The purpose of hypertension control, including initial prevention, early diagnosis and appropriate treatment, was clarified in a 1996 report of who expert comintee (WHO Expert Meeting). The author of this paper is the chair of who expert meeting, and agrees with the need to supplement these objectives, namely, to use various restriction programs in the population and to mobilize social participation to change the lifestyle, to use diagnostic techniques in high risk factors, to measure lifestyle, and to treat drugs. The report clearly emphasizes the integrated programme for controlling hypertension in order to reduce the risk of cardiovascular disease in general, and points out the importance of systolic hypertension and annual hypertension treatment and importance. The report reminds us that hypertension is an important health problem in most countries, involving 20 per cent of adults. The long-term goal designed for all countries is to eliminate preventable cardiovascular diseases among young and middle-aged people and to minimize them in the elderly.
Definition and classification of hypertension
The new who report, like the 1978 report before, is needed but difficult and artificial. The difference between normal and hypertension can only grasp the benefits of intervention clinical trials after hypotension are uncertain. Since 1978, the definition of hypertension has not only been limited to diastolic blood pressure, but also systolic blood pressure. Therefore, hypertension is defined in who's report as systolic period of more than 140mmHg, and diastolic pressure equal to that of me over 90mmHg, and emphasizes that it should be the result of repeated blood pressure measurement in weeks, sometimes even months.
The report proposes two classifications of hypertension: one is based on blood pressure level and the other is the scope of organ damage. This is based on 1978 report and 1993 who international society of hypertention (ISH). These classifications are somewhat different from the fifth joint US National Committee report (1993jnc-v), so further discussion is needed. The blood pressure level in WHO classification keeps "light, medium and heavy" hypertension because of the fact that it is commonly used in clinical work and replaced by "grade" in US classification. The WHO report emphasizes that using "light, medium, heavy" as popular users does not mean the severity of the overall clinical situation, but simply indicates the range of blood pressure rise. The severity of clinical conditions is also based on all cardiovascular risk factors. This category of organ damage in terms of scope and severity is used in the new WHO classification as in the 1978who report. This classification helps us to clarify the concept of organ damage in the development of hypertension over time.
Epidemiology of hypertension
A large part of the report deals with the epidemiology of hypertension. Hypertension is the risk factor of cardiovascular disease, the prevalence of hypertension, the risk factors and predictors of hypertension include genetic and lifestyle factors.
The report points out that systolic blood pressure rise is an important risk factor for cardiovascular disease, and the borderline character between blood pressure level and risk, but it can not prove the critical value of risk or J-curve relationship. The risk of cardiovascular events and organ damage in patients with hypertension increases due to the co existence of other risk factors, such as smoking, high cholesterol and diabetes. Therefore, it is important to determine the whole cardiovascular risk factors in the high blood pressure population in order to determine the treatment limits. The report emphasizes that the absolute number of complications in a group of patients with mild hypertension is high. Therefore, the control of hypertension in the population requires that the patients in this group should be treated with antihypertensive measures like those with obvious blood pressure rise.
clinical examination
The report points out that a patient who has observed and confirmed hypertension must have several objectives: to determine that blood pressure is a chronic increase; to estimate the whole cardiovascular risk; to find out the existing organ damage and concomitant diseases; and to find out the causes of high blood pressure. It is clear that all of these aims can be identified in a single consistent, consistent, and step-by-step diagnostic process, the medical record experience test. The scope of the test is scalable according to the medical record and physical examination and recommended tests.
The new report emphasizes that hypertension is only one of many risk factors for cardiovascular disease. Since the absolute benefits of antihypertensive treatment are determined based on the absolute risk of cardiovascular disease (i.e. greater benefits are achieved in those with higher risk), each cardiovascular risk factor should be carefully determined before the decision to treat hypertension is recommended.
Blood pressure measurement
The report noted that the measurement of blood pressure should be highly valued. Blood pressure measurement is usually done in outpatient or in the doctor's office or by the patient's bed using mercury sphygmomanometers and stethoscope. These values are often referred to as "outpatient" or "office" blood pressure. It is used in all intervention clinical trials to measure the benefit of antihypertensive and is currently recognized as the standard of high blood pressure.
