2012欧洲肥胖和难治性高血压共识声明解读
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&&&&肥胖和高血压是两项经常合并存在的重要心血管危险因素。早在19世纪20年代，人们就已经认识到肥胖与高血压的密切关系。1948年世界卫生组织（WHO）正式将肥胖列入疾病名单，并认为是高血压、2型糖尿病等多种疾病的危险因素。
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正常人的血压随内外环境变化在一定范围内波动。在整体人群，血压水平随年龄逐渐升高，以收缩压更为明显，但50岁后舒张压呈现下降趋势，脉压也随之加大。近年来，人们对心血管病多重危险因素作用以及心、脑、肾靶器官保护的认识不断深入，高血压的诊断标准也在不断调整，目前认为同一血压水平的患者发生心血管病的危险不同，因此有了血压分层的概念，即发生心血管病危险度不同的患者，适宜血压水平应有不同。医生面对患者时在参考标准的基础上，根据其具体情况判断该患者最合适的血压范围，采用针对性的治疗措施。
内科，心血管内科
遗传，环境，年龄，肥胖等
1.习惯因素遗传
大约半数高血压患者有家族史。
2.环境因素
发病率着随年龄增长而增高的趋势，40岁以上者发病率高。
肥胖者发病率高；避孕药；睡眠呼吸暂停低通气综合征。临床上高血压可分为两类：
1.原发性高血压
是一种以血压升高为主要临床表现而病因尚未明确的独立疾病。
2.继发性高血压
又称为症状性高血压，在这类疾病中病因明确，高血压仅是该种疾病的临床表现之一，血压可暂时性或持久性升高。高血压的症状因人而异。早期可能无症状或症状不明显，仅仅会在劳累、精神紧张、情绪波动后发生血压升高，并在休息后恢复正常。随着病程延长，血压明显的持续升高，逐渐会出现各种症状。此时被称为缓进型高血压病。缓进型高血压病常见的临床症状有头痛、头晕、注意力不集中、记忆力减退、肢体麻木、夜尿增多、心悸、胸闷、乏力等。当血压突然升高到一定程度时甚至会出现剧烈头痛、呕吐、心悸、眩晕等症状，严重时会发生神志不清、抽搐。这就属于急进型高血压和高血压危重症，多会在短期内发生严重的心、脑、肾等器官的损害和病变，如中风、心梗、肾衰等。症状与血压升高的水平并无一致的关系。目前国内高血压的诊断采用2000年中国高血压治疗指南建议的标准：
收缩压（mmHg）
舒张压（mmHg）
1级高血压（轻度）
2级高血压（中度）
3级高血压（重度）
单纯收缩期高血压
如患者的收缩压与舒张压分属不同的级别时，则以较高的分级标准为准。单纯收缩期高血压也可按照收缩压水平分为1、2、3级。
高血压患者心血管危险分层标准：
其他危险因素和病史
无其他危险因素
1-2个危险因素
≥3个危险因素或糖尿病或靶器官损害
1.治疗目的及原则
降压治疗的最终目的是减少高血压患者心、脑血管病的发生率和死亡率。降压治疗应该确立血压控制目标值。另一方面，高血压常常与其他心、脑血管病的危险因素合并存在，例如高胆固醇血症、肥胖、糖尿病等，协同加重心血管疾病危险，治疗措施应该是综合性的。
（1）改善生活行为①减轻体重。②减少钠盐摄入。③补充钙和钾盐。④减少脂肪摄入。⑤增加运动。⑥戒烟、限制饮酒。
（2）血压控制标准个体化由于病因不同，高血压发病机制不尽相同，临床用药分别对待，选择最合适药物和剂量，以获得最佳疗效。
（3）多重心血管危险因素协同控制降压治疗后尽管血压控制在正常范围，血压升高以外的多种危险因素依然对预后产生重要影响。
2.降压药物治疗
（1）降压药物种类①利尿药。②β受体阻滞剂。③钙通道阻滞剂。④血管紧张素转换酶抑制剂。⑤血管紧张素II受体阻滞剂。
（2）治疗方案大多数无并发症或合并症患者可以单独或者联合使用噻嗪类利尿剂、β受体阻滞剂等。治疗应从小剂量开始，逐步递增剂量。临床实际使用时，患者心血管危险因素状况、靶器官损害、并发症、合并症、降压疗效、不良反应等，都会影响降压药的选择。2级高血压患者在开始时就可以采用两种降压药物联合治疗。1.原发性高血压
2.继发性高血压
3.肾血管性高血压
4.白大衣高血压
5.妊娠高血压疾病
于康 主任医师 北京协和医院 营养科 来自：
于康 主任医师 北京协和医院 营养科 来自：
黄桂忠 主任医师 广西百色市人民医院 心血管内科 来自：
殷惠军 主任医师 中国中医科学院西苑医院 心血管内科 来自：
于康 主任医师 北京协和医院 营养科 来自：
惠汝太 教授；主任医师 中国医学科学院阜外心血管病医院 心血管内科
孙宁玲，中国医师协会高血压专业委员会主任委员、中国高血压联盟副主席、北大人民医院心脏中心副主任、主任医师、教授。
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【medical-news】药物抵抗型高血压正越来越成为健康的威胁
心血管内科
【medical-news】药物抵抗型高血压正越来越成为健康的威胁
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Drug-Resistant High Blood Pressure on the RiseHigh blood pressure, the most commonly diagnosed condition in the United States, is becoming increasingly resistant to drugs that lower it, according to a panel of experts assembled by the American Heart Association.“It’s becoming more difficult to treat and it’s requiring more and more medications to do so,” said the panel chairman, Dr. David A. Calhoun, a hypertension specialist at the University of Alabama at Birmingham. The problem is not that the medications have stopped working, said the report, published this month in the journal Hypertension. Instead, many blood-pressure patients are sicker to begin with and require more drugs, at greater dosages, to manage their conditions.The doctors say this is especially worrisome because recent surveys estimate that one in three Americans have hypertension, an underlying cause of heart attacks, strokes, kidney disease and heart failure.Starting at a blood pressure of 115/80, research shows that the risk of a heart attack or stroke doubles with every 20-point increase of systolic pressure, the top number, or 10-point increase of diastolic pressure, the bottom number.