中国高血压临床实践指南

指南心血管内科· 高血压 · 2022 · 国家心血管病中心中国医师协会中国医师协会

高血压不仅是中国患病人数最多的慢性非传染性疾病，也是导致城乡居民心血管疾病死亡的最重要的危险因素。为实现高血压临床诊治标准化，由国家心血管病中心、中国医师协会、中国医师协会高血压专业委员会、中华医学会心血管病学分会、海峡两岸医药卫生交流协会高血压专业委员会联合发起制订《中国高血压临床实践指南》，指南采用推荐意见分级的评估、制订及评价（GRADE）分级体系和卫生保健实践指南报告条目（RIGHT）的标准制订，针对高血压（包括原发性高血压和继发性高血压）领域有关诊断、评估和治疗的44 个临床问题，给出了较为详细的循证推荐，旨在通过循证指导临床实践，全面提升我国高血压诊治水平。

高血压指南证据质量与推荐强度分级

指南形成方法

本指南已在国际实践指南注册平台（International Practice Guideline Registry Platform）上以中英双语注册（注册号：IPGRP‑2021CN346），并发表了相应指南计划书［7］。指南制订原则，制订机构，目标用户，适用人群，临床问题和结局指标的确定，证据的检索、评价与合成，证据质量分级，患者偏好与价值观调查，形成推荐意见，外审，指南发布与更新等方法学流程与细节详见计划书。

在指南实际制订过程中，考虑到多方面因素，对计划书中的以下内容进行了调整和完善，特此说明：1）指南制订工作组成员数量有所调整：工作组由4个小组构成，分别为指导委员会（7名心血管领域的资深临床医师）、指南制订组（以心血管科和高血压专业医师为主，还包括肾脏病科、内分泌科、泌尿外科、血管外科、精神心理科、流行病学、护理学、临床药学、卫生经济学等领域专家以及患者代表，共52 名成员）、证据评价及秘书组（34 名临床专业成员、15 名循证医学/方法学专业成员和2 名总协调员）以及外审组（11 名高血压领域的临床医学专家及4 名政策制定者）。2）进一步明确了利益冲突管理办法：汇总后的利益冲突声明表在方法学主席的指导下由指导委员会成员评估和管理，若工作组成员声明的利益关系对指南内容构成利益冲突，则根据利益冲突的程度限制其参与核心工作或不参与本次指南的制订工作。利益冲突声明表可联系工作组获取。3）资金来源调整：本指南制订所需资金来源于国家卫生健康委员会疾病预防与控制局项目（T2021‑ZC02）和中国医学科学院医学与健康科技创新工程项目（2021‑I2M‑1‑007）。资金主要用于支付劳务、资料、差旅和会务费用，指南推荐意见未受资助影响。4）推荐意见的形成：本指南采用推荐意见分级的评估、制订及评价（grading ofrecommendations assessment， development and

evaluation，GRADE）分级体系对推荐意见的支持证据体进行评级（表1）8］。对于部分无证据支持的临床问题，则依据专家临床经验，形成基于专家共识的推荐意见，即良好实践主张（good practicestatement，GPS）9］。综合考虑证据以及我国患者的偏好与价值观、干预措施的成本和利弊等因素后，指南工作组提出了符合我国临床诊疗实践的推荐意见，于2022 年6 月4 日针对指南制订组专家进行第1 轮德尔菲推荐意见调查，对于第1 轮未达成共识的9 条推荐意见（共识度 ${<}75\%$ ），分别于2022 年6 月18 和19 日召开线上专家共识会进行讨论，根据专家意见修改后的推荐意见于2022 年6 月23 日进行了第2 轮德尔菲推荐意见调查，最终所有临床问题的推荐意见均达成共识（共识度 ${\it\Omega}\approx\!75\%$ ）。

表1 证据质量与推荐强度分级

|GRADE分级|具体描述| |---|---| |证据质量分级|| |高（A）|非常有把握：观察值接近真实值| |中（B）| 对观察值有中等把握：观察值有可能接近真实值，但也有可能差别很大 | |低（C）| 对观察值的把握有限：观察值可能与真实值有很大差别 | |极低（D）| 对观察值几乎没有把握：观察值与真实值可能有极大差别 | |推荐强度分级|| |强（1）|明确显示干预措施利大于弊或大于利| |弱（2）|利不确定或无论证据质量高低均显示利相当|

注：GRADE为推荐意见分级的评估、制订和评价体系

指南推荐意见及说明

临床问题1 中国成人能否采用 $\mathbf{SBP{\geqslant}130\;mmHg}$ 和/或 $\mathbf{DBP}{\geqslant}80\mathbf{\mm}\mathbf{Hg}$ 作为高血压的诊断标准？

