18 至 39 岁人群的 7% 至 >60 岁人群的 66% 不等。[9]Ong KL, Cheung BM, Man YB, et al. Prevalence, awareness, treatment, and control of hypertension among United States adults 1999-2004. Hypertension. 2007 Jan;49(1):69-75.http://hyper.ahajournals.org/cgi/content/full/49/1/69http://www.ncbi.nlm.nih.gov/pubmed/17159087?tool=bestpractice.com 患病率在西欧似乎更高一些。[10]Wolf-Maier K, Cooper RS, Banegas JR, et al. Hypertension prevalence and blood pressure levels in 6 European countries, Canada, and the United States. JAMA. 2003 May 14;289(18):2363-9.http://jama.ama-assn.org/cgi/content/full/289/18/2363http://www.ncbi.nlm.nih.gov/pubmed/12746359?tool=bestpractice.com 然而，由于血压升高通常无症状，确切的高血压患病率很难评估，同时如果高血压的诊断重新定义在较低的阈值水平，其患病率预计会增高。
并发症和靶器官损害
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。[11]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/35/2/539http://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风险和预防脑血管事件。慢性高血压对器官的影响被称为靶器官损害。
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。[12]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。[13]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
心血管风险
高血压管理指南强调评估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。对于 40-70 岁的个体而言，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。[14]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 meta 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。[15]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）。[15]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
