Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St (Private Bag 23), Hobart, TAS, 7000, Australia.
School of Medicine, University of Tasmania, 17 Liverpool St (Private Bag 23), Hobart, TAS, 7000, Australia.
Curr Hypertens Rep. 2019 Jan 18;21(1):6. doi: 10.1007/s11906-019-0912-4.
To address the tension between guideline recommendations and the evidence from clinical trials supporting them and clinician concerns of overtreatment of elevated blood pressure.
Systolic Blood Pressure Intervention trial (SPRINT) demonstrated lower blood pressure targets provided robust clinical benefit (reduced all-cause mortality) but also expected adverse events due to hypotension. Treatment thresholds for systolic blood pressure in the latest US guidelines have been lowered to 130 mmHg, although this has not been adopted elsewhere. These guidelines specify that treatment in the 130 s should be considered in the setting of absolute risk, i.e. treatment should be directed to those at high risk. This review argues that this hybrid approach, treatment thresholds in the 130 s based on absolute risk and above 140 mmHg on blood pressure level alone is a compromise, and that risk stratification should be the basis of drug treatment decision-making unless blood pressure is very high. Who receives blood pressure lowering medication is best determined by who is most likely to have a heart attack or stroke in the intermediate period rather than medicalising individuals who have a mildly elevated blood pressure.
解决指南推荐与支持这些推荐的临床试验证据之间的紧张关系，以及临床医生对过度治疗高血压的担忧。
收缩压干预试验（SPRINT）表明，较低的血压目标提供了强大的临床获益（降低全因死亡率），但也因低血压导致预期的不良事件。最新的美国指南中，收缩压的治疗阈值已降低至 130mmHg，尽管其他地方尚未采用这一标准。这些指南规定，在绝对风险的情况下，应考虑将 130 以内的收缩压作为治疗目标，即治疗应针对高危人群。本综述认为，这种混合方法，即基于绝对风险的 130mmHg 以内的治疗阈值和单纯血压水平 140mmHg 以上的治疗阈值，是一种妥协，除非血压非常高，否则风险分层应成为药物治疗决策的基础。谁需要接受降压药物治疗，最好根据谁在中期更有可能发生心脏病或中风来确定，而不是将血压轻度升高的个体视为患者。
