2022台灣高血壓指引(英文版) 何時考慮使用降血壓藥物-血壓控制目標值

2026-06-10

2022台灣高血壓指引(英文版)

工作小組共識摘要(筆記最下面一段)

1. 每年心血管事件發生率 > 1.0% 的患者（基於更廣泛的 ASCVD 定義），藥物將血壓降低至 < 130/80 mmHg 通常可以帶來心血管獲益

2. 年心血管風險 > 3%（極高風險，圖 4）的患者，進一步將血壓降低至 < 120/80 mmHg 似乎是有益的，特別是對於收縮壓在 120-130 mmHg 範​​圍內的患者

3. 過度降低血壓（即使血壓目標設定得很高）也可能造成傷害。 即使生理機能充分適應，將血壓降至臨界值以下仍可能損害器官灌注。抗高血壓治療會抑制血管調節反應，進而進一步加劇終末器官損傷。 高血壓管理的首要任務是確保患者能夠耐受目標血壓。 一旦出現終末器官灌注不足的症狀或體徵，應放寬血壓目標值（證據等級 IIb，C 級）。

4. 血壓目標值的下限差異很大，難以界定。年齡本身並非對積極血壓目標耐受性差的必要條件。研究發現. 與年輕成人相比，老年人（70-80 歲）在收縮壓目標值 < 130 mmHg 時，相對風險降低幅度相似，而絕對風險降低幅度更大。

5. 低風險患者中，中年高血壓也與長期（> 15 年）心血管疾病和失智症事件有關。
6. 建議所有高血壓患者的血壓目標值應為 < 130/80 mmHg，該目標值是基於按照 722 方式測量的居家血壓

7. 建議對於已確診心血管疾病或心血管風險較高的患者，如果能夠耐受，收縮壓目標值可以低於 120 mmHg

高血壓何時考慮開始使用藥物治療

低心血管疾病風險. 140/90 以上

其他患者 130/80 以上

血壓控制目標

1. 所有高血壓患者. 建議控制在 130/80 之下

2. 曾發生心血管疾病或高風險患者. 若病患能耐受建議維持在 120/80 以下

其他狀況的血壓控制目標

1. 多數中風患者 < 130/80

2. 若有兩側內頸動脈狹窄或基底動脈狹窄(狹窄>70%). 需小心過度降壓導致的腦灌流不足

3. 慢性腎臟病 CKD. 收縮壓 SBP 建議維持在 < 130

4. CKD患者尚未開始洗腎前. 若病患能承受. 建議維持 < 120 

5. CKD已經洗腎患者建議維持< 130/80 

6. 年長者(65歲以上)  收縮壓 SBP 建議維持在 < 130

7. 懷孕婦女. 若血壓 > 170/110 建議住院降壓治療

8. 中度或重度前置胎盤孕婦. 在第 12-36(37)周可給予低劑量aspirin 75-150 mg QD

使用google中文翻譯

6.1 高血壓管理的目標與閾值 

抗高血壓治療的目標是預防動脈粥狀硬化性心腦血管疾病的發生與發展。有效的血壓控制甚至可以逆轉已存在的動脈粥狀硬化性病變。 根據最近發表的統合分析，該分析納入了來自48項抗高血壓治療隨機試驗的344,716名個別參與者的數據，結果顯示，收縮壓每降低5 mmHg，在平均4.2年的追蹤後，主要心血管事件的風險降低10%，中風風險降低13%，缺血性心臟病風險降低8%，心臟衰竭風險降低13%，心血管死亡率降低5%，全因死亡率降低2%。

抗高血壓治療降低心血管疾病相對風險的程度在不同年齡、性別、是否有合併症或基線收縮壓程度（<120至170 mmHg）的受試者中無顯著差異。 需要強調的是，這些統合分析中 MACE 主要心血管事件的平均年發生率>3.0%，這表明…入組的大多數患者都具有較高的心血管風險。這些證據表明，對於收縮壓在 120 至 170 mmHg 之間的高風險患者，一定程度的藥物降血壓可以帶來心血管益處。

