1120310-最新台灣高血壓治療指引.pdf

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2023 Updated Hypertension Guideline
高雄醫學大學附設中和紀念醫院
心臟血管內科
林宗憲
Conflict of Interest: nil

Journal of the Chinese Medical Association 2015;78:1-47

Systolic Blood Pressure Intervention Trial (SPRINT)
Principal Results
Paul K. Whelton, MB, MD, MSc
Chair, SPRINT Steering ...

SPRINT Research Question
Examine effect of more intensive high blood pressure treatment
than is currently recommended
Rand...

Major Inclusion Criteria
• ≥50 years old
• Systolic blood pressure : 130 – 180 mm Hg (treated or untreated)
• Additional c...

Major Exclusion Criteria
• Stroke
• Diabetes mellitus
• Polycystic kidney disease
• Congestive heart failure (symptoms or ...

Lancet. 2013 Aug 10;382(9891):507-15

Lancet. 2013 Aug 10;382(9891):507-15
1 Endpoint

ACCORD in The Diabetics
N Engl J Med. 2010 Apr 29;362(17):1575-85.

Eur Heart J. 2017 Apr 14;38(15):1132-1143.
*SBP at baseline

J Am Coll Cardiol. 2020 Apr 14;75(14):1644-1656.
PARAGON-HF
Baseline and mean achieved
SBP of 120 to 129 mm Hg
identified ...

Pre-specified Subgroups of Special Interest
• Age (<75 vs. ≥75 years)
• Gender (Men vs. Women)
• Race/ethnicity (African-A...

Systolic BP During Follow-up
Mean SBP
136.2 mm Hg
Mean SBP
121.4 mm Hg
Average SBP
(During Follow-up)
Standard: 134.6 mm H...

Number of
Participants
Hazard Ratio = 0.75 (95% CI: 0.64 to 0.89)
Standard
Intensive
(243 events)
During Trial (median fol...

SPRINT Primary Outcome and its Components
Event Rates and Hazard Ratios
Intensive Standard
No. of Events Rate, %/year No. ...

Primary Outcome Experience in the Six Pre-specified Subgroups of Interest
*Treatment by subgroup interaction

Intensive Standard
Events %/yr Events %/yr HR (95% CI) P
Participants with CKD
at Baseline
Primary CKD outcome 14 0.33 15 ...

Kidney Int. 2021 Mar;99(3S):S1-S87.

SPRINT vs. SPRINT-SENIOR
JAMA. 2016;315(24):2673-2682.
Slides courtesy of CE Chiang

JAMA. 2016 Jun 28;315(24):2673-82

N Engl J Med 2015;373:2103-16.

Hypertension. 2020 Mar;75(3):660-667.

Number (%) of Participants with a
Monitored Clinical Measure During Follow-up
Number (%) of Participants
Intensive Standar...

Arch Intern Med. 2012 Aug 13;172(15):1162-8.
2340 persons  65 years

26
Lancet. 2021 Sep 18;398(10305):1053-1064.

27
Lancet. 2021 Sep 18;398(10305):1053-1064.

28
Sci Rep. 2019 Sep 10;9(1):13070.
*Occurrence of myocardial infarction, acute coronary syndrome not resulting in myocard...

2017 BP Thresholds for and Goals of Pharmacological Therapy in
Patients With Hypertension According to Clinical Conditions...

Hypertension. 2016 May;67(5):808-12

Acta Cardiol Sin 2017;33:213-225

Acta Cardiol Sin. 2017 May;33(3):213-225.

Acta Cardiol Sin. 2017 May;33(3):213-225.

Hypertension. 2019 Feb;73(2):481-490.
SBP
AOBP = HBPM

Hypertension. 2019 Feb;73(2):481-490.
DBP
AOBP = HBPM

Hypertension. 2019 Feb;73(2):481-490.
SBP
AOBP = DT_ABPM

Hypertension. 2019 Feb;73(2):481-490.
DBP
AOBP = DT_ABPM

AOBP = HBPM = DT_ABPM

39
Clinic HBPM Daytime
ABPM
Nighttime
ABPM
24-Hour
ABPM
120/80 120/80 120/80 100/65 115/75
130/80 130/80 130/80 110/65 125...

Corresponding values between OBP, HBP, ABP
OBP HBPM/AOBP ABPM
Daytime 24-hr Nighttime
120/80 120/80 120/80 115/75 100/65
1...