临床问题2 中国成人高血压患者如何按照血压水平分级？

临床问题6 高血压患者HBPM 的测量时间和频率如何推荐？

临床问题7 高血压患者推荐哪些非药物干预措施？

• 建议钾摄入目标为 $\mathbf{3\,500{\sim}4\,700\,m g/d\left(2B\right)}$ 。

临床问题11 如何根据心血管危险分层确定高血压患者启动降压治疗的时机？

临床问题13 高血压患者是否需要在4 周内实现血压达标？

临床问题16 高血压合并冠心病患者如何推荐降压药物？

临床问题17 高血压合并心衰患者，如何推荐首选降压药物？

推荐意见

• 高血压合并HFrEF 患者，推荐血管紧张素受体‑脑啡肽酶抑制剂（angiotensin receptor

neprilysin inhibitor，ARNI）替代ACEI/ARB 作为首选用药（2B）。

• 高血压合并HFpEF 患者，ARNI/ARB/ACEI 均可作为首选用药（2C）。

临床问题18 高血压合并卒中的患者如何推荐降压药物？

临床问题21 哪些高血压患者应该服用阿司匹林？

临床问题22 高血压患者进行降压药物治疗后再次随访需间隔多长时间？

临床问题23 螺内酯是否应作为难治性高血压患者的第4种药物选择？

临床问题 24 肾脏去交感神经术（renaldenervation，RDN）适用哪些高血压人群？

临床问题25 高血压急症的急诊处理原则？

• 对存在血压显著升高（ $\mathbf{(SBP{>}180~mmHg$ 和/或 $\mathbf{DBP{>}120~mmHg}\,)$ ）的高血压患者，建议尽快评估是否存在新出现的、进行性加重的靶器官功能损害（GPS）。 • 对合并新出现的、进行性加重的靶器官损害的高血压患者，建议收入急诊抢救室或监护室治疗，并持续监测血压与靶器官损害状况，同时给予静脉降压药物治疗（GPS）。 • 高血压急症的急性期降压原则：建议在保证充分器官灌注的前提下，分阶段将血压降至相对安全

的范围（治疗的第1 个小时内SBP 的降低幅度不超过治疗前水平的 $25\%$ ；如病情稳定，在随后的2\~6 h内将血压降至 $\mathbf{160/100\mmHg}$ 左右；此后在24\~ $\mathbf{48\;h}$ 内逐步将血压降至目标水平）；降压幅度和速度应根据患者具体情况个体化制定和调整（GPS）。• 对存在严重合并症（如严重先兆子痫或子痫、嗜铬细胞瘤危象等）的高血压急症患者，建议在治疗的第1 个小时内将SBP 降至 $\mathbf{140\mmHg}$ 以下（GPS）。

• 对于合并主动脉夹层的高血压急症患者，在耐受的情况下，建议在1 h 内将SBP 降至110\~ $\mathbf{120\mmHg}$ ，同时心率控制在 $\scriptstyle{<60}$ 次/min（GPS）。

临床问题26 哪些高血压患者需要进行继发性高血压筛查？

推荐意见

• 建议对以下患者进行常见继发性高血压筛查（2C）：（1）新诊断高血压患者；（2）发病年龄 ${\tt<}{\bf40}$ 岁的高血压患者；（3）难治性高血压患者；（4）有继发高血压临床线索或存在广泛高血压介导靶器官损害的高血压患者。

临床问题27 哪些高血压患者需要筛查原发性醛固酮增多症（简称原醛症）？

临床问题28 原醛症的初步筛查指标及各项指标的切点值如何推荐？

临床问题30 原醛症筛查全程是否需要药物洗脱？

临床问题31 哪些高血压患者需要筛查库欣综合征？

• 在成人高血压患者中，存在以下情况，建议筛查库欣综合征（2C）：（1）典型临床特征（皮肤瘀斑、多血质貌、近端肌萎缩、皮肤紫纹）；（2）其他临床特征（如月经紊乱、痤疮、体重增加、向心性肥胖）；（3）难治性高血压；（4）与年龄不符的骨质疏松；（5）肾上腺意外瘤；（6）合并2 型糖尿病的特殊人群（需要使用胰岛素或使用2 种及以上降压

药物）。

临床问题32 高血压患者如何筛查库欣综合征？推荐意见

• 建议对临床怀疑库欣综合征的高血压患者使用以下任一方法进行筛查：（1）过夜 $\mathbf{1}\,\mathbf{m}\mathbf{g}$ 地塞米松抑制试验（2D）；（2）24 h 尿游离皮质醇（2C）；（3）午夜唾液皮质醇（2C）。

临床问题33 哪些高血压患者应筛查嗜铬细胞瘤和副神经节瘤（pheochromocytoma andparaganglioma，PPGL）？

临床问题34 如何筛查诊断PPGL？推荐意见

• 推荐将血浆游离或24 h 尿液甲氧基肾上腺素（metanephrine，MN）、甲氧基去甲肾上腺素（normetanephrine，NMN）浓度测定作为PPGL 诊断的首选检测指标（1B）。

