2019 Chinese guidelines for the management of hypertension in the elderly

doi:10.3877/cma.j.issn.2095-8757.2019.02.001

Abstract

Hypertension Branch of Chinese Geriatrics Society, National Clinical Research Center for Geriatric Diseases - Chinese Alliance of Geriatric Cardiovascular Disease. 2019 Chinese guidelines for the management of hypertension in the elderly[J]. Chinese Journal of Geriatrics Research(Electronic Edition), 2019, 06(02): 1-27.

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推荐类别		定义	建议使用的表述
Ⅰ类		证据和（或）总体一致认为，该治疗或方法有益、有用或有效	推荐/有指征
Ⅱ类		关于该治疗或方法的用途/疗效，证据不一致和（或）观点有分歧	?
?	Ⅱa类	证据/观点倾向于有用/有效	应该考虑
?	Ⅱb类	证据/观点不足以确立有用/有效	可以考虑
Ⅲ类		证据和（或）专家一致认为，该治疗或方法无用/无效，在某些情况下可能有害	不推荐

推荐类别		定义	建议使用的表述
Ⅰ类		证据和（或）总体一致认为，该治疗或方法有益、有用或有效	推荐/有指征
Ⅱ类		关于该治疗或方法的用途/疗效，证据不一致和（或）观点有分歧	?
?	Ⅱa类	证据/观点倾向于有用/有效	应该考虑
?	Ⅱb类	证据/观点不足以确立有用/有效	可以考虑
Ⅲ类		证据和（或）专家一致认为，该治疗或方法无用/无效，在某些情况下可能有害	不推荐

证据分级	定义
A级	数据来自多项随机对照临床试验或由随机对照临床试验组成的荟萃分析
B级	数据来自单项随机临床试验或多个大型非随机对照研究
C级	数据来自专家共识和（或）小规模研究、回顾性研究或登记注册研究

证据分级	定义
A级	数据来自多项随机对照临床试验或由随机对照临床试验组成的荟萃分析
B级	数据来自单项随机临床试验或多个大型非随机对照研究
C级	数据来自专家共识和（或）小规模研究、回顾性研究或登记注册研究

分级		SBP（mmHg）		DBP（mmHg）
正常血压		<120	和	<80
正常高值		120～139	和（或）	80～89
高血压		≥140	和（或）	≥90
?	1级高血压	140～159	和（或）	90～99
?	2级高血压	160～179	和（或）	100～109
?	3级高血压	≥180	和（或）	≥110
单纯收缩期高血压		≥140	和	<90

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其它危险因素和病史	血压水平
其它危险因素和病史	1级	2级	3级
1～2个危险因素	中危	中危	很高危
≥3个危险因素或靶器官损害或糖尿病	高危	高危	很高危
并存临床情况	很高危	很高危	很高危

序号	条目	询问方式
1	疲乏	过去4周内大部分时间或者所有时间感到疲乏
2	阻力增加/耐力减退	在不用任何辅助工具以及不用他人帮助的情况下，中途不休息爬1层楼梯有困难
3	自由活动下降	在不用任何辅助工具以及不用他人帮助的情况下，走完1个街区（100 m）较困难
4	疾病情况	医生曾经告诉你存在5种以上如下疾病：高血压、糖尿病、急性心脏疾病发作、脑卒中、恶性肿瘤（微小皮肤癌除外）、充血性心力衰竭、哮喘、关节炎、慢性肺病、肾脏疾病、心绞痛等
5	体重下降	1年或更短时间内出现体重下降≥5%

序号	检测项目	男性	女性
1	体质量下降	过去1年中，意外出现体重下降>10磅（4.5 kg）或>5%体重	?
2	行走时间（4.57 m）	身高≤173 cm：≥7 s身高>173 cm：≥6 s	身高≤159 cm：≥7 s身高>159 cm：≥6 s
3	握力	BMI≤24.0 kg/m²：≤29 kg	BMI≤23.0 kg/m²：≤17 kg
?	?	BMI 24.1～26.0 kg/m²：≤30 kg	BMI 23.1～26.0 kg/m²：≤17.3 kg
?	?	BMI 26.1～28.0 kg/m²：≤30 kg	BMI 26.1～29.0 kg/m²：≤18 kg
?	?	BMI >28.0 kg/m²：≤32 kg	BMI >29.0 kg/m²：≤21 kg
4	体力活动（MLTA）	<383 kcal/周（约散步2.5 h）	<270 kcal/周（约散步2 h）
5	疲乏	CES-D的任一问题得分2～3分	?
?	?	您过去的1周以下现象发生了几天？	?
?	?	（1）我感觉我做每件事都需要经过努力；	?
?	?	（2）我不能向前行走。	?
?	?	0分：<1 d；1分：1～2 d；2分：3～4 d；	?
?	?	3分：>4 d	?