Slides courtesy of CE Chiang

42
Lancet. 2021 May 1;397(10285):1625-1636.

43
SBP at baseline

44
5 mm Hg systolic blood pressure reduction

Why Select HBPM?
45

Comparison of four BP measurement methods
Clinical characteristics
Feasibility
In Taiwan
(routine use)
Variability
(routin...

Home BP Monitoring
•Guideline recommended
•Improves diagnostic precision
- identifies white coat and masked hypertension
•...

Reliability of Office, Home, and Ambulatory BP
measurements and correlation with LV Mass
Schwartz, J.E. et al. J Am Coll C...

49
J Hum Hypertens. 2005 Oct;19(10):801-7.

50
Circulation. 2005 Apr 12;111(14):1777-83

51
Hypertension. 2010 Jun;55(6):1346-51.

Why is HBP more associated with Risk than OBP?
• OBP is often poorly performed
• Better characterization of blood pressure...

Hypertension. 2019 Feb;73(2):481-490.

54
Blood Press Monit. 2006 Apr;11(2):59-62.

55
J Hypertens. 1998 Jul;16(7):971-5.

Method to obtain reliable HBP estimates
56
"722"
principle
Timing of HBP monitoring
"7" 7 (at least 4) consecutive days
"2...

Methods to perform HBP monitoring correctly

The “722” principle for home BP monitoring
58
Settings in the clinic Frequency of HBP monitoring with the “722” principle
...

Comparison of four BP measurement methods
Clinical characteristics Outcome study
Feasibility
In Taiwan
(routine use)
Varia...

STEP
• Prospective, multi-center, randomized controlled trial
• 9624 patients screened from 42 clinical centers in China
I...

Inclusion & Exclusion Criteria
Inclusion criteria
1. Systolic blood pressure (SBP) between 140190 mm Hg in the three scre...

Intervention
Blood Pressure Monitoring
Office blood pressure measurements:
• By a trained physician or nurse
• Using valid...

Endpoints
Primary outcome
A composite of :
• Stroke;
• Acute coronary Syndrome
(myocardial infarction and hospitalized uns...

Medications
VISIT_12M VISIT_24M VISIT_36M VISIT_42M
Intensive
(n=4172)
Standard
(n=4158)
Intensive
(n=4130)
Standard
(n=41...

Time after randomization (Months)
Cumulative
incidence
26%
Results- Primary Composite Outcome
Standard
treatment
4268 4147...

Results- Secondary Outcomes
B. Acute coronary syndrome C. Heart failure
A. Stroke
33%
E. Mortality from CV causes
D. Major...

HBPM-based universal BP target for pharmacological management
* Threshold: ≥140/90 mmHg for initiation of pharmacological ...

70
Effects of reduced-sodium, added-potassium salt substitute
on stroke – the salt substitute and stroke study (SSaSS)
Pro...

Design
• Pragmatic, large-scale (n=20,995), open, cluster randomised trial
• Salt substitute (70%NaCl, 30%KCl) versus regu...

Follow-up and intermediate outcomes
Follow-up
• Mean follow-up 4.74 years
• 100% vital status for all participants
• 99.9%...

Stroke
• Participants with event = 2678
• Rate ratio = 0.86 (0.77 to 0.96)
• P value = 0.006

Major adverse cardiovascular events
• Participants with event = 4499
• Rate ratio = 0.87 (0.80 to 0.94)
• P value <0.001

Total mortality
75
• Participants with event = 4172
• Rate ratio = 0.88 (0.82 to 0.95)
• P value <0.001

Hyperkalemia
76
• Participants with event = 315
• Rate ratio = 1.04 (0.80 to 1.37)
• P value = 0.76
Sudden vascular death
...

1 drug or SPC*
if <20/10 mmHg
above BP target
2 drugs or SPC
if ≥20/10 mmHg
above BP target
Wang TD, 2022.
H: HBPM confirm...

Slides courtesy of TD Wang

Hypertension. 2021 Feb;77(2):692-705.

Hypertension. 2021 Feb;77(2):692-705.
SBP

Hypertension. 2021 Feb;77(2):692-705.
DBP

Circulation. 2019 Jul 23;140(4):303-315
132 non-obese, older patients with well-controlled blood glucose

Take Home Messages
• Blood pressure universal goals
- < 130/80 mmHg
• From office to home blood pressure
- better prognost...

謝謝聆聽敬請指教

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