另一方面，目前尚無證據表明，對於心血管風險較低（10年動脈粥樣硬化性心血管疾病[非致命性心肌梗塞、中風或心血管死亡]風險<5%）且基線收縮壓<140 mmHg的患者，在3-5年追蹤後，固定程度的藥物降壓能夠帶來明顯的心血管獲益或生存獲益。

根據ESC/ESH、ISH和JSH指南，低風險狀態定義為心血管危險因子少於3個，且無高風險功能障礙（HMOD）或已確診動脈粥樣硬化性心血管疾病（ASCVD）證據的患者（圖4中為1期，危險因子<3個，血壓<140/90 mmHg）。因此，工作小組建議，對於低風險（無ASCVD或HMOD，且ASCVD危險因子<3個）高血壓患者，應將血壓水平140/90 mmHg作為啟動藥物治療的閾值。

治療（證據等級 I，證據等級 A）。對於其餘高血壓患者，建議將血壓水平 130/80 mmHg 作為啟動藥物治療的閾值（證據等級 I，證據等級 A）。然而，中年高血壓與長期（> 15 年）心血管事件和失智事件有關。 應將基於生活型態介入 (LSM) 的非藥物治療應用於血壓升高族群和高血壓患者，以減輕終生血壓負擔，這似乎是所有血管事件的根本原因。

6.2 基於風險圖的通用血壓目標和管理策略 

在引入基於風險圖的血壓目標進行藥物降血壓治療之前，我們必須強調兩個原則。首先，所有血壓水平為 120/80 mmHg 的個體都需要進行生活方式乾預，以將血壓控制在 120/80 mmHg 以下，如果無法耐受，則應控制在更高水平。為了減輕終生血壓負擔。其次，醫護人員應指導患者在家中測量血壓，最好遵循「722」方案和說明（圖1和表6、7）。工作小組建議醫護人員應使用居家血壓監測（HBPM），而非非標準化的遠距血壓監測（ROBP），來指導其高血壓管理決策，尤其是在診室血壓與平均家庭血壓有較大差異的情況下。

鑑於血壓控制的目的是預防心血管事件的發生，我們在推薦血壓目標值和設計試驗以填補證據空白時，應考慮兩個關鍵因素：

血壓降低的幅度以及固有的心血管風險

這兩個因素決定了血壓管理帶來的絕對益處。風險圖和血壓目標值的結合反映了在製定高血壓管理策略時進行綜合考慮的原則（圖4）。這也是首個基於風險圖的血壓閾值。並制定了促進其實施的目標。在風險圖中，橫軸列出了不同類別的血壓，縱軸列出了不同類別的整體心血管風險。我們將血壓本身分為不同的「等級」。同時，我們將整體心血管風險分為“階段”，以使該分類方案與心臟衰竭的分類方案保持一致。 此外，與等級相比，階段在血壓負擔、損傷和預後預測方面具有更廣泛的意義。

風險因子（1期）、亞臨床HMOD的程度（2期）以及ASCVD和高血壓相關CVD的存在（3期）均與高血壓患者預後不良呈遞增相關，這已在全球隊列研究和多項抗高血壓藥物試驗的薈萃分析中得到證實。為了確定風險圖中每個類別的血壓目標值，我們應考慮降低血壓帶來的益處和危害之間的平衡，以及來自高品質隨機對照試驗（RCT）的證據。

工作小組達成以下共識。
首先，對於年心血管事件發生率 > 1.0% 的患者（基於更廣泛的 ASCVD 定義），藥物將血壓降低至 < 130/80 mmHg 通常可以帶來心血管獲益，STEP、SPRINT、HOPE-3 和各種薈萃分析均證實了這一點。
其次，對於年心血管風險 > 3%（極高風險，圖 4）的患者，進一步將血壓降低至 < 120/80 mmHg 似乎是有益的，特別是對於收縮壓在 120-130 mmHg 範​​圍內的患者，這一結論基於薈萃分析和 2021 年 Ksup> 2021 年 KDI>202