推荐方案	推荐类别	证据水平
年龄≥65岁，血压≥140/90 mmHg，在生活方式干预的同时启动降压药物治疗^[52,53]，将血压降至<140/90 mmHg^[54,55]	Ⅰ类	A级
年龄≥80岁，血压≥150/90 mmHg，即启动降压药物治疗^[54]，首先应将血压降至<150/90 mmHg，若耐受性良好，则进一步将血压降至<140/90 mmHg^[51,56]	Ⅱa类	B级
经评估确定为衰弱的高龄高血压患者，血压≥160/90 mmHg，应考虑启动降压药物治疗，收缩压控制目标为<150 mmHg，但尽量不低于130 mmHg	Ⅱa类	C级
如果患者对降压治疗耐受性良好，不应停止降压治疗^[57]	Ⅲ类	A级

分类	药物	每日剂量(mg/d)	每日服药次数	注意事项
噻嗪类利尿剂	氢氯噻嗪	6.25～25	1	监测钠、钾、尿酸和钙浓度。
噻嗪类利尿剂	吲哒帕胺	0.625～2.5	1	有痛风病史者慎用，除非已接受降尿酸治疗。
袢利尿剂	布美他尼	0.5～4	2	合并症状性心衰优选袢利尿剂。
	呋塞米	20～80	1～2	CKD 3～4期患者优选袢利尿剂。
	托拉塞米	5～10	1	?
保钾利尿剂	阿米洛利	5～10	1～2	单用降压效果不明显。
保钾利尿剂	氨苯蝶啶	25～100	1～2	CKD 5期患者避免应用。
醛固酮受体拮抗剂	依普利酮	50～100	1～2	螺内酯、比依普利酮增加男性乳腺增生和ED风险。
醛固酮受体拮抗剂	螺内酯	20～60	1～3	避免联合应用补钾、保钾药。CKD 3～4期患者避免应用。
CCB（二氢吡啶）	苯磺酸氨氯地平	2.5～10	1	无绝对禁忌证。
	马来酸左旋氨氯地平	1.25～5	1	剂量相关的踝部水肿、颜面潮红、便秘，女性多见于男性。左旋氨氯地平踝部水肿等副作用相对少。
	苯磺酸左旋氨氯地平	1.25～5	1	?
	非洛地平	2.5～10	1	?
	乐卡地平	10～20	1	?
	硝苯地平缓释	10～80	2	?
	硝苯地平控释	30～60	1	?
	拉西地平	4～8	1	?
	西尼地平	5～10	1	?
	贝尼地平	4～8	1	?
CCB(非二氢吡啶)	地尔硫卓	90～180	2～3	避免与β阻滞剂常规合用，会增加心动过缓和传导阻滞。
	地尔硫卓缓释	90～360	1～2	不用于收缩性心力衰竭。
	维拉帕米缓释	120～240	1～2	?
ACEI	贝那普利	5～40	1～2	ACEI禁止与ARB合用。
	卡托普利	25～300	2～3	合并CKD患者或使用补钾或保钾药物者增加高钾血症风险。
	依那普利	2.5～40	1～2	严重双侧肾动脉狭窄患者增加急性肾衰风险。
	福辛普利	10～40	1	服用ACEI发生血管性水肿病史的患者禁用。
	赖诺普利	2.5～40	1	血肌酐水平大于3 mg/dl者禁用。
	咪哒普利	2.5～10	1	?
	培哚普利	4～8	1	?
	雷米普利	1.25～20	1	?
ARB	坎地沙坦	4～32	1	适应证与禁忌证同ACEI。
	厄贝沙坦	150～300	1	ACEI禁止与ARB合用。
	氯沙坦	25～100	1	因干咳而不能耐受ACEI者可换用ARB。
	奥美沙坦	20～40	1	?
	替米沙坦	20～80	1	?
	缬沙坦	80～160	1	?
	阿利沙坦	240	1	?
β受体阻滞剂-心脏选择性	阿替洛尔	12.5～50	1～2	有气道痉挛性疾病患者禁用，必须应用时应选高选β1阻滞剂。
	比索洛尔	2.5～10	1	避免突然停药。
	酒石酸美托洛尔	25～100	2	?
	琥珀酸美托洛尔	23.75～190	1	?
β受体阻滞剂-α+β	卡维地络	12.5～50	2	有气道痉挛性疾病患者禁用，必须应用时应选高选β1阻滞剂。
	阿罗洛尔	10～20	1～2	避免突然停药。
	拉贝洛尔	200～600	2	?
α1受体阻滞剂	多沙唑嗪	1～16	1	可引起体位性低血压，尤其是老年人更易发生。
	哌唑嗪	1～10	2～3	伴良性前列腺增生患者可作为二线用药。
	特拉唑嗪	1～20	1～2	?
中枢性降压药	可乐定	0.1～0.8	2～3	避免突然停药引起高血压危象。
	甲基多巴	250～1000	2～3	?
	利血平	0.05～0.25	1	?
直接血管扩张药	肼屈嗪	25～100	2	大量可引起多毛症和狼疮综合征。

