Blood Pressure Screening Methods and Rescreening Intervals: An Updated

Systematic Review for the USPSTF

PracticeUpdate 2015-01-07 07:38 点击次数：4393 发表评论

分享到

《内科学年鉴》2014 年 11 月 23 日发表的研究总结了血压筛查间隔时间以及筛查方式准确度的证据，支持将
动态血压测量作为参照标准，对诊室血压筛查的较高结果进行确认，以此避免误诊单纯临床高血压患者。40
多个研究的数据表明，再次筛查时高血压的发生率随时间间隔（1~6 年）不同而明显不同。6 年内进行再次筛
查时高血压风险较高的个体包括：较年长者、黑种人、血压处于正常范围的较高水平者以及 BMI 处于正常范
围较高水平者。西奈心脏研究所 Ronald G Victor 博士对此进行了点评。

《内科学年鉴》本周（2014 年 11 月 23 日）发表了两项研究，分别向 2014 年美国成人高血压治疗指南

（JNC8）的两条关键内容发起了挑战，持有的观点包括：① JNC8 采纳的高血压试验所纳入的患者主要为Ⅱ
期高血压患者（基线 BP> 160/100 mmHg），故其证据对轻度高血压患者治疗的获益并不具说服力，而存在
轻度高血压的患者更为普遍；② JNC8 采纳的多项研究完全是采用在诊室测量 BP 的传统方法来证明治疗的获
益。

第一项研究是由血压治疗试验协作组进行的 Meta 分析，该分析提出新的证据证明，对于轻度高血压的治疗也

可以显著减少卒中和死亡的风险。作者分析了 10 项试验中 6000 例患者的特异性数据，这些患者（96%存在
糖尿病）无明显心血管疾病，平均年龄 64 岁，平均基线血压值为 146/84 mmHg；他们被随机分配进行积极治
疗 vs 安慰剂治疗或者是高强度 vs 低强度治疗。积极治疗组患者与对照组相比，在 BP 仅降低 4/2mmHg 的情
况下，5 年后卒中减少 28%，心血管性死亡减少 25%，全因死亡率减少 22%。而在收缩压<150mmHg、年龄
大于 60 且无糖尿病的这一较小患者群中，所得结果几乎相同。这些数据可以说是对 JNC 8 报告中等级最强同
时也是争议最大的推荐提出了质疑。因为卒中与收缩期血压紧密相关，所以我会考虑对那些存在轻度高血压的
患者进行治疗，而这些患者的主要顾虑在于如何避免卒中发生。

另一项研究来自美国预防服务工作组（USPSTF），这项研究证实了 2011 英国 NICE（英国国家卫生与临床

优化研究所）高血压指南以及 2013 欧洲高血压学会/欧洲心脏病学会指南中所支持的结论，即动态 BP 监测比
传统诊室 BP 检查在预测长期心血管结局方面更胜一筹，这也是一项广受支持的结论，也是对 JNC 8 的质疑。
这项系统评价所纳入的 27 个研究中，5%~65%的无既往高血压诊断的个体在初次临床筛查时发现 BP 较高，
而随后的动态血压监测则表明这些个体血压正常，即存在白大衣高血压。此外，其他研究也已表明，多达
30%的糖尿病患者和 40%的慢性肾脏疾病患者存在隐匿性高血压，即临床 BP 检查结果正常，而动态血压监测
证明这些患者在日间生活和/或夜间睡眠中存在明确的高血压。我认为，政府部门尤其是医疗保险和医疗补助
服务中心（CMS），本应在以前就像英国和欧洲政府那样，将对动态 BP 监测的偿付常态化，以便于确证/排
除高血压的初次诊断，并对存在隐匿性高血压的高风险患者进行筛查。这样，美国民众中数百万例高血压过度
治疗和治疗不足的情况就会大大减少。

TAKE-HOME MESSAGE
The authors of this review summarize evidence on blood pressure (BP) rescreening intervals and accuracy
of different BP methods. Evidence supports ambulatory BP monitoring as a reference standard for
confirming elevated office BP screening results to avoid misdiagnosis of patients with isolated clinic
hypertension. Data from 40 studies showed that the incidence of hypertension after rescreening varied
considerably when measured at yearly intervals up to 6 years.

Individuals at higher risk for hypertension on rescreening within 6 years include older individuals, blacks,
those with BP in the high-normal range, and those with above-normal BMI.

Expert Comment

Two studies published this week in the Annals of Internal Medicine challenge two major tenets of the JNC 8
Report, namely that hypertension trials have: (1) enrolled patients with mainly Stage 2 hypertension
(baseline BP > 160/100 mmHg) and thus provide no convincing evidence for benefits of treating mild
hypertension, which is far more common; (2) relied strictly on conventional office-based BP measurements
to show the benefits of therapy. Results of the Blood Pressure (BP) Treatment Trialists’ Collaboration meta-
analysis challenges the first tenet by providing new evidence that treatment of even mild hypertension
significantly reduces the risk of stroke and death. They analyzed patient-specific data from 10 trials in which
over 6,000 patients (96% of whom had diabetes) who were free of overt cardiovascular disease, mean age
of 64 years, and mean baseline BP of 146/84 mmHg were randomized to either active therapy vs. placebo
or more intensive vs. less intensive therapy. Mild additional BP reductions of only 4/2 mm Hg in active
treatment groups versus comparison groups were accompanied 5 years later by 28% fewer strokes, 25%
fewer cardiovascular deaths, and 22% fewer total deaths. Virtually identical results were found in the small
subgroup of patients with systolic BP < 150 mmHg, age > 60, and no diabetes—thus directly challenging the
strongest but also most controversial recommendation of the JNC 8 Report. Stroke is so tightly linked to
systolic BP that I consider treating such mild hypertension with my patients whose major concern is to avoid
a stroke.

Next, a systemic review by the U.S. Preventive Services Task Force challenges the second tenet by
confirming the widely held conclusion of both the 2011 British (National Institute for Clinical Excellence)
Hypertension Guidelines and the 2013 European Society of Hypertension/European Society of Cardiology
Guidelines that ambulatory BP monitoring is far superior to conventional office BP in predicting long-term
cardiovascular outcomes. Across 27 studies, 5% to 65% of persons with no prior diagnosis of hypertension
and an elevated BP at initial office screening were subsequently found to be normotensive by ambulatory
monitoring—i.e., to have white coat hypertension. Other studies have shown that up to 30% of patients with
diabetes and 40% of patients with chronic kidney disease will have masked hypertension—normotensive BP
readings in the office but clearly high BP during their daily lives and/or at night by ambulatory monitoring. In
my opinion, time is long overdue for our government—specifically the Center for Medicare and Medicaid
Services (CMS)—to join the British and European governments in routinely reimbursing ambulatory BP
monitoring both to confirm/reject the initial diagnosis of hypertension and to screen for masked hypertension
in high risk patients. This would eliminate millions of cases in the U.S. of both over-treatment and under-
treatment of hypertension.
Annals of Internal Medicine

Diagnostic and Predictive Accuracy of Blood Pressure Screening Methods With Consideration of
Rescreening Intervals: An Updated Systematic Review for the US Preventive Services Task Force

Ann. Intern. Med 2014 Dec 23;[EPub Ahead of Print], MA Piper, CV Evans, BU Burda, KL Margolis, E
O'Connor, EP Whitlock

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

This abstract is available on the publisher's site.

Access this abstract now

Copyright © 2015 Elsevier Inc. All rights reserved.

独家授权，未经许可，请勿转载