“High blood pressure is currently the biggest single contributor to death around the world because it is so common,” said Dr. Neil R. Poulter of the International Center for Circulatory Health at Imperial College London. In the United States, it is particularly common among blacks, with 41 percent found to have it in a 2005 study, compared with 27 percent of whites.Resistant hypertension is defined as blood pressure that remains above clinical goals, even after a patient has been put on three or more different classes of medications. Additionally, patients whose blood pressure can be lowered to normal on four or more drugs should be considered resistant and should be closely monitored, the panel said. After reviewing the available research on drug-resistant hypertension, a phenomenon first described in the 1970s, the panel found that it became more likely with advanced age, weight gain, a diet high in sodium, sleep apnea or chronic kidney disease. Living in the Southeast, a region long recognized as the “stroke belt” of the United States, is also a risk factor for blacks and whites, though researchers are not sure why. An author of the new paper, Dr. William C. Cushman, chief of preventive medicine at the Veterans Affairs Medical Center in Memphis, said he suspected factors like inactivity, obesity and diets high in salt and fat. Pat J. Dixon, 58, a nurse in Atlanta, takes five medications to lower her blood pressure. In many ways, Ms. Dixon is typical of a patient who develops resistant hypertension. At 5 feet and 172 pounds, she is obese, and her weight gain has caused mild Type 2 diabetes, for which she takes yet another drug. The diabetes is an extra strain on the kidneys, in turn worsening her blood pressure. Ms. Dixon said that she did not use much salt when she cooked but that she did like to snack on potato chips. “My doctor tells me about every week that I’m going to eat myself to death,” she said. “You do kind of get worn out and depressed every morning that you have to take five or six pills.” The new report is one of the first to help doctors recognize and manage this growing group of difficult cases. Because so few studies have focused on resistance, the authors say, the number of drug-resistant patients is unclear. By reviewing studies of patients with at least some hypertension, the panel estimated that 20 to 30 percent could not control their blood pressure with three or more drugs, even when taking them exactly as prescribed. The 20 to 30 percent cohort appears to be growing. A large study in 2006 from Stanford found that the number of blood-pressure patients who were prescribed three or more drugs had increased over 12 years, to 24 percent from 14 percent.If patients need that many drugs, experts say, they are likely to be at greater risk for illness even if they lower their blood pressure to normal. These patients have usually had high blood pressure for some time and, as a result, have more organ damage.“It’s a critically important issue,” said Dr. Sheldon Hirsch, chief of nephrology at Michael Reese Hospital in Chicago. “One of the biggest failings in medicine is that as we increasingly realize the importance of treating hypertension, that lower numbers are better than higher numbers, we have increasing trouble reaching those goals.”