临床问题35 如何对PPGL 患者进行肿瘤定位诊断？

临床问题36 哪些PPGL患者应进行基因检测？推荐意见

• 建议所有PPGL 患者，尤其是多发性病变、转移性病变、双侧肾上腺病变、家族性PPGL、有遗传综合征表现的患者进行基因检测（2C）。

临床问题38 推荐哪些检查手段用于诊断RAS？推荐意见

• $\mathbf{eG F R\!\geqslant\!30\ m l\!\cdot\!m i n^{\!-\!1}\!\cdot\!1.73\ m^{\!-\!2}}$ 时，建议优选肾动脉计算机断层血管造影（computedtomography angiography，CTA），备选钆对比剂增强磁共振血管造影及肾动脉超声（1B）。• $\mathbf{eG F R<}30\ \mathbf{ml\cdotmin^{-1}\cdot1.73\ m^{-2}}$ 时，建议优选肾动脉超声，备选非增强磁共振血管造影，尽量避免使用CTA或增强磁共振血管造影（GPS）。• 数字减影成像（digital subtraction imaging，DSA）是影像诊断RAS 的金标准，但主要用于上述检查不能确诊或拟行肾动脉介入治疗时。• 肾功能无明显异常 $(\mathbf{eG F R}\geqslant\mathbf{60}\,\mathbf{ml}\!\cdot\!\mathbf{min}^{\scriptscriptstyle-1}\!\cdot\!\mathbf{1.73}\,\mathbf{m}^{\scriptscriptstyle-2})$ ）时，可考虑使用卡托普利肾动态显像（2C）。

临床问题39 对于RAS 的高血压患者，是否推荐使用RASI控制血压？

证据缺口及未来需解决的临床问题

本指南部分临床问题目前还缺乏强有力的循证医学证据，同时临床实践中也存在一些待回答的问题，汇总如下，为未来高血压的研究提供方向。

1.血压测量与评估• 房颤患者如何准确测量血压？• 对应诊室血压 $130/80\;\mathrm{mmHg}$ ，HBPM 和ABPM的诊断标准如何确定？• 基于HBPM 和ABPM，最佳的血压治疗目标值是多少？2. 针对 SBP130\~139 mmHg 和/或 DBP80\~ $89\ \mathrm{mmHg}$ 的高血压人群• 是否需要降压药物治疗？• 何时启动降压药物治疗？• 生活方式干预的有效方法和依从性如何？3.有关降压目标值• 高血压合并糖尿病、CKD、冠心病、心衰（包括HFrEF 和HFpEF）及卒中患者的降压目标值是多少？• ${\geqslant}80$ 岁的老年高血压患者的降压目标值是多少？• DBP的降压目标值是多少？• 临床实践中强化降压治疗的可行性、资源和成本效益评估。4.降压药物治疗• 高血压合并稳定性卒中患者的降压药物选择？• 经典的β受体阻滞剂与扩张血管的β受体阻滞剂降压治疗对心血管终点事件影响的比较。• SPC与单药联合降压治疗策略对临床结局的影响？• 噻嗪类与噻嗪样利尿剂对降压疗效及临床结局的影响有何差别？5.高血压患者随访的频率如何确定？6. 高血压患者应该在多长时间内实现血压达标？

7. 远程血压监测和社区/基层卫生工作者在高血压管理中的作用？8.降压治疗对于老年人认知功能的影响？9. 基于器械的降压治疗（如RDN）对心血管临床结局的影响？

汇总本指南有关高血压诊断、治疗相关的若干推荐意见，形成高血压诊疗路径图（图1）。

首席专家：蔡军（国家心血管病中心中国医学科学院阜外医院）

首席方法学家：陈耀龙（中国医学科学院循证评价与指南研究创新单元兰州大学基础医学院）

2022年《中国高血压临床实践指南》工作组名单

指导委员会委员名单：高润霖（国家心血管病中心中国医学科学院阜外医院），胡盛寿（国家心血管病中心中国医学科学院阜外医院），韩雅玲（解放军北部战区总医院心内科），葛均波（复旦大学附属中山医院心内科），张运（山东大学齐鲁医院心内科），惠汝太（中国医学科学院阜外医院高血压中心），赵连友（空军军医大学唐都医院心内科）

指南制订组名单（按姓氏笔画排序）：卜培莉（山东大学齐鲁医院心内科），马文君（中国医学科学院阜外医院高血压中心），王梅（国家体育总局体育科学研究所国民体质与科学健身研究中心），卞瑾（中国医学科学院阜外医院高血压中心），尹新华（深圳大学总医院心内科），卢新政（南京医科大学第一附属医院心内科），田刚（西安交通大学第一附属医院心内科），冯颖青（广东省人民医院心血管病中心），任明（青海大学附属医院心内科），刘全（吉林大学第一医院心内

科），刘克军（国家卫生健康委卫生发展研究中心卫生技术评估室），刘丽宏（中日友好医院药剂科），刘敏（河南省人民医院高血压科），孙刚（包头医学院第二附属医院高血压科），孙英贤（中国医科大学附属第一医院心内科），牟建军（西安交通大学第一附属医院心内科），严晓伟（中国医学科学院北京协和医院心内科），李玉明（天津泰达国际心血管病医院心内科），李启富（重庆医科大学附属第一医院内分泌科），李拥军（北京医院血管外科），李勇（复旦大学附属华山医院心内科），李萍（南昌大学第二附属医院心内科），杨金凤（天津蓟州区人民医院心内科），杨艳敏（中国医学科学院阜外医院急诊中心），吴寿岭（开滦总医院心内科），吴忠（海南省人民医院心内科），吴浩（首都医科大学全科医学与继续教育学院），余静（兰州大学第二医院高血压中心），汪道文（华中科技大学附属同济医院心内科），宋雷（中国医学科学院阜外医院心内科），张红卫（北京顺义区医院心内科），张慧敏（中国医学科学院阜外医院高血压中心），陈芳（银川市第一人民医院心脏诊疗中心），陈晓平（四川大学华西医院心内科），岳伟华（北京大学第六医院精神卫生研究所国家精神心理疾病临床医学研究中心），周碧蓉（安徽医科大学附属第一医院心内科），赵冬（首都医科大学附属北京安贞医院临床与流行病研究中心），赵晓龙（上海市公共卫生临床中心内分泌代谢科），俞蔚（浙江医院浙江省心脑血管病防治研究中心），姜一农（大连医科大学附属第一医院心内科），姚岚（华中科技大学同济医学院医药卫生管理学院），袁洪（中南大学湘雅三医院临床试验研究中心），徐新娟（新疆医科大学第一附属医院心脏中心高血压科），郭子宏（云南省阜外心血管病医院高血压中心），郭艺芳（河北省人民医院老年心内科），陶军（中山大学附属第一医院心

