Hypertension, the world’s most common and modifiable cardiovascular risk factor,1 has been the focus of multiple clinical practice guidelines dating back to the first Joint National Committee in 1977. In 2014, a writing group commissioned by the National Heart, Lung, and Blood Institute focused on a few key treatment questions and used data only from randomized clinical trials (RCTs) to inform their recommendations.2 Based on a lack of RCT evidence, the writing group recommended relaxing some of the treatment goals for several subgroups, including patients aged 60 years or older and those with diabetes or kidney disease. Even before publication, these somewhat conservative recommendations were criticized and ultimately not endorsed either by major professional societies or by some of the original guideline writing group.3 To address the ensuing controversies and to account for new evidence from recent RCTs that focused on hypertension, the American College of Cardiology and the American Heart Association (ACC/AHA) have now produced the 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults.4,5 The new guideline is summarized inaClinicalGuidelinesSynopsis inthis issueof JAMA.6 Thescope of this guideline is much more extensive than its 2014 predecessor, examining a broad range of topics including the definition of hypertension, diagnostic workup and evaluation, lifestyle management strategies both for prevention and for treatment, bloodpressure(BP)treatmentthresholdsandinitialdrugchoices, andlong-termmonitoring.TheACC/AHA2017guidelinealsoconsiders a broader range of evidence in forming the recommendations, including epidemiological studies and, in selected cases, expert opinion. Summarizing the full list of these recommendations in an Editorial would be impractical. Instead, we focus on those most likely to affect current clinical practice. The first noteworthy change in the 2017 guideline relates to the definition of hypertension and treatment targets. This guideline now categorizes BP as normal (systolic BP [SBP] <120 mm Hg AND diastolic BP [DBP] <80 mm Hg); elevated (SBP 120-129 mm Hg AND DBP <80 mm Hg); stage 1 hypertension (SBP 130-139 mm Hg OR DBP 80-89 mm Hg); and stage 2 hypertension (SBP ≥140 mm Hg OR DBP ≥90 mm Hg). Although the exact cut points for each of these classifications are somewhat arbitrary, there is well characterized and strong epidemiological evidence to support a generally linear association between lower SBP and DBP and cardiovascular risk.7 From a clinical perspective, lowering the diagnostic thresholds for “hypertension” beyond previous guidelines will significantly increase the number of individuals with this diagnosis. Importantly, this guideline uses a uniform BP definition for elevated BP and hypertension for all individuals, without regard to patient age or comorbid illness status. The 2017 ACC/AHA guideline also proposes more aggressive thresholds and goals for treatment relative to prior guidelines. Treatment recommendations are now based on an individual’s underlying cardiovascular disease (CVD) risk. For those with known CVD or diabetes, the guideline recommends intervention (both lifestyle and pharmacological treatment) for stage 1 hypertension (SBP ≥130 mm Hg or DBP ≥80 mm Hg). For all others, the guideline proposes use of BP-lowering medications in stage 1 hypertension only if a patient’s estimated 10-year atherosclerotic CVD (ASCVD) risk is 10% or higher. For those with lower ASCVD risk, lifestyle modification is recommended until the individual reaches stage 2 hypertension (140/90 mm Hg), above which drug therapy is recommended. In terms of treatment targets, for high-risk adults with known CVD or a 10-year ASCVDriskestimategreaterthan10%,theBPtargetsarelessthan 130/80 mm Hg. For adults without CVD and an estimated 10-year ASCVD risk