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Drug-Resistant High Blood Pressure on the RiseHigh blood pressure, the most commonly diagnosed condition in the United States, is becoming increasingly resistant to drugs that lower it, according to a panel of experts assembled by the American Heart Association.美国心脏病协会的一个专家小组称，美国最常见的疾病之一高血压正越来越对降压药产生耐受。“It’s becoming more difficult to treat and it’s requiring more and more medications to do so,” said the panel chairman, Dr. David A. Calhoun, a hypertension specialist at the University of Alabama at Birmingham. “现在正变得越来越困难，我们需要更多药物来控制血压，”这个小组的负责人、美国伯明翰亚拉巴马州立大学的高血压专家Dr. David A. Calhoun称。The problem is not that the medications have stopped working, said the report, published this month in the journal Hypertension. Instead, many blood-pressure patients are sicker to begin with and require more drugs, at greater dosages, to manage their conditions.发表在这个月《高血压》杂志上的这篇报告称，问题并不在药物失去了疗效，而是许多高血压患者病情加重，需要更多药物以及更大剂量来控制他们的血压。The doctors say this is especially worrisome because recent surveys estimate that one in three Americans have hypertension, an underlying cause of heart attacks, strokes, kidney disease and heart failure.医生说这是非常令人担忧的，因为根据最近的调查估计，1/3的美国人患有高血压——心脏病、脑卒中、肾脏疾病和心衰的潜在危险因素。Starting at a blood pressure of 115/80, research shows that the risk of a heart attack or stroke doubles with every 20-point increase of systolic pressure, the top number, or 10-point increase of diastolic pressure, the bottom number.从血压115/80mmHg开始，收缩压每增加20mmHg或舒张压每增加10mmHg，心脏病或脑卒中的风险都会加倍。“High blood pressure is currently the biggest single contributor to death around the world because it is so common,” said Dr. Neil R. Poulter of the International Center for Circulatory Health at Imperial College London. In the United States, it is particularly common among blacks, with 41 percent found to have it in a 2005 study, compared with 27 percent of whites.“由于高血压如此常见，在世界范围内，目前已成为最大的导致死亡的单一的原因。”英国伦敦帝国学院国际心血管中心的Dr. Neil R. Poulter称。在美国，黑人更常见，在2005年的一项调查中有41%的黑人患有高血压，而在白人中这一比例只有27%。Resistant hypertension is defined as blood pressure that remains above clinical goals, even after a patient has been put on three or more different classes of medications. Additionally, patients whose blood pressure can be lowered to normal on four or more drugs should be considered resistant and should be closely monitored, the panel said. 这个小组这样定义药物抵抗型高血压（Resistant hypertension）：在给予3种或更多种降压药物后，血压仍然高于目标血压者，称为药物抵抗型高血压；另外，依靠4种或更多种药物才能使血压维持在正常水平，并需要密切监测血压者，也被考虑是药物抵抗型高血压。