情况		药物
无症状靶器官损害		?
?	左心室肥厚	ACEI、CCB、ARB
?	无症状动脉粥样硬化	ACEI、CCB、ARB
?	微量白蛋白尿	ACEI、ARB
?	轻度肾功能不全	ACEI、ARB
临床心血管事件		?
?	既往心肌梗死	βB、ACEI、ARB
?	心绞痛	βB、CCB
?	心力衰竭	利尿剂、βB、ACEI、ARB、醛固酮受体拮抗剂
?	主动脉瘤	βB
?	房颤，预防	ACEI、ARB、βB、醛固酮拮抗剂
?	房颤，心室率控制	βB、非二氢吡啶类CCB
?	外周动脉疾病	ACEI、CCB、ARB
其他		?
?	单纯收缩期高血压（老年人）	利尿剂、CCB
?	代谢综合征	ACEI、ARB、CCB
?	糖尿病	ACEI、ARB

推荐方案	推荐类别	证据水平
推荐使用噻嗪类/样利尿剂、CCB、ACEI和ARB进行降压的起始和维持治疗^{[56,82,83,85,86]}	Ⅰ类	A级
对于大多数高于靶目标值20 mmHg以上的老年患者，起始治疗可采用两药联合^[95,96,97]	Ⅰ类	A级
如果两种药物联合治疗血压仍不能达标，推荐采用噻嗪类/样利尿剂、CCB、ACEI或ARB三种药物联合治疗，或使用单片复方制剂^[98,99]	Ⅰ类	A级
≥80岁的高龄患者和衰弱的老年患者，推荐初始降压采用小剂量单药治疗^[54,55,56]	Ⅰ类	A级
不推荐两种RAS抑制剂联用^{[56,82,83,84,85,86,88,90,91,92]}	Ⅲ类	A级

推荐方案	推荐类别	证据水平
急性脑出血的患者，应将收缩压控制在<180 mmHg^[117,118]	Ⅱa类	B级
急性缺血性卒中的患者，应将收缩压控制在<200 mmHg	Ⅱa类	C级
既往长期接受降压药物治疗的急性缺血性脑卒中或短暂性脑缺血发作患者，为预防卒中复发和其他血管事件，推荐发病后数日恢复降压治疗^[91,119]	Ⅰ类	A级
既往缺血性脑卒中或短暂性脑缺血发作患者，应根据患者具体情况确定降压目标。一般认为应将血压控制在140/90 mmHg以下^[91,119]	Ⅱa类	B级
既往缺血性脑卒中高龄患者血压应控制在150/90 mmHg以下	Ⅱa类	C级