estimate less than 10%, BP less than 130/80 mm Hg is still targeted but received a softer recommendation (IIb). These recommendations are the same for patients of all ages. The 2017 guideline strategy of tailoring treatment to a combination of both BP and underlying 10-year estimated risk of ASCVD is a huge step forward for hypertension management. This change reflects epidemiologic data showing that both underlying risk and change in BP while receiving treatment determine one’s absolute benefit from BP lowering.8 Furthermore, this risk-based approach is now more consistent with the recent cholesterol guidelines.9 The use of a risk-based approach as well as more aggressive BP targets reflect a strong influence in these guidelines from the SPRINT trial. SPRINT demonstrated that an SBP goal of less than 120 mm Hg was superior to a goal of less than 140 mm Hg among adults with SBP greater than 130 mm Hg.10,11 SPRINT enrolled adults who had either preexisting CVD or a 10-year Framingham ASCVD risk of greater than 15%. The SPRINT results likely influenced the 2017 guideline authors to limit the 130/80–mm Hg medication threshold to only those with known disease or higher predicted CVD risk. Yet the application of SPRINT results in the new guideline also required compromise. First, while SPRINT treated patients to an SBP goal of less than 120 mm Hg, because repeated BP measurements in SPRINT are likely lower than what is seen in clinical practice, the guideline recommended a target of less than 130 mm Hg, not 120 mm Hg. Second, despite the negative results Viewpoint

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新的 2017 年 ACC/AHA 指南“加大了高血压诊断和治疗的压力”

高血压是世界上最常见和可改变的心血管危险因素，1 一直是多项临床实践指南的重点，可追溯到 1977 年的第一届全国联合委员会。 2014 年，由国家心肺血液研究所委托的一个写作小组专注于几个关键的治疗问题，仅使用随机临床试验 (RCT) 的数据来提供建议。2 基于缺乏 RCT 证据，写作小组建议放宽一些亚组的治疗目标，包括 60 岁的患者年或以上以及患有糖尿病或肾病的人。甚至在出版之前，这些有些保守的建议就受到了批评，最终没有得到主要专业协会或一些原始指南编写小组的认可。包括流行病学研究，以及在特定情况下的专家意见。在社论中总结这些建议的完整列表是不切实际的。相反，我们专注于最有可能影响当前临床实践的那些。2017 年指南中第一个值得注意的变化与高血压和治疗目标的定义有关。该指南现在将血压归类为正常（收缩压 [SBP] <120 毫米汞柱和舒张压 [DBP] <80 毫米汞柱）；升高（收缩压 120-129 毫米汞柱和舒张压 <80 毫米汞柱）；1 期高血压（收缩压 130-139 毫米汞柱或舒张压 80-89 毫米汞柱）；和 2 期高血压（SBP ≥ 140 mmHg 或 DBP ≥ 90 mmHg）。尽管这些分类的确切切点有些随意，有充分表征和强有力的流行病学证据支持较低的 SBP 和 DBP 与心血管风险之间存在总体线性关联。 7 从临床角度来看，将“高血压”的诊断阈值降低到超出先前指南的水平将显着增加具有这种诊断的人数. 重要的是，该指南对所有个体的血压升高和高血压使用统一的血压定义，而不考虑患者的年龄或合并症状态。2017 年 ACC/AHA 指南还提出了相对于先前指南更积极的治疗阈值和目标。治疗建议现在基于个人的潜在心血管疾病 (CVD) 风险。对于已知患有心血管疾病或糖尿病的人，该指南建议对 1 期高血压（SBP ≥ 130 mmHg 或 DBP ≥ 80 mmHg）进行干预（生活方式和药物治疗）。对于所有其他患者，指南建议仅在患者估计 10 年动脉粥样硬化 CVD (ASCVD) 风险为 10% 或更高的情况下，才在 1 期高血压中使用降压药物。对于 ASCVD 风险较低的人，建议改变生活方式，直到个人达到 2 级高血压（140/90 mmHg），超过该阶段建议药物治疗。在治疗目标方面，对于已知CVD或10年ASCVD风险估计大于10%的高危成人，BP目标小于130/80 mm Hg。对于没有 CVD 且估计 10 年 ASCVD 风险估计值低于 10% 的成年人，血压低于 130/80 mmHg 仍是目标，但获得了较软的推荐 (IIb)。这些建议对所有年龄段的患者都是相同的。2017 年指南策略针对 BP 和潜在的 10 年 ASCVD 估计风险量身定制治疗方案，这是高血压管理向前迈出的一大步。这一变化反映了流行病学数据，表明潜在风险和接受治疗时血压的变化决定了一个人从降压中获得的绝对益处。8此外，这种基于风险的方法现在更符合最近的胆固醇指南。9基于方法以及更激进的血压目标反映了 SPRINT 试验中这些指南的强大影响。SPRINT 证明，在 SBP 大于 130 毫米汞柱的成人中，小于 120 毫米汞柱的 SBP 目标优于小于 140 毫米汞柱的目标。10，11 SPRINT 招募了既往存在 CVD 或 10 年 Framingham ASCVD 风险大于 15% 的成年人。SPRINT 结果可能影响了 2017 年指南作者将 130/80-mm Hg 药物阈值限制为仅那些患有已知疾病或具有较高预测 CVD 风险的人。然而，新指南中 SPRINT 结果的应用也需要妥协。首先，虽然 SPRINT 治疗患者的 SBP 目标低于 120 毫米汞柱，但由于 SPRINT 中重复的血压测量值可能低于临床实践中看到的值，指南推荐的目标是低于 130 毫米汞柱，而不是 120 毫米汞柱. 二、尽管有负面结果 观点 SPRINT 结果可能影响了 2017 年指南作者将 130/80-mm Hg 药物阈值限制为仅那些患有已知疾病或具有较高预测 CVD 风险的人。然而，新指南中 SPRINT 结果的应用也需要妥协。首先，虽然 SPRINT 治疗患者的 SBP 目标低于 120 毫米汞柱，但由于 SPRINT 中重复的血压测量值可能低于临床实践中看到的值，指南推荐的目标是低于 130 毫米汞柱，而不是 120 毫米汞柱. 二、尽管有负面结果 观点 SPRINT 结果可能影响了 2017 年指南作者将 130/80-mm Hg 药物阈值限制为仅那些患有已知疾病或具有较高预测 CVD 风险的人。然而，新指南中 SPRINT 结果的应用也需要妥协。首先，虽然 SPRINT 治疗患者的 SBP 目标低于 120 毫米汞柱，但由于 SPRINT 中重复的血压测量值可能低于临床实践中看到的值，指南推荐的目标是低于 130 毫米汞柱，而不是 120 毫米汞柱. 二、尽管有负面结果 观点 该指南推荐的目标是低于 130 毫米汞柱，而不是 120 毫米汞柱。二、尽管有负面结果 观点 该指南推荐的目标是低于 130 毫米汞柱，而不是 120 毫米汞柱。二、尽管有负面结果 观点