![SBP≥130 mmHg和/或DBP≥80 mmHg，考虑诊断高血压 6%3I'PP+J'фڈ''%3I'PP+JJߎ ᒎ ҙ߱ Т҅Ҥܴݾ J ېIؽ҃I I ԳI ܦ生活方式干预：饮食、运动、减压、减重、戒烟限酒 SBP 130\~139 mmHg和/或 DBP 80\~89mmHg 6%3'a'PP+J'фڈ''%3'a'PP+J SBP≥140 mmHg 和/或 DBP≥90 mmHg 6%3I'PP+J'фڈ''%3I'PP+J0\~2个心血管危险因素 a'ϬК߱܉ ӹ 伴临床合并症或靶器官损害 ׁ ڈḠ ܥ ߛ或≥3个心血管危险因素 ڈI'ϬК߱܉ ӹ ߹س ҃ 立即启动降压药物浴疗生活方式干预3\~6个月后 Т҅Ҥܴݾ aϬ֊њ血压仍不达标 ߱ Ϥܼ 2～4周随访 a'رڦ ϥ血压达标 ߱ ܼ 香确认依从性、调整药物随访 ڶ ԪԛI݆ݱ ҟ'a'رڦ 43个月随试 ϥ血压达标 ߱ ܼ 香 ԡ ԛҙ߱ ٷ难治性高血压患者可加用 aНӸѓ螺内酯或转高血压专科 ᖁֵ"ڈ׆ҙ߱ ֠ ](https://venus-trag-1258344701.cos-internal.ap-guangzhou.tencentcos.cn/userUpload/is-62e36cd9/2025-04-04/cb5df9cc-2870-4b94-b512-b09ed073deb2/cb5df9cc-2870-4b94-b512-b09ed073deb2.jpg?q-sign-algorithm=sha1&q-ak=AKID61g5D5fy1TjiRv84nEOHtFJ8gyzjCPL0&q-sign-time=1743774782%3B1743778382&q-key-time=1743774782%3B1743778382&q-header-list=host&q-url-param-list=&q-signature=8fd5338e3b0740ef18f361408dc10847a964619a) 图1 高血压诊疗路径图

SBP：收缩压，DBP：舒张压；难治性高血压定义为在改善生活方式的基础上应用了可耐受、剂量足够且合理的3 种降压药物（包括1 种血管紧张素Ⅱ受体阻滞剂或血管紧张素转化酶抑制剂、1 种钙通道阻滞剂、1 种噻嗪类利尿剂）治疗至少4 周后，诊室和诊室外血压值仍在目标水平之上 $1\ \mathrm{mmHg}{=}0.133\ \mathrm{kPa}$