After reviewing the available research on drug-resistant hypertension, a phenomenon first described in the 1970s, the panel found that it became more likely with advanced age, weight gain, a diet high in sodium, sleep apnea or chronic kidney disease. 在回顾能获取的药物抵抗型高血压（最早在1970年代的一个研究中被描述）的研究资料后，这个小组发现，药物抵抗型高血压在那些老龄、超重、高盐饮食、睡眠呼吸暂停和慢性肾脏疾病人群中更易发生。Living in the Southeast, a region long recognized as the “stroke belt” of the United States, is also a risk factor for blacks and whites, though researchers are not sure why. An author of the new paper, Dr. William C. Cushman, chief of preventive medicine at the Veterans Affairs Medical Center in Memphis, said he suspected factors like inactivity, obesity and diets high in salt and fat. 美国东南部被称为“脑卒中带”，生活在这里也是高血压的一个危险因素，虽然人们还不清楚这是为什么。生活在这里的Dr. William C. Cushman是孟菲斯退伍军人事务医学中心预防医学部主任，他怀疑不运动、肥胖、高盐和高脂肪饮食是主要原因。Pat J. Dixon, 58, a nurse in Atlanta, takes five medications to lower her blood pressure. In many ways, Ms. Dixon is typical of a patient who develops resistant hypertension. At 5 feet and 172 pounds, she is obese, and her weight gain has caused mild Type 2 diabetes, for which she takes yet another drug. The diabetes is an extra strain on the kidneys, in turn worsening her blood pressure. 58岁的Pat J. Dixon是亚特兰大的一名护士，她需要服用五种药物来降血压。从很多方面看，她都是一个典型的药物抵抗型高血压患者。5英尺（152cm）和一百七十二磅（78kg）的她属于超重，由于肥胖她还患上了2型糖尿病，因此而要再服用另一种药物。糖尿病又能造成肾脏损伤，从而进一步升高血压。Ms. Dixon said that she did not use much salt when she cooked but that she did like to snack on potato chips. “My doctor tells me about every week that I’m going to eat myself to death,” she said. “You do kind of get worn out and depressed every morning that you have to take five or six pills.” Dixon女士说，她做菜时并没有放很多盐，但对薯片情有独钟。“我的医生每周都在告诉我，我会为吃付出死亡的代价，但当每个早晨都需要吃五六颗药片时，你确实会感到很累很沮丧。”The new report is one of the first to help doctors recognize and manage this growing group of difficult cases. Because so few studies have focused on resistance, the authors say, the number of drug-resistant patients is unclear. 这是最早的帮医生认识和了解正在增长的这个群体（药物抵抗型高血压）的报道之一，作者称，由于对药物抵抗高血压的研究如此少，还不能了解到这些病人的数量。By reviewing studies of patients with at least some hypertension, the panel estimated that 20 to 30 percent could not control their blood pressure with three or more drugs, even when taking them exactly as prescribed. The 20 to 30 percent cohort appears to be growing. A large study in 2006 from Stanford found that the number of blood-pressure patients who were prescribed three or more drugs had increased over 12 years, to 24 percent from 14 percent.通过对一些关于的高血压研究的回顾，这个小组估计，大约有20%到30%的高血压患者不能控制他们的血压，即使吃三种或以上的降压药，即使严格按照医嘱吃药。