Family blood pressure measurement and ambulatory blood pressure are complementary means of clinical blood pressure measurement. Ambulatory blood pressure is the best sound for the following cases: when there is a large difference between outpatient and family blood pressure measurement values; when there is evidence of increased blood pressure without organ damage; when there is a significant difference in blood pressure measured in outpatient service: when there is resistance to treatment. In all cases, the recent summary of the population must be paid attention to that the 24-hour mean value of home blood pressure and ambulatory blood pressure is lower than that of outpatient blood pressure measurement mmHg. For the elderly and the patients with higher outpatient blood pressure, the difference between outpatient value and dynamic value is greater, although it is well known that the appearance of a doctor and a winner (to a lesser extent) can lead to a certain degree of increase in blood pressure ("white big" But people who have low ambulatory blood pressure or at home have doubts about the effect of "clothes"), but the use of white coat hypertension to show that outpatient blood pressure is in the category of hypertension. The report does not advocate the use and suggests that the more precise term "isolated outpatient hypertension" should be used instead. It is not proved that the so-called white coat hypertension is "conscious" hypertension, and there is no sexual risk, so no treatment is needed. Once the physician decides to use home or ambulatory blood pressure, he or she must bear in mind that the blood pressure values provided by these methods are several mmHg lower than those in the outpatient, especially in older patients. When the blood pressure measured by these methods is set as the threshold value of hypertension to be treated and the expected blood pressure value is reached after treatment, the low point should be set to avoid excessive diagnosis and over treatment.
Organ damage
The report emphasizes that organ damage involved in hypertension is affected by the presence of other risk factors, such as smoking, obesity and diabetes. The term "hypertension heart disease" is not advocated because hypertension involves the heart to produce these complications and has a very different relationship with high blood pressure. The term used in the report is for individual cases: left ventricular hypertrophy, coronary heart disease, micro coronary artery disease and congestive heart failure.
Many articles explain the relationship between brain damage and hypertension, but it has not been resolved, regardless of whether the instrument is improving in evaluating cerebrovascular disease or not. These articles also contain the relative efficacy of antihypertensive therapy in preventing different types of stroke, such as lacunar disease, leucoaraiosis, antihypertensive therapy in reducing vascular dementia, reducing blood pressure in preventing cerebral infarction again, and opening treatment window in the early stage of ischemic stroke.
The first manifestation of proteinuria is often emphasized in reviewing renal damage caused by hypertension. Although the report mentions that the renal function damage of hypertension can be delayed by antihypertensive treatment, it is also disappointing that long-term antihypertensive treatment can not prevent the end-stage of renal disease. Of all kidney failure in the United States, 15-20% are from high blood pressure, and African Americans 33%.
Prevention and control
The report states that there are two aspects to be needed in the treatment of hypertension prevention and complications in any population: one is "treatment of the population" to treat the population as a whole to reduce the risk of hypertension; the other is to determine and treat the patients with high risk factors who have the risk of complications in order to reduce the risk of complications.
The two aspects of the treatment are not only complementary but collaborative and not contradictory. Indeed, the determination and treatment of clinically hypertensive patients in the population does not reduce the overall risk, or even in the most satisfactory cases. The recent national health and Nutrition Examination Survey (NHANES III) "international health and nutrition test method" confirmed that only half of the patients with hypertension received drug treatment and only about 1/4 of them had blood pressure below 140/90mmhg. The situation is worse in developing countries. Society plays a role in the transformation of epidemiology, which is harmful to the physical and mental lifestyle and economic development. Prevention and control at the level of such a population is even more important, and training programs for lifestyle workers are needed in both developed and developing countries.
The report considered that the actual effect of reducing blood pressure was weight loss, alcohol consumption, physical activity and moderate salt restriction. Those with limited or unproven effects include load management, dietary supply of potassium, calcium or magnesium therapy, micronutrient supply and cellulose supply.
These changes are adopted by the community collectively and the commandments are accepted by individuals, which require changes in behavior. In turn, there are three training plans: public education, professional education and patient education with high blood pressure. Such a plan will succeed only through the joint efforts of health professionals, policy makers, industry, intermediates and other media to develop long-term plans for all sectors of society and age groups.