内科），崔兆强（复旦大学附属中山医院心内科），蒋绍博（山东第一医科大学附属省立医院泌尿外科），蒋雄京（中国医学科学院阜外医院血管外科中心），韩清华（山西医科大学第一医院心内科），谢良地（福建医科大学附属第一医院心内科），蔡广研（解放军总医院第一医学中心肾脏病医学部）证据评价及秘书组名单（按姓氏笔画排序）：山缨（复旦大学附属华山医院心内科），马青峰（首都医科大学宣武医院神经内科），王子君（兰州大学健康数据科学研究院），王璐（中国医学科学院阜外医院高血压中心），申泉（重庆医科大学附属儿童医院），史乾灵（兰州大学健康数据科学研究院），边波（天津医科大学总医院心内科），邢爱君（开滦总医院心内科），任洁（山西医学院山西白求恩医院心内科），任梦娟（兰州大学公共卫生学院），刘云兰（兰州大学公共卫生学院），刘凯（中国医学科学院阜外医院心内科），刘萧（兰州大学公共卫生学院），刘辉（兰州大学公共卫生学院），齐玥（首都医科大学附属北京安贞医院临床与流行病研究中心），孙润民（兰州大学第二医院高血压中心），孙雅佳（兰州大学公共卫生学院），孙瑶瑶（北京大学第六医院精神卫生研究所国家精神心理疾病临床医学研究中心），苏仁凤（兰州大学公共卫生学院），苏津自（福建医科大学附属第一医院心内科），杜昕（首都医科大学附属北京安贞医院心内科），李师承（中国医学科学院北京协和医院心内科），李昭（中国医科大学附属第一医院心内科），杨宁（天津泰达国际心血管病医院高血压科），杨亚玲（上海市公共卫生临床中心内分泌代谢科），杨丽睿（首都医科大学附属北京安贞医院心内科），杨晓敏（浙江大学医学院附属邵逸夫医院全科医学科），杨楠（兰州大学健康数据科学研究院），吴守媛（兰州大学公共卫生学院），邹玉宝（中国医学科学院阜外医院心内科），宋玮（大连医科大学附属第一医院心内科），张涛（中国医学科学院阜外医院急诊中心），陆瑶（中南大学湘雅三医院临床试验研究中心），陈作观（北京医院血管外科），陈改玲（中日友好医院心内科），范超群（国家体育总局体育科学研究所国民体质与科学健身研究中心），周晓阳（武汉大学人民医院心内科），郑颖（解放军总医院第一医学中心肾脏病医学部），赵俊贤（兰州大学公共卫生学院），胡金波（重庆医科大学附属第一医院内分泌科），侯天春（重庆医科大学附属儿童医院儿童卓越证据与指南协调创新实验室），娄莹（中国医学科学院阜外医院高血压中心），姚丽霞（河北省人民医院老年心内科），索宁（山东第一医科大学附属省立医院泌尿外科），贾艾楠（中国疾病预防控制中心慢病中心健康促进与行为干预室），夏文豪（中山大学附属第一医院心内科），郭强强（兰州大学公共卫生学院），黄峥嵘（厦门大学附属第一医院心内科），彭强（南昌大学第二附属医院心内科），雷若冰（国家儿童健康与疾病临床医学研究中心），赫连曼（河南省人民医院高血压科）外审组名单（按姓氏笔画排序）：王宗道（台湾大学医学院附设医院心内科），华琦（首都医科大学宣武医院心内科），刘蔚（北京医院心内科），李滔（国家医疗保障局），杨新春（首

都医科大学附属北京朝阳医院心脏中心），吴良有（国家疾病预防控制局），吴海英（中国医学科学院阜外医院高血压中心），陈有仁（汕头大学医学院第二附属医院心内科），陈红（北京大学人民医院心内科），赵洛沙（郑州大学第一附属医院心内科），段琳（国家疾病预防控制局），祝之明（陆军特色医学中心内分泌科），黄晶（重庆医科大学附属第二医院心内科），黄磊（国家卫生健康委员会基层卫生健康司），曾春雨（陆军特色医学中心心内科）

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参考文献

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表1 证据质量与推荐强度分级
GRADE分级	具体描述
证据质量分级
高（A）	非常有把握：观察值接近真实值
中（B）	对观察值有中等把握：观察值有可能接近真实值，但也有可能差别很大
低（C）	对观察值的把握有限：观察值可能与真实值有很大差别
极低（D）	对观察值几乎没有把握：观察值与真实值可能有极大差别
推荐强度分级
强（1）	明确显示干预措施利大于弊或大于利
弱（2）	利不确定或无论证据质量高低均显示利相当

表2 影响高血压患者心血管危险分层的重要因素
项目	内容
心血管危险	年龄(男≥45岁,女≥55岁）吸烟或被动吸烟
心血管危险
因素	高密度脂蛋白胆固醇

表3 高血压患者的非药物干预措施
方式	干预内容
饮食干预	DASH：坚持服用富含水果、蔬菜、全谷物和低钠低脂乳制品
	食用替代盐或低钠富含钾饮食：使用替代盐烹饪或食用替代盐食品；建议钠盐的摄人

表4 常见继发性高血压的原因及临床线索
病因	临床特点
睡眠呼吸暂停综合征	打鼾，肥胖(也可见于非肥胖人群)，晨起头痛，日间嗜睡，夜间血压升高
肾实质性疾病	肾脏病史,血尿、蛋白尿、夜尿增多，肾功能异常，贫血，肾脏大小、形态异常
肾血管疾病	反复一过性肺水肿，腹部有血管杂音，单侧肾萎缩，低钾血症,难治性高血压,服用RASI后血肌酐明显升高
原发性醛固酮增多症	低钾血症，肾上腺意外瘤，肌无力(罕见),不明原因心房颤动
	嗜铬细胞瘤/副神经节瘤为阵发性、持续性或阵发性加重的高血压，发作时伴头痛、出汗、心悸，可伴糖、脂代谢异常，药物诱发的血压骤升（如β受体阻滞剂、胃复安、拟交感神经药物、阿片类药物和单胺氧化酶抑制剂等)
库欣综合征	满月脸、向心性肥胖、多血质、皮肤紫纹，糖代谢异常，低钾血症和骨质疏松
甲状腺疾病	甲状腺功能亢进症：怕热、多汗、心动过速、体重下降、腹泻甲状腺功能减退症：怕冷、少汗、行动迟缓、心动过缓、体重增加、便秘
主动脉缩窄	上下肢之间和/或右臂之间血压差（≥20/10mmHg），双下肢血压明显低于上肢（ABI0.9）,听诊肩胛间有血管杂音，胸片可见肋骨切迹