推荐方案	推荐类别	证据水平
对于<80岁者，血压控制目标为<140/90 mmHg^[120,121]	Ⅰ类	A级
若一般状况好、能耐受降压治疗，尤其伴既往心肌梗死者，可降至<130/80 mmHg^[55]	Ⅱa类	B级
对于≥80岁者，血压控制目标为<150/90 mmHg，如耐受性良好，可进一步降至140/90 mmHg以下^[56]	Ⅱa类	B级
对于脉压增大者（≥60 mmHg）强调SBP达标。DBP<60 mmHg时，需在密切监测下逐步降至目标SBP	Ⅱa类	C级

推荐方案	推荐类别	证据水平
合并心力衰竭的老年高血压患者首先应将血压控制在<140/90 mmHg，若能耐受进一步降至<130/80 mmHg^[54,123,130]	Ⅱa类	B级
若无禁忌证，血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、醛固酮受体拮抗剂、利尿剂、β受体阻滞剂、血管紧张素受体脑啡肽酶抑制剂均可作为治疗的选择^[51,124,125]	Ⅰ类	A级
对于心力衰竭患者，不推荐应用非二氢吡啶类钙通道阻滞剂	Ⅲ类	C级

年份	年龄（岁）	患病率(%)	知晓率（%）	治疗率（%）	控制率（%）
2002	≥60	49.1	37.6	32.2	7.6
2012-2015	≥60	53.2	57.1	51.4	18.2

年份	年龄（岁）	患病率(%)	知晓率（%）	治疗率（%）	控制率（%）
2002	≥60	49.1	37.6	32.2	7.6
2012-2015	≥60	53.2	57.1	51.4	18.2

推荐方案	推荐类别	证据水平
对于老年慢性肾脏病患者，推荐血压降至140/90 mmHg以下^[54,133]	Ⅰ类	A级
对于尿蛋白>30～300 mg/d或更高者，推荐血压降至130/80 mmHg以下^[51,134,135]	Ⅰ类	C级
血液透析患者透析前收缩压应小于160 mmHg；老年腹膜透析患者血压控制目标可放宽至150/90 mmHg以下^{[136,137,138]}	Ⅱa类	C级

推荐方案	推荐类别	证据水平
慢性肾脏病患者首选血管紧张素转换酶抑制剂或血管紧张素受体抑制剂，尤其对合并蛋白尿患者^[131]	Ⅰ类	A级
应用血管紧张素转换酶抑制剂或血管紧张素受体抑制剂，应从小剂量开始，对于高血压合并糖尿病肾病者，用至可耐受最大剂量^[130]	Ⅱb类	C级
慢性肾脏病3～4期的患者使用时，初始剂量可减半，严密监测血钾和血肌酐水平以及肾小球滤过率，并及时调整药物剂量和剂型	Ⅱa类	C级
不推荐血管紧张素转换酶抑制剂与血管紧张素受体抑制剂合用^[139]	Ⅲ类	A级
对于有明显肾功能异常及盐敏感性高血压患者，推荐应用钙通道阻滞剂^[140]	Ⅰ类	C级
容量负荷过重的慢性肾脏病患者，慢性肾脏病4～5期推荐应用袢利尿剂（如呋塞米）	Ⅰ类	C级
α/β受体阻滞剂可以考虑用于难治性高血压患者的联合降压治疗	Ⅱb类	C级

推荐方案	推荐类别	证据水平
对于老年糖尿病患者，推荐血压控制在<140/90 mmHg ，若能耐受进一步降低至<130/80 mmHg ^[137,140]	Ⅰ类	A级
推荐舒张压尽量不低于70 mmHg	Ⅰ类	C级

推荐方案	推荐类别	证据水平
高血压合并糖尿病患者首选ACEI/ARB，ACEI不能耐受时考虑ARB替代^[141,142]	Ⅰ类	A级
若存在糖尿病肾脏损害，特别是UACR>300 mg/g或者eGFR<60 ml·min^-1·1.73 m^-2者，推荐使用ACEI^[143]/ARB^[144,145]，或成为联合用药的一部分	Ⅰ类	A级
对于糖尿病患者，推荐二氢吡啶类CCB与ACEI或ARB联合应用^[146,147]	Ⅰ类	B级
糖尿病患者eGFR<30 ml·min^-1·1.73 m^-2时可选用袢利尿剂^[148]	Ⅱb类	C级
糖尿病患者慎用大剂量利尿剂	Ⅲ类	C级
糖尿病患者可选用小剂量、高选择性β1受体阻滞剂与ACEI或ARB联合治疗^[149]	Ⅱb类	C级
糖尿病患者应避免β受体阻滞剂与利尿剂联合应用^[150]	Ⅲ类	C级
老年前列腺肥大患者可考虑应用α受体阻滞剂，但需考虑到体位性低血压的风险^[151]	Ⅱb类	C级