第三，工作小組體認到，過度降低血壓（即使血壓目標設定得很高）也可能造成傷害。 即使生理機能充分適應，將血壓降至臨界值以下仍可能損害器官灌注。抗高血壓治療會抑制血管調節反應，進而進一步加劇終末器官損傷。 高血壓管理的首要任務是確保患者能夠耐受目標血壓。

工作小組建議，一旦出現終末器官灌注不足的症狀或體徵，應放寬血壓目標值（證據等級 IIb，C 級）。目前尚無隨機對照試驗旨在探討目標血壓水平的下限。所有提示性報告均來自事後分析，因此無法排除反向因果關係的可能性（參見 6.3 節）。

因此，工作小組認為血壓目標值的下限差異很大，難以界定。年齡本身並非對積極血壓目標耐受性差的必要條件。相反，SPRINT 和 STEP 兩項試驗均表明，與年輕成人相比，老年人（70-80 歲）在收縮壓目標值 < 130 mmHg 時，相對風險降低幅度相似，而絕對風險降低幅度更大。

最後，即使在低風險患者中，中年高血壓也與長期（> 15 年）心血管疾病和失智症事件有關。

綜合來看，工作小組建議所有高血壓患者的血壓目標值應為 < 130/80 mmHg，該目標值是基於按照 722 方案獲得的 HBPM（建議等級 I，證據等級 A）。

工作小組也建議，對於已確診心血管疾病或心血管風險較高的患者，如果能夠耐受，收縮壓目標值可以低於 120 mmHg（COR IIa，LOE B）（圖 4）。

6.1 Objectives and thresholds of hypertension management The objectives of antihypertensive treatment are to prevent the development and progression of atherosclerotic cardio- and cerebrovascular diseases. Effective BP control can even reverse the existing atherosclerotic Cascular changes.230,231 According to the most recently published meta-analysis of 344,716 individual participant-level data from 48 randomized trials of antihypertensive treatment, a 5 mmHg decrease in SBP reduced the risks of major CV events by 10%, stroke by 13%, ischemic heart disease by 8%, heart failure by 13%, CV mortality by 5%, and all-cause mortality by 2% after a median 4.2 years’ follow-up.3 The extent of reduction in the relative risk for CV diseases achieved by antihypertensive treatment did not differ significantly among subjects who have different ages, sex, presence or absence of associated diseases, or baseline SBP levels (ranging from < 120 to  170 mmHg).3,232,233 It should be emphasized that the average major CV event rate was > 3.0% annually in these meta-analyses, suggesting the majority of patients enrolled were at high CV risk. These lines of evidence indicate that a fixed degree of pharmacological BP lowering can confer CV benefits for high-risk patients with SBP ranging from < 120 to  170 mmHg. On the other hand, there is still no evidence to demonstrate a clear CV or survival benefit of a fixed degree of pharmacological BP lowering in patients with low CV risk (10-year ASCVD [nonfatal myocardial infarction, stroke, or CV death] risk < 5%) and baseline SBP < 140 mmHg after 3-5 years’ follow-up.9,234-236 According to ESC/ESH, ISH, and JSH guidelines, low-risk status is defined as patients with fewer than 3 CV risk factors and no evidence of HMOD or established ASCVD (stage 1, risk factors < 3, and BP < 140/90 mmHg in Figure 4).10,11,13 The Task Force thus recommends that a BP level of  140/90 mmHg should be the threshold for low-risk (no ASCVD or HMOD, and number of ASCVD r

