Alderman M H
Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY.
Ann Intern Med. 1993 Aug 15;119(4):329-35. doi: 10.7326/0003-4819-119-4-199308150-00013.
Clinical practice often conflicts with epidemiologic evidence in the management of blood pressure. Antihypertensive therapy is generally prescribed if blood pressure exceeds some arbitrary level, thus committing many persons with minimal cardiovascular risk to long-term drug therapy. By contrast, below that level, regardless of cardiovascular risk, blood pressure reduction is rarely sought. Epidemiologic data, however, consistently show a continuous, positive, linear relationship of the height of both systolic and diastolic blood pressure with the incidence of stroke and heart attack. No threshold level distinguishes those who will have a cardiovascular event from those who will not. In fact, most heart attacks and many strokes occur among persons with "normal" blood pressures. Observational experience suggests that benefit could be obtained from universal blood pressure reduction of even a few millimeters of mercury. This public health strategy can be augmented by identifying those individuals, at every level of blood pressure, whose risk for cardiovascular disease justifies the cost of pharmacologic intervention. Antihypertensive drug therapy will be most efficient and effective if directed at those who, by virtue of their constellation of risk factors or evidence of preclinical vascular disease, are likely to have a heart attack or stroke. The resulting redirection of clinical resources will spare many hypertensive persons whose absolute risk for a cardiovascular event is small, from life-long treatment. At the same time, other persons, currently classified as normotensive, will become candidates for blood pressure reduction because their cardiovascular risk is high.
在血压管理方面，临床实践常常与流行病学证据相冲突。如果血压超过某个任意设定的水平，通常就会开出抗高血压治疗的处方，从而使许多心血管风险极小的人接受长期药物治疗。相比之下，在该水平以下，无论心血管风险如何，很少有人寻求降低血压。然而，流行病学数据始终显示，收缩压和舒张压的高度与中风和心脏病发作的发生率之间存在持续、正向、线性关系。没有阈值水平能区分哪些人会发生心血管事件，哪些人不会。事实上，大多数心脏病发作和许多中风发生在血压“正常”的人群中。观察经验表明，即使血压仅降低几毫米汞柱，普遍降低血压也能带来益处。通过识别在各个血压水平上，那些心血管疾病风险足以证明药物干预成本合理的个体，可以增强这一公共卫生策略。如果将抗高血压药物治疗针对那些由于其危险因素组合或临床前血管疾病证据而可能发生心脏病发作或中风的人，将会最有效率和效果。由此导致的临床资源重新分配，将使许多心血管事件绝对风险较小的高血压患者免于终身治疗。同时，其他目前被归类为血压正常的人，将因心血管风险高而成为降低血压的候选对象。
