Studies have shown that every 10mmHg decrease in systolic blood pressure or 5mmHg decrease in diastolic blood pressure will reduce the risk of death by 10%~15%, stroke by 35%, coronary heart disease by 20% and heart failure by 40%. Prevention and control of hypertension is one of the core strategies to curb the prevalence of cardiovascular and cerebrovascular diseases in China.
First, the correct measurement of blood pressure
1. No smoking, drinking coffee or tea within 30 minutes before the measurement, emptying the bladder and resting quietly for at least 5 minutes.
2. Measure the blood pressure of both upper arms at the first visit, and then usually measure the side with higher reading. If the difference between the two measured values exceeds 20mmHg, the possibility of subclavian artery stenosis should be ruled out.
3. Every outpatient service is measured twice, with an interval of 1~2 minutes, and the average value of the two times is recorded. If the difference between the two times is greater than ＞10mmHg, measure it for the third time, and record the average value of the last two times.
Second, the diagnosis standard of hypertension in clinic and out of clinic
The systolic blood pressure ≥140mmHg and/or diastolic blood pressure ≥90mmHg were found in the first diagnosis, so it is suggested to recheck it twice within 4 weeks, and the diagnosis can be made after three measurements on the same day reach the above diagnostic threshold.
Third, emergency treatment of blood pressure ≥180/110mmHg
1. Clinical symptoms of blood pressure ≥180/110mmHg without acute complications of heart, brain and kidney:
Oral short-acting antihypertensive drugs, such as captopril 12.5~25mg or metoprolol tartrate 25mg, can be given repeatedly after 1 hour, and observed in outpatient clinic until it drops below 180/110mmHg;
Note: it is not recommended to take nifedipine under the tongue to reduce blood pressure quickly.
2. Suggestions for initial diagnosis and referral
1) The blood pressure increased significantly ≥180/110mmHg, which was still uncontrollable after short-term treatment;
2) Suspicion of new cardiac, cerebral and renal complications or other serious clinical conditions;
3) Pregnant and lactating women;
4) onset age < 30 years old;
5) with proteinuria or hematuria;
6) Hypokalemia caused by non-diuretics or low-dose diuretics (blood potassium < 3.5 mmol/L);
7) paroxysmal hypertension with headache, palpitation and hyperhidrosis;
8) The difference of systolic blood pressure between upper limbs is > ＞20mmHg；;
9) Go to the superior hospital for further examination due to diagnosis.
Fourth, the target of blood pressure reduction
1. General hypertension patients, blood pressure dropped below 140/90mmHg.
2. Patients with diabetes, coronary heart disease, heart failure and chronic kidney disease with proteinuria should have their blood pressure below 130/80mmHg if they can tolerate it;
3.65~79 years old patients’ blood pressure drops below 150/90mmHg, and if they can tolerate it, their blood pressure can further drop below 140/90mmHg;
The blood pressure of patients aged 4.80 and above dropped below 150/90mmHg.
Five, healthy lifestyle trilogy
Six-part healthy lifestyle: limit salt, lose weight and exercise more, and quit smoking and drinking with a calm mind.
Sixth, start the drug treatment opportunity
Once all patients with hypertension are diagnosed, it is suggested to start drug treatment immediately while lifestyle intervention.
Only hypertensive patients with systolic blood pressure < ＜160mmHg and diastolic blood pressure < ＜100mmHg without coronary heart disease, heart failure, stroke, peripheral atherosclerosis, kidney disease or diabetes, doctors can also suspend medication according to the condition and patient’s wishes, and adopt simple lifestyle intervention for up to 3 months. If it still fails to meet the standard, then start drug treatment.
Seven, commonly used antihypertensive drugs and their advantages and disadvantages
1.ACEI and ARB (abbreviation: A)
The two drugs have definite antihypertensive effects, especially for patients with heart failure, post-myocardial infarction, diabetes and chronic kidney disease, and there is sufficient evidence to prove that they can improve the prognosis.
For patients with proteinuria, it can reduce urinary protein and has renal protection, but it is forbidden for patients with bilateral renal artery stenosis, severe renal insufficiency with creatinine (Cr) ≥ 3 mg/dl (265 mol/l) and hyperkalemia.
Pregnant or planned pregnancy patients are prohibited.
Usage, indications, contraindications and adverse reactions of ACEI drugs commonly used in grass-roots units.
Usage, indications, contraindications and adverse reactions of ARB drugs commonly used at grassroots level.