图示：SBP≥130 mmHg和/或DBP≥80 mmHg，考虑诊断高血压 6%3I'PP+J'фڈ''%3I'PP+JJߎ ᒎ ҙ߱ Т҅Ҥܴݾ J ېIؽ҃I I ԳI ܦ生活方式干预：饮食、运动、减压、减重、戒烟限酒 SBP 130\~139 mmHg和/或 DBP 80\~89mmHg 6%3'a'PP+J'фڈ''%3'a'PP+J SBP≥140 mmHg 和/或 DBP≥90 mmHg 6%3I'PP+J'фڈ''%3I'PP+J0\~2个心血管危险因素 a'ϬК߱܉ ӹ 伴临床合并症或靶器官损害 ׁ ڈḠ ܥ ߛ或≥3个心血管危险因素 ڈI'ϬК߱܉ ӹ ߹س ҃ 立即启动降压药物浴疗生活方式干预3\~6个月后 Т҅Ҥܴݾ aϬ֊њ血压仍不达标 ߱ Ϥܼ 2～4周随访 a'رڦ ϥ血压达标 ߱ ܼ 香确认依从性、调整药物随访 ڶ ԪԛI݆ݱ ҟ'a'رڦ 43个月随试 ϥ血压达标 ߱ ܼ 香 ԡ ԛҙ߱ ٷ难治性高血压患者可加用 aНӸѓ螺内酯或转高血压专科 ᖁֵ"ڈ׆ҙ߱ ֠

