The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II - Therapy
The 2006 Canadian Hypertension Education Program recommendations for the management of hypertension: Part II - Therapy
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DOI：
10.1016/s0828-282x(06)70280-x
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发表时间：
2006-05-15
影响因子：
6.2
通讯作者：
Touyz, RM
中科院分区：
文献类型：
--
作者：
Khan, NA;McAlister, FA;Touyz, RM
目的：为成人高血压的管理提供最新的、基于证据的建议。 选择和结果：对于生活方式和药物干预，优先审查随机对照试验和系统评价试验的证据。心血管发病率和死亡率的变化是主要的关注结果。对于生活方式干预，鉴于缺乏该领域的长期发病率/死亡率数据，降低血压（BP）被认为是主要结局。对于肾病患者的治疗，蛋白尿的发生或肾功能恶化也被认为是临床相关的主要结局。证据：MEDLINE 搜索于 2004 年 11 月至 2005 年 10 月进行，以更新 2005 年的建议。此外，还扫描了参考文献列表并联系了专家以确定其他已发表的研究。所有相关文章均由内容和方法专家使用预先设定的证据水平进行独立审查和评估。 建议：预防和/或治疗高血压的生活方式改变包括：每周 4 至 7 天进行 30 分钟至 60 分钟的有氧运动；保持健康的体重（体重指数为18.5公斤/米(2)至24.9公斤/米(2)）和腰围（男性小于102厘米，女性小于88厘米）；将饮酒量限制为男性每周不超过 14 个标准杯，女性每周不超过 9 个标准杯；遵循减少饱和脂肪和胆固醇的饮食，并强调水果、蔬菜和低脂乳制品；限制盐的摄入量；并考虑对选定的个人进行压力管理。治疗阈值和目标应考虑每个人的整体动脉粥样硬化风险、靶器官损伤和合并症。所有患者的血压应降低至 140/90 mmHg 以下，糖尿病或慢性肾病患者（无论蛋白尿程度如何）应降低至 130/80 mmHg 以下。大多数患有高血压的成年人需要不止一种药物才能达到这些目标血压。对于没有其他药物强制适应症的成年人，初始治疗应包括噻嗪类利尿剂。适用于伴有或不伴有收缩期高血压的舒张期高血压一线治疗的其他药物包括 β 受体阻滞剂（对于 60 岁以下的患者）、血管紧张素转换酶 (ACE) 抑制剂（对于非黑人患者）、长效钙通道阻滞剂或血管紧张素受体拮抗剂。用于单纯收缩期高血压一线治疗的其他药物包括长效二氢吡啶钙通道阻滞剂或血管紧张素受体拮抗剂。某些合并症为一线使用其他药物提供了令人信服的适应症：对于患有心绞痛、近期心肌梗塞或心力衰竭的患者，建议将β受体阻滞剂和ACE抑制剂作为一线治疗；对于糖尿病患者，ACE抑制剂或血管紧张素受体拮抗剂（或无蛋白尿的患者、噻嗪类或二氢吡啶钙通道阻滞剂）是合适的一线治疗，而对于非糖尿病慢性肾病患者，推荐使用ACE抑制剂。所有高血压患者都应进行空腹血脂筛查，血脂异常患者应使用加拿大高血压教育计划工作组推荐的血脂异常管理和心血管疾病预防阈值、目标和药物进行治疗。选定的高血压但无血脂异常的患者也应接受他汀类药物治疗和/或乙酰水杨酸治疗。 验证：所有建议均根据证据强度进行分级，并由加拿大高血压教育计划循证建议工作组的 45 名成员投票表决。此处报告的所有建议均获得了至少 95% 的共识。这些指南将继续每年更新。
OBJECTIVE: To provide updated, evidence-based recommendations for the management of hypertension in adults.OPTIONS AND OUTCOMES: For lifestyle and pharmacological interventions, evidence from randomized, controlled trials and systematic reviews of trials was preferentially reviewed. Changes in cardiovascular morbidity and mortality were the primary outcomes of interest. For lifestyle interventions, blood pressure (BP) lowering was accepted as a primary outcome given the lack of long-term morbidity/mortality data in this field. For treatment of patients with kidney disease, the development of proteinuria or worsening of kidney function was also accepted as a clinically relevant primary outcome. EVIDENCE: MEDLINE searches were conducted from November 2004 to October 2005 to update the 2005 recommendations. In addition, reference lists were scanned and experts were contacted to identify additional published studies. All relevant articles were reviewed and appraised independently by content and methodological experts using prespecified levels of evidence.RECOMMENDATIONS: Lifestyle modifications to prevent and/or treat hypertension include the following: perform 30 min to 60 min of aerobic exercise four to seven days per week; maintain a healthy body weight (body mass index of 18.5 kg/m(2) to 24.9 kg/m(2)) and waist circumference (less than 102 cm for men and less than 88 cm for women); limit alcohol consumption to no more than 14 standard drinks per week in men or nine standard drinks per week in women; follow a diet that is reduced in saturated fat and cholesterol and that emphasizes fruits, vegetables and low-fat dairy products; restrict salt intake; and consider stress management in selected individuals. Treatment thresholds and targets should take into account each individual's global atherosclerotic risk, target organ damage and comorbid conditions. BP should be lowered to less than 140/90 mmHg in all patients, and to less than 130/80 mmHg in those with diabetes mellitus or chronic kidney disease (regardless of the degree of proteinuria). Most adults with hypertension require more than one agent to achieve these target BPs. For adults without compelling indications for other agents, initial therapy should include thiazide diuretics. Other agents appropriate for first-line therapy for diastolic hypertension with or without systolic hypertension include beta-blockers (in those younger than 60 years), angiotensin-converting enzyme (ACE) inhibitors (in nonblack patients), long-acting calcium channel blockers or angiotensin receptor antagonists. Other agents for first-line therapy for isolated systolic hypertension include long-acting dihydropyridine calcium channel blockers or angiotensin receptor antagonists. Certain comorbid conditions provide compelling indications for first-line use of other agents: in patients with angina, recent myocardial infarction or heart failure, beta-blockers and ACE inhibitors are recommended as first-line therapy; in patients with diabetes mellitus, ACE inhibitors or angiotensin receptor antagonists (or in patients without albuminuria, thiazides or dihydropyridine calcium channel blockers) are appropriate first-line therapies-, and in patients with nondiabetic chronic kidney disease, ACE inhibitors are recommended. All hypertensive patients should have their fasting lipids screened, and those with dyslipidemia should be treated using the thresholds, targets and agents recommended by the Canadian Hypertension Education Program Working Group on the management of dyslipidemia and the prevention of cardiovascular disease. Selected patients with hypertension, but without dyslipidemia, should also receive statin therapy and/or acetylsalicylic acid therapy.VALIDATION: All recommendations were graded according to strength of the evidence and voted on by the 45 members of the Canadian Hypertension Education Program Evidence-Based Recommendations Task Force. All recommendations reported here achieved at least 95% consensus. These guidelines will continue to be updated annually.