推荐方案	推荐类别	证据水平
纠正影响血压控制的因素，积极改善生活方式，提高治疗依从性^[159]	Ⅰ类	B级
血压不达标者应考虑加用醛固酮受体拮抗剂^[160]	Ⅱa类	B级
静息心率快，合并冠心病和心力衰竭患者可选用β阻滞剂^[161,162]	Ⅰ类	A级
老年男性患者合并前列腺增生可选择α1受体阻滞剂^[161,162]	Ⅱa类	B级
对于老年难治性高血压患者,可加用直接血管扩张剂（如肼苯哒嗪、米诺地尔）或中枢性降压药（如可乐定、α-甲基多巴）^[163,164]	Ⅱb类	B级

临床情况	降压要求	降压目标	药物选择及用量	推荐类别	证据水平
高血压脑病^[171,172]	降低血压的同时需保证脑灌注，给药开始1 h内将收缩压降低20%～25%，不超过50%	160～180/100～110 mmHg	乌拉地尔（10～50 mg，6～24 mg/h）拉贝洛尔（20～100 mg，0.5～2 mg/min，24 h不超过300 mg）尼卡地平（0.5～10 μg·kg^-1·min^-1）	Ⅰ类	C级
脑出血^[173,174]	当急性脑出血患者收缩压大于220 mmHg，积极静脉降压同时严密监测血压；收缩压大于等于180 mmHg，静脉降压并根据临床表现调整降压速度	收缩压小于180 mmHg	乌拉地尔（10～50 mg，6-24 mg/h）拉贝洛尔（20～100 mg，0.5～2 mg/min，24 h不超过300 mg）	Ⅱa类	B级
蛛网膜下腔出血^[175]	防止出血加剧及血压过度下降，引起短暂性神经功能缺陷，造成迟发弥漫性脑血管致死性痉挛	收缩压小于150～160 mmHg	尼卡地平（0.5～10 μg·kg^-1·min^-1）拉贝洛尔（20～100 mg，0.5～2 mg/min，24 h不超过300 mg）艾司洛尔（250～500 μg/kg，随后50～300 μg·kg^-1·min^-1）	Ⅰ类	C级
脑梗死^{[176,177,178]}	一般不积极降压，稍高的血压有利于缺血区灌注，除非血压大于等于200/110 mmHg，或伴有心功能不全、主动脉夹层、高血压脑病等。如考虑紧急溶栓治疗，为防止高血压致脑出血，血压大于等于180/100 mmHg就应降压治疗	24 h降压应不超过25%	乌拉地尔（10～50 mg，6～24 mg/h）拉贝洛尔（20～100 mg，0.5～2 mg/min），24 h不超过300 mg）尼卡地平（0.5～10 μg·kg^-1·min^-1）	Ⅱa类	C级
恶性高血压伴或不伴肾脏损害^{[179,180,181]}	避免血压剧烈波动，平稳降压，保证肾灌注	140/90 mmHg	利尿剂乌拉地尔（10～50 mg，6～24 mg/h）尼卡地平（0.5～10 μg·kg^-1·min^-1）拉贝洛尔（20～100 mg，0.5～2 mg/min，24 h不超过300 mg）	Ⅰ类	C级
急性心力衰竭^{[56,151,182,183,184]}	常表现为急性肺水肿，为缓解症状和减少充血，推荐血管扩张剂联合利尿剂治疗	<140/90 mmHg	硝普钠（0.25～10 μg·kg^-1·min^-1）硝酸甘油（5～100 μg/min）乌拉地尔（10～50 mg，6～24 mg/h）利尿剂	Ⅰ类	C级
急性冠状动脉综合征^{[185,186,187]}	降低血压、减少心肌氧耗量，但不影响冠状动脉灌注压及冠状动脉血流，不能诱发反射性心动过速	<140/90 mmHg	硝酸甘油（5～100 μg/min）艾司洛尔（250～500 μg/kg，随后50～300 μg·kg^-1·min^-1 iv）地尔硫卓（10 mg，5～15 μg·kg^-1·min^-1）乌拉地尔(10～50 mg，6～24 mg/h)	Ⅰ类	C级
主动脉夹层^[188]	扩张血管、控制心室率、抑制心脏收缩，在保证器官灌注的前提下，迅速将血压降低并维持在尽可能低的水平；首选静脉途径的β受体阻滞剂、非二氢吡啶类钙通道阻滞剂，必要时可联合使用乌拉地尔、硝普钠、尼卡地平等	SBP<120 mmHg	艾司洛尔（250～500 μg/kg，随后50～300 μg/kg/min iv）拉贝洛尔（20～100 mg，0.5～2 mg/min，24 h不超过300 mg）地尔硫卓（10 mg，5～15 μg·kg^-1·min^-1）乌拉地尔（10～50 mg，6～24 mg/h）硝普钠（0.25～10 μg·kg^-1·min^-1）尼卡地平（0.5～10 μg·kg^-1·min^-1）	Ⅰ类	C级