#	推荐意见	证据等级
1	• 推荐我国成人高血压患者按血压水平分为1 级（SBP130\~139 mmHg 和/或 $\mathbf{DBP80{\sim}89\ m m H g}.$ ）和2级（ $\mathbf{\langleSBP\!\geqslant\!140\;mmHg}$ 和/或 $\mathbf{DBP}{\geqslant}\mathbf{90}\mathbf{\mm}\mathbf{Hg}$ ）（1B）。	1B
2	• 测量设备：推荐成人采用经过标准化方案验证的上臂式电子血压计测量血压（1B）。	1B
3	（2）选择合适的袖带（气囊长度为臂围的 $\mathbf{75\%{\sim}100\%}$ ，宽度为臂围的 $\scriptstyle\mathbf{37\%}\sim\mathbf{50\%}$ ，袖带气囊宽 $\mathbf{12\;cm}$ 、长 $\mathbf{22\!\sim\!26\;cm}$ 可满足大多数成人）进行血压测量，上臂围 ${>}42\;\mathrm{cm}$ 者可选择腕式电子血压计（1B）。	1B
4	（3）测量血压的上臂应充分暴露或只覆盖单层衣物（勿挽袖子），袖带下缘置于肘窝上方2\~3 cm（1C）。	1C
5	首次测量血压时应测量双上臂血压，以血压高的一侧为准（2C）。	2C
6	（5）推荐心房颤动（房颤）患者采用电子血压计测量血压，每次测量至少获得3 次血压读数，取3次血压读数的平均值（1C）。	1C
7	• 高血压的诊断可依据OBPM、ABPM 或HBPM，如有条件优先选择ABPM（2C）。	2C
8	• 对于高血压管理，建议首选HBPM；若条件不允许，建议根据OBPM 结合ABPM 进行管理（2C）。	2C
9	• 推荐早上在服药前、早餐前、排空膀胱后测量血压（1B）。	1B
10	• 建议晚上在晚餐前测量血压，条件不允许时建议在睡前1 h内测量（2D）。	2D
11	• 初诊或血压未控制的患者，推荐每周至少连续3 d进行HBPM（1B）。	1B
12	• 血压控制良好的患者，建议每周进行1\~2 d 的HBPM（2D）。	2D
13	• 建议所有高血压患者均进行生活方式干预，包括饮食干预、运动干预、减压干预、减重干预、戒烟限酒和综合生活方式干预（2B）。	2B
14	• 推荐中国高血压患者应用低钠盐替代普通食盐（1B）。	1B
15	• 推荐钠摄入量减少至 $\mathbf{2\,000\,m g/d}$ （约 $\textbf{5g}$ 氯化钠）以下（1B）。	1B
16	• 推荐 $\mathbf{SBP<}160~\mathbf{mmHg}$ 和 $\mathbf{DBP{<}100\ m m H g}$ 的高血压患者，每周进行5\~7 d、每次 $\mathbf{30{\sim}60\ m i n}$ 的中等或高强度有氧运动，且每周进行2\~3 次抗阻力量练习（1B）。	1B
17	• 由于身体原因无法完成上述推荐量的高血压患者，应根据自身情况尽可能地增加各种力所能及的身体活动（1B）。	1B
18	• 年龄18\~65 岁、体重指数 $\left(\mathbf{BMI}\right){\geqslant}28.0\ \mathbf{kg/m}^{2}$ 的高血压患者，经综合生活方式干预体重控制不佳时可考虑应用经临床研究证实获益的药物控制体重（2B）。	2B
19	• 年龄18\~65 岁 $\mathbf{B M I}{\geqslant}35.0\;\mathbf{kg}/\mathbf{m}^{2}$ 的高血压患者，经非手术方式干预体重控制不佳时可考虑代谢手术治疗（2B）。	2B
20	• 推荐心血管危险分层为高危的患者立即启动降压药物治疗，包括如下3 种情况：（1）SBP≥ $\mathbf{140\mmHg}$ 和/或 $\mathbf{DBP}{\geqslant}\mathbf{90}\mathbf{\:mmHg}$ ，推荐立即启动降压药物治疗（1B）；（2）SBP130\~139 mmHg 和/或 $\mathbf{D B P80{\sim}89\ m m H g}$ 伴临床合并症，推荐启动降压药物治疗（1B）；（3）SBP130\~139 mmHg 和/或DBP80\~89 mmHg 伴靶器官损害（GPS）或 ${\geqslant}3$ 个心血管危险因素，可以启动降压药物治疗（2C）。	1B
21	• 心血管危险分层为非高危即SBP130\~ $\mathbf{139\mmHg}$ 和/或DBP $\mathbf{80{\sim}89\ m m H g}$ 的患者，伴0\~2 个心血管危险因素，可进行3\~6 个月的生活方式干预，若 SBP 仍 $\geqslant\!130\:\mathrm{mmHg}$ 和/或 DBP≥ $\mathbf{80\mmHg}$ ，可考虑启动降压药物治疗（2C）。	2C
22	• 对于高血压合并糖尿病患者，建议血压控制目标值为 $\mathbf{SBP{<}130\ m m H g}$ （2C）和 $\mathbf{DBP<}80\mathbf{\mmHg}$ （GPS）。	2C
23	• 对于未进行静脉溶栓及血管内治疗（endovascular treatment，EVT）的AIS 患者，建议 $\mathbf{SBP\!\geqslant\!220\;mmHg}$ 和/或 $\mathbf{DBP}{\geqslant}120~\mathbf{mm}\mathbf{Hg}$ 启动降压治疗（2C）。	2C
24	• 推荐高血压合并病情稳定的卒中患者血压控制目标值为 $\mathbf{\angleleft130/80\;mmHg}$ ，以预防卒中复发（1A）。	1A
25	• 建议无临床合并症、年龄<65 岁的高血压患者在4周内实现血压达标（2D）。	2D
26	• 推荐将ACEI、ARB、CCB 和利尿剂作为无临床合并症的高血压患者的一线初始降压药物（1B）。	1B
27	临床问题15 高血压患者何时需要联合降压药物治疗？选用自由联合还是单片复方制剂（single‑pill combination，SPC）？推荐意见• 对血压 $\mathbf{\geqslant}140/90\mathbf{\mmHg}$ 的高血压患者，推荐初始联合降压药物治疗（1B）。	1B
28	• 对需要联合降压药物治疗的高血压患者，建议优先选用SPC（2C）。	2C
29	• SPC 的选择，建议优先选用肾素‑血管紧张素系统抑制剂（renin‑angiotensin system inhibitor，RASI） $+\mathbf{CCB}$ 或RASI+利尿剂组合（2C）。	2C
30	药物推荐首选β受体阻滞剂和CCB（1C）。	1C
31	• 高血压合并冠心病，有心肌梗死病史的患者，降压药物推荐首选β受体阻滞剂和ACEI/ARB（1C）。	1C
32	neprilysin inhibitor，ARNI）替代ACEI/ARB 作为首选用药（2B）。	2B
33	• 高血压合并HFpEF 患者，ARNI/ARB/ACEI 均可作为首选用药（2C）。	2C