2. Beta blockers (abbreviation: B)
It can reduce the heart rate, especially for patients with high heart rate, and can improve the prognosis for patients with myocardial infarction or heart failure. It can be used for patients with coronary heart disease and angina pectoris, and can relieve angina symptoms.
However, it should be used with caution in the early stage (within 24 hours) after acute myocardial infarction, and it is not suitable for the acute stage of heart failure (shortness of breath, sitting and breathing, inability to lie down) and should be used after the condition is stable.
It is not recommended to use beta blockers at the primary level in acute phase of myocardial infarction or heart failure.
Alpha-beta blockers, such as carvedilol, arolol and labetalol, which mainly block beta receptors, are also suitable for the above population.
Beta blockers can reduce the heart rate, and are forbidden to patients with severe bradycardia, such as heart rate < 55 beats/min, sick sinus syndrome and second or third degree atrioventricular block.
Patients with bronchial asthma are prohibited.
High-dose application may have an effect on glucose and lipid metabolism, while highly selective β1 receptor blockers and α -β receptor blockers, such as bisoprolol, metoprolol and carvedilol, have little effect on glucose and lipid metabolism.
3.CCB (abbreviation: C)
Dihydropyridine calcium channel blockers, such as amlodipine, nifedipine sustained-release tablets or controlled-release tablets, felodipine sustained-release tablets and so on, are most commonly used for lowering blood pressure.
These drugs have strong antihypertensive effect, good tolerance, no absolute contraindication, and relatively wide application range, especially for elderly patients with isolated systolic hypertension.
Common adverse reactions include headache, facial flushing, ankle edema, rapid heartbeat and gingival hyperplasia.
4. Diuretics (abbreviation: D)
Thiazine diuretics are commonly used, especially for the elderly, patients with isolated systolic hypertension and heart failure.
The main adverse reaction of thiazide diuretics is hypokalemia, and with the increase of the dosage of diuretics, the incidence of hypokalemia increases accordingly, so it is recommended to use it in small doses, such as hydrochlorothiazide tablets 12.5mg once a day.
Diuretics combined with ACEI or ARB drugs can offset or alleviate the adverse reactions of low potassium.
Thiazine diuretics are generally prohibited in gout patients.
When severe heart failure or chronic renal insufficiency occurs, loop diuretics (such as furosemide) may be needed, and potassium supplementation is needed at the same time. At this time, it is recommended to refer to a higher hospital for further diagnosis and treatment.
Eight, hypertension drug treatment plan
1. Drug treatment scheme for hypertension without complications:
2. Drug treatment plan for hypertension with complications.
Nine, hypertension patients with blood lipid management objectives
The lipid-lowering targets of hypertension complicated with related diseases or conditions are shown in the table below.
Statins are generally well tolerated, but they may cause adverse reactions such as myopathy, rhabdomyolysis and elevated transaminase, and the risk increases with the increase of dose.
The blood lipid, transaminase and creatine kinase should be rechecked within 6 weeks for patients who take the initial drug. After there is no adverse reaction and LDL-C reaches the standard, it can be adjusted to recheck once every 6~12 months.
Ten, long-term follow-up management of hypertension
1. Follow-up frequency
Patients with blood pressure reaching the standard should be followed up at least once every 3 months; Patients whose blood pressure is not up to standard are followed up once every 2~4 weeks.
2. Follow-up content
Whether there are newly diagnosed complications, such as coronary heart disease, heart failure, stroke, diabetes, chronic kidney disease or peripheral atherosclerosis, etc.
Every follow-up should be physical examination (check blood pressure, heart rate, etc., overweight or obese people should monitor their weight and waist circumference), lifestyle evaluation and suggestions, understand drug compliance and adverse reactions, and adjust treatment when necessary.
3. Annual evaluation
All patients should be evaluated once a year.
In addition to routine physical examination, weight and waist circumference should be measured at least once a year.
It is recommended to carry out necessary auxiliary examinations every year, including blood routine, urine routine, biochemistry (creatinine, uric acid, alanine aminotransferase, blood potassium, blood sodium, blood chlorine, blood sugar and blood lipid) and electrocardiogram. Conditional candidates can do: ambulatory blood pressure monitoring, echocardiography, carotid ultrasound, urinary albumin/creatinine ratio, chest X-ray, fundus examination, etc.
Author/Gcplive Laiyuan/Drug Evaluation Center