斯坦福2006年的一个大型研究表明，在过去的12年里，吃三种或以上的降压药来控制血压的患者已经由14%增加到24%。If patients need that many drugs, experts say, they are likely to be at greater risk for illness even if they lower their blood pressure to normal. These patients have usually had high blood pressure for some time and, as a result, have more organ damage.专家称，如果患者需要如此吃多的药，那么即使他们能将血压降到正常水平，仍然有较大的风险。这些患者的高血压通常已经持续较长时间，并造成了器官损伤。“It’s a critically important issue,” said Dr. Sheldon Hirsch, chief of nephrology at Michael Reese Hospital in Chicago. “One of the biggest failings in medicine is that as we increasingly realize the importance of treating hypertension, that lower numbers are better than higher numbers, we have increasing trouble reaching those goals.”芝加哥Michael Reese医院肾病科主任Dr. Sheldon Hirsch说，“这是一个非常重要的问题，用药上最大的失败是，当我们越来越认识到控制血压的重要性，即血压计上低的数字比高的数字要好，我们也越来越难达到这个目标了。”红色部分不太确定另外，关于两个概念查了药理书是这样的：耐受性（tolerance）：机体在连续多次用药后反应性降低。耐药性（drug resistance）：病原体或肿瘤细胞对反复应用的化学治疗药物的敏感性降低。
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回复：【medical-news】药物抵抗型高血压正成为威胁
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编译：美国心脏病协会的一个专家小组称，美国最常见的疾病之一高血压正越来越对降压药产生耐受。“现在正变得越来越困难，我们需要更多药物来控制血压，”这个小组的负责人、美国伯明翰亚拉巴马州立大学的高血压专家Dr. David A. Calhoun称。发表在这个月《高血压》杂志上的这篇报告称，问题并不在药物失去了疗效，而是许多高血压患者病情加重，需要更多药物以及更大剂量来控制他们的血压。医生说这是非常令人担忧的，因为根据最近的调查估计，1/3的美国人患有高血压——心脏病、脑卒中、肾脏疾病和心衰的潜在危险因素。从血压115/80mmHg开始，收缩压每增加20mmHg或舒张压每增加10mmHg，心脏病或脑卒中的风险都会加倍。“由于高血压如此常见，在世界范围内，目前已成为最大的导致死亡的单一的原因。”英国伦敦帝国学院国际心血管中心的Dr. Neil R. Poulter称。在美国，黑人更常见，在2005年的一项调查中有41%的黑人患有高血压，而在白人中这一比例为27%。这个小组这样定义药物抵抗型高血压（Resistant hypertension）：在给予3种或更多种降压药物后，血压仍然高于目标血压者，称为药物抵抗型高血压；另外，依靠4种或更多种药物才能使血压维持在正常水平，并需要密切监测血压者，也被考虑是药物抵抗型高血压。在回顾能获取的药物抵抗型高血压（最早在1970年代的一个研究中被描述）的研究资料后，这个小组发现，药物抵抗型高血压在那些老龄、超重、高盐饮食、睡眠呼吸暂停和慢性肾脏疾病人群中更易发生。美国东南部被称为“脑卒中带”，生活在这里也是高血压的一个危险因素，虽然人们还不清楚这是为什么。生活在这里的Dr. William C. Cushman是孟菲斯退伍军人事务医学中心预防医学部主任，他怀疑不运动、肥胖、高盐和高脂肪饮食是主要原因。58岁的Pat J. Dixon是亚特兰大的一名护士，她需要服用五种药物来降血压。从很多方面看，她都是一个典型的药物抵抗型高血压患者。5英尺（152cm）和一百七十二磅（78kg）的她属于超重，由于肥胖她还患上了2型糖尿病，因此而要再服用另一种药物。糖尿病又能造成肾脏损伤，从而进一步升高血压。Dixon女士说，她做菜时并没有放很多盐，但对薯片情有独钟。“我的医生每周都在告诉我，我会为吃付出死亡的代价，但当每个早晨都需要吃五六颗药片时，你确实会感到很累很沮丧。”这是最早的帮医生认识和了解正在增长的这个群体（药物抵抗型高血压）的报道之一，作者称，由于对药物抵抗高血压的研究如此少，还不能了解到这些病人的数量。通过对一些关于的高血压研究的回顾，这个小组估计，大约有20%到30%的高血压患者不能控制他们的血压，即使吃三种或以上的降压药，即使严格按照医嘱吃药。斯坦福2006年的一个大型研究表明，在过去的12年里，吃三种或以上的降压药来控制血压的患者已经由14%增加到24%。专家称，如果患者需要如此吃多的药，那么即使他们能将血压降到正常水平，仍然有较大的风险。这些患者的高血压通常已经持续较长时间，并造成了器官损伤。芝加哥Michael Reese医院肾病科主任Dr. Sheldon Hirsch说，“这是一个非常重要的问题，用药上最大的失败是，当我们越来越认识到控制血压的重要性，即血压计上低的数字比高的数字要好，我们也越来越难达到这个目标了。”
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