isk factors < 3) hypertensive patients to initiate pharmacological treatment (COR I, LOE A). For the rest of hypertensive patients, a BP level of  130/80 mmHg is recommended as the threshold for initiation of pharmacological treatment (COR I, LOE A). However, mid-life elevated BP was associated with longterm (> 15 years) CV and dementia events.237,238 Lifestyle modification (LSM)-based non-pharmacological therapy should be applied to people with elevated BP and hypertensive patients to reduce life-time BP burden, which seems to be the root cause of all vascular events.239 6.2 Risk chart-based universal blood pressure targets and management strategy There are two principles we have to emphasize before the introduction of risk chart-based BP targets for pharmacological antihypertensive treatment. First, all individuals with BP levels of  120/80 mmHg require lifestyle modifications to keep their BP below 120/80 mmHg, or higher if not tolerable, to alleviate life-time BP burden. Second, healthcare professionals should instruct patients to measure their BP at home, preferably following the “722” protocol and instructions (Figure 1 and Tables 6 and 7).1 The Task Force recommends that healthcare professionals should use HBPM, rather than nonstandardized ROBP, to guide their decisions regarding hypertension management, especially if there is a large discrepancy between office BP and averaged home BP. Given that the purpose of BP control is to prevent the occurrence of CV events, we should consider the two essential factors, the magnitude of BP reductions and inherent CV risk, which determine the absolute benefits obtained from BP management, in recommending BP targets and designing trials to fill the evidence gap. The combination of risk chart and BP targets embodies the comprehensive consideration in the determination of hypertension management strategy (Figure 4). This is also the first-ever risk chart-based BP thresholds and targets to facilitate its implementation. In the risk chart, different categories of BP are listed in the horizontal axis, whereas different categories of overall CV risks are listed in the vertical axis. We categorize BP itself into different “grades”. While we categorize overall CV risks as “stages” to make this classification scheme consistent with that being used in the classification of heart failure.240,241 Further, stages, compared with grades, have a broader meaning concerning BP burden, damages incurred, and prognostic prediction. Risk factors (stage 1), the extent of subclinical HMOD (stage 2), and the existence of ASCVD and hypertensionrelated CVD (stage 3) are incrementally associated with worse prognosis in hypertensive patients, as shown in cohort studies worldwide and several meta-analyses of antihypertensive drug trials. To determine the BP targets in each category of the risk chart, we should consider the balance of benefits and harms associated with BP reductions, as well as evidence from high-quality randomized controlled trials (RCTs). 

高血壓工作小組共識

The following consensus was reached in the Task Force. 

First, pharmacological BP lowering to < 130/80 mmHg can generally confer CV benefits in patients with an annual CV event rate of > 1.0% (based on the broader definition of ASCVD), as demonstrated in the STEP, SPRINT, HOPE-3, and various meta-analyses.3,8,9,234 

Second, among patients with an annual CV risk of > 3% (very high risk, Figure 4), further BP reductions down to < 120/80 mmHg seem beneficial, particularly for patients with their SBP in the range between 120-130 mmHg, based on evidence from the metaanalyses3,232 and the 2021 KDIGO guideline.12 

Third, the Task Force recognizes that, together with aggressive BP targets, excessive BP reductions can cause harms.242 Lowering BP below a critical limit may compromise organ perfusion despite adequate physiological adaptation.243 End-organ damage can be further precipitated by blunted vasoregulatory responses with anti-hypertensive therapy.244 Tolerability to the BP target is the first priority in hypertension management. 

The Task Force recommends to relax the BP target once symptoms or signs of endorgan hypoperfusion ensue (COR IIb, LOE C). There is no RCT designed to explore the lower limit of target BP levels. All suggestive reports are from post-hoc analyses, which cannot exclude the possibility of reverse causality (see Section 6.3). 

The Task Force therefore considered the lower limit of BP targets is highly variable and hard to define. Age alone is not a prerequisite for poor tolerability to aggressive BP targets. Instead, both SPRINT and STEP trials demonstrated that, compared to younger adults, older adults (70-80 s) are associated with similar relative risk reductions and greater absolute risk reductions with the SBP target of < 130 mmHg compared to  130 mmHg. 

Finally, mid-life elevated BP was associated with long-term (> 15 years) CV and dementia events even in low-risk patients. 

Taken together, the Task Force recommends a universal BP target of < 130/80 mmHg, based on HBPM obtained according to the 722 protocol, for all hypertensive patients (COR I, LOE A).

The Task Force also recommends that the SBP target can be < 120 mmHg for patients with established CV diseases or at high CV risk, if tolerable (COR IIa, LOE B) (Figure 4).