Hypertension in children and adults in special population
Unfortunately, there is no prospective study involving children and adults with high blood pressure, so we need to rely on epidemiological definitions to consider hypertension at least three times when the average systolic or diastolic pressure of young people is equal to or greater than 95 per cent of his age. The report emphasizes that it is not possible to prove that isolated mild systolic hypertension in adults and young people needs treatment in addition to lifestyle advice.
woman
The report found that the extent to which large antihypertensive trials benefit men and women is limited. Although the overall cardiovascular risk of middle-aged women is significantly lower than that of men, there is insufficient data to support different treatment of hypertension in women.
Women have two special types of hypertension, that is, daily contraceptive induced hypertension and pregnancy hypertension. Hypertension caused by daily contraceptive treatment usually improves after months of stopping. It is not known that hormone like contraceptives, such as low estrogen or only progesterone, can also lead to high blood pressure. However, hormone replacement therapy is not taboo for menopausal women, although their blood pressure must be monitored from time to time.
The report noted that high blood pressure during pregnancy was the main cause of premature and perinatal death and 1 / 5 maternal death. In developing countries, health issues are the main. Mothers with hypertension and proteinuria born in late pregnancy are small, often born, and are at high risk of death in the neonatal period. The incidence rate of reported disease varies greatly. However, according to the estimate, less than 5% of pregnancies are associated with elevated clinical blood pressure. The classification of pregnancy hypertension has been discussed.
Hypertension in the elderly
The attention to hypertension in the elderly is one of the main new topics in the new who report, which was not existed before 1978. Although in 1978, it was not possible to prove the benefits and risks of antihypertensive treatment in the elderly. In recent 10 years, several randomized elderly anti hypertension trials have been completed, which makes the new report can suggest that it is particularly beneficial for the elderly to treat hypertension.
diabetes
Hypertension and type II diabetes coexist very frequently, often with dyslipidemia and central obesity. Patients with hypertension and diabetes are particularly prone to cardiovascular and renal complications. Therefore, it is very important to control hypertension and dyslipidemia and quit smoking. The blood pressure of patients with early diabetic nephropathy can be reduced to 130 / 85mmHg.
Treatment of hypertension
This is briefly summarized in this article because the report is different from those of 1978, but it is very close to the method recommended by 1993who/ish. The decision to need treatment must be based on diastolic and systolic blood pressure, as well as the overall cardiovascular risk of individual patients. If the blood pressure of moderate and severe hypertension is larger than 105mmhg, the systolic) is 180mmhg, or even without other risk factors, the treatment should also be started immediately. However, blood pressure diastolic pressure is lower than 105 contractions (180mmhg) and treatment must be determined after careful examination for weeks or months. The treatment plan for light hypertension is essentially the same as that of 1993, but the new report uses a simplified flow chart as shown in Figure I.
The report also referred to who/ish brief introduction in 1993 and JNC-V profile, and five groups of drugs were used as first-line drugs for the treatment of high blood. The results showed that diuretics, B block, ACE-I, calcium channel blockers and a blockers were used. Other drug groups can be used in specific cases. Diuretics and B- blockers have been extensively studied for the first time in the 5 groups of drugs. They can reduce blood pressure and reduce incidence rate. But the report noted that all of these studies were designed to determine the effect of blood pressure on it rather than the benefits of a particular drug or group of drugs. Therefore, the first-line drug selection of individual patients is largely determined by the Albert syndrome. Especially the risk factors of patients, the organ damage, pay for the role and coexist with the disease. Drug selection also depends on socio-economic factors so that countries that do not sell are more applicable.
Input / effect ratio
The report recommends that the investment effectiveness ratio analysis of hypertension treatment should seek balance in benefit, health status and economic income. It also recommends that the system of input effect ratio analyze all factors, namely, there are high risk programs for individual patients and national and local treatment of high blood pressure control. This is important because it allows all countries to choose those programmes that maximize health benefits and to spend limited inputs to the appropriate level where financial support is permitted.
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