推荐方案	推荐类别	证据水平
TIA或缺血性卒中患者推荐短程心电图及随后连续心电监测至少72 h进行房颤筛查^{[191,192,193]}	Ⅰ类	B级
对于房颤患者，特别是正接受抗凝治疗的患者，应积极降压治疗，将血压控制在<140/90 mmHg^{[194,195,196]}	Ⅱa类	B级
推荐应用ARB及ACEI进行降压治疗预防新发房颤和阵发性房颤复发^{[103,104,105,106,107,108,109,110,111,112,113,114,115,116,117,118,119,120,121,122,123,124,125,126,127,128,129,130,131,132,133,134,135,136,137,138,139,140,141,142,143,144,145,146,147,148,149,150,151,152,153,154,155,156,157,158,159,160,161,162,163,164,165,166,167,168,169,170,171,172,173,174,175,176,177,178,179,180,181,182,183,184,185,186,187,188,189,190,191,192,193,194,197,198]}	Ⅰ类	B级
推荐所有无禁忌证的CHA2DS-VASC≥2分男性、≥3分女性患者口服抗凝药物进行抗凝治疗^[199,200]	Ⅰ类	A级
药物治疗无效、有症状的阵发性房颤推荐行射频消融治疗^[201]	Ⅰ类	A级
药物治疗无效、有症状的长期持续性房颤应考虑行射频消融治疗	Ⅱa类	C级

推荐方案	推荐类别	证据水平
对于择期手术，SBP≥180 mmHg和（或）DBP≥110 mmHg者推荐推迟手术	Ⅱa类	C级
对于围手术期老年高血压患者，推荐血压降至<150/90 mmHg；若合并糖尿病或慢性肾病，且耐受性良好，可进一步降至<140/90 mmHg	Ⅱa类	C级
围手术期血压波动幅度应控制在基础血压的10%以内	Ⅱa类	C级
长期服用β受体阻滞剂者，术前不应中断使用^[205]	Ⅲ类	B级
服用ACEI或ARB的老年患者，应在非心脏手术前停用	Ⅱa类	C级

药物名称	药物类别	剂量	不良反应	注意事项
米多君	α受体激动剂	推荐剂量为2.5～10 mg，3次/d	紫癜、尿潴留、卧位高血压	避免在入睡前4～5 h使用
屈昔多巴	去甲上腺素前体物质	起始剂量为100 mg，3次/d，每隔3～7d递增剂量100 mg，直至适宜维持剂量	卧位高血压、头痛、头晕及恶心	充血性心力衰竭、慢性肾功能不全应慎用
氟氢可的松	发挥肾上盐皮质激素受体作用	通常的起始剂量是0.1 mg，不超过0.3 mg/d	卧位高血压、水肿、低钾血症、头痛，严重者可发生肾上腺功能抑制	心力衰竭、肾功能衰竭或严重高血压时应禁用

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2019 Chinese guidelines for the management of hypertension in the elderly

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