34	• 对于既往有卒中或短暂性脑缺血发作（transient ischemic attack，TIA）病史的高血压患者，推荐ACEI（1A）、利尿剂（1A）或ACEI+利尿剂（1A）进行降压治疗。	1A
35	若以上药物不适用或效果不佳，可选用CCB（2C）或ARB（2C）。	2C
36	• 对于既往有卒中或TIA 病史的高血压患者，不推荐β受体阻滞剂作为一线降压药物（1A）。	1A
37	• 高血压合并2型糖尿病患者，推荐首选ACEI/ARB控制血压（1B）。	1B
38	• 高血压合并2 型糖尿病患者，建议优选SGLT2i（2B）或胰高糖素样肽‑1 受体激动剂（glucagon‑likepeptide‑1 receptor agonist，GLP‑1RA）（2B）治疗。	2B
39	• 推荐RASI 作为有微量白蛋白尿和蛋白尿的CKD患者降压治疗的首选药物（1B）。	1B
40	• RASI 可作为无微量白蛋白尿及蛋白尿的CKD患者降压治疗的首选药物（2B）。	2B
41	患者，推荐服用 $\mathbf{75{\sim}100\ m g/d}$ 阿司匹林进行长期二级预防（1A）。	1A
42	• 40\~65岁高血压伴心血管高危者，如出血风险不高，可以考虑使用小剂量阿司匹林（ $(75{\sim}100~\mathrm{mg/d})$ ）进行一级预防（2B）。	2B
43	• 出血高风险人群（如有胃肠道出血、个月内脑出血或其他部位出血病史；同时服用其他增加出血风险的药物；未控制的高血压等）不建议服用阿司匹林进行一级预防（2C）。	2C
44	• 对于 $\mathbf{eG F R\!\geqslant\!45\:\:mol\!\cdot\!m i n^{\!-\!1}\!\cdot\!1.73\:\:m^{\!-\!2}}$ ，血清钾 $<$ $4.5\;\mathrm{mm0/L}$ 的难治性高血压患者，推荐使用螺内酯（ $\mathbf{\langle20{\sim}40{\mathrm{~mg/d}}\rangle}$ ）作为第4种药物选择（1B）。	1B
45	• 对于难治性高血压、不能耐受降压药物治疗、临床特征符合交感神经功能亢进的高血压患者，RDN可以作为一种降低血压的策略（2B）。	2B
46	• 建议对以下患者进行常见继发性高血压筛查（2C）：（1）新诊断高血压患者；（2）发病年龄 ${\tt<}{\bf40}$ 岁的高血压患者；（3）难治性高血压患者；（4）有继发高血压临床线索或存在广泛高血压介导靶器官损害的高血压患者。	2C
47	• 建议所有高血压患者至少进行1 次原发性醛固酮增多症筛查，尤其是新诊断高血压、难治性高血压或合并低钾血症的高血压患者（2C）。	2C
48	• 推荐检测非卧位2 h 的血浆醛固酮、肾素水平，并将醛固酮与肾素比值（aldosterone to reninratio，ARR）作为原醛症的筛查指标（1B）。	1B
49	• 建议基于肾素浓度的ARR 切点为 $\mathbf{2.0\,(\,n g/d l\,)/\partial}$ （mU/L），基于肾素活性的ARR 切点为30（ng/dl） $\left(\mathbf{n}\mathbf{g}\cdot\mathbf{m}\mathbf{l}^{-1}\cdot\mathbf{h}^{-1}\right)$ ）（2C）。	2C
50	• 推荐卡托普利抑制试验或盐水输注试验作为原醛症的确诊试验（2C）。	2C
51	• 高血压患者优先考虑在停用对ARR 有明显影响的药物（或换用对ARR 影响较小的药物）的情况下筛查原醛症；对于未停（换）药条件下检测的ARR结果，应合理解读（2D）。	2D
52	• 在成人高血压患者中，存在以下情况，建议筛查库欣综合征（2C）：（1）典型临床特征（皮肤瘀斑、多血质貌、近端肌萎缩、皮肤紫纹）；（2）其他临床特征（如月经紊乱、痤疮、体重增加、向心性肥胖）；（3）难治性高血压；（4）与年龄不符的骨质疏松；（5）肾上腺意外瘤；（6）合并2 型糖尿病的特殊人群（需要使用胰岛素或使用2 种及以上降压。	2C
53	• 建议对临床怀疑库欣综合征的高血压患者使用以下任一方法进行筛查：（1）过夜 $\mathbf{1}\,\mathbf{m}\mathbf{g}$ 地塞米松抑制试验（2D）；（2）24 h 尿游离皮质醇（2C）；（3）午夜唾液皮质醇（2C）。	2D
54	• 建议对以下人群筛查PPGL：（1）有阵发性高血压，伴头痛、心悸、多汗三联征的患者（1C）；（2）服用影响肾上腺素能受体的药物、腹压改变、麻醉或手术等诱发PPGL 症状发作的患者（1C）；（3）肾上腺意外瘤的患者（1C）；（4）有PPGL 或相关遗传综合征家族史的患者（1C）；（5）不明原因心肌损害和应激性心肌病的患者（2D）。	1C
55	• 推荐将血浆游离或24 h 尿液甲氧基肾上腺素（metanephrine，MN）、甲氧基去甲肾上腺素（normetanephrine，NMN）浓度测定作为PPGL 诊断的首选检测指标（1B）。	1B
56	• 首选CT 作为PPGL 肿瘤定位的影像学检查方法（1B）。	1B
57	• 间碘苄胍（metaiodobenzylguanidine，MIBG）（1C）、Ga‑Dotatate PET/CT（2B）、生长抑素受体奥曲肽显像（2C）等可用于对PPGL 的功能影像学定位诊断。	1C
58	• 建议所有PPGL 患者，尤其是多发性病变、转移性病变、双侧肾上腺病变、家族性PPGL、有遗传综合征表现的患者进行基因检测（2C）。	2C
59	• $\mathbf{eG F R\!\geqslant\!30\ m l\!\cdot\!m i n^{\!-\!1}\!\cdot\!1.73\ m^{\!-\!2}}$ 时，建议优选肾动脉计算机断层血管造影（computedtomography angiography，CTA），备选钆对比剂增强磁共振血管造影及肾动脉超声（1B）。	1B
60	• 肾功能无明显异常 $(\mathbf{eG F R}\geqslant\mathbf{60}\,\mathbf{ml}\!\cdot\!\mathbf{min}^{\scriptscriptstyle-1}\!\cdot\!\mathbf{1.73}\,\mathbf{m}^{\scriptscriptstyle-2})$ ）时，可考虑使用卡托普利肾动态显像（2C）。	2C

引用 / 出处

国家心血管病中心中国医师协会中国医师协会. 中国高血压临床实践指南[S/OL]. 2022.

中国高血压临床实践指南

指南形成方法

指南推荐意见及说明

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临床问题2 中国成人高血压患者如何按照血压水平分级？

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临床问题6 高血压患者HBPM 的测量时间和频率如何推荐？

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临床问题7 高血压患者推荐哪些非药物干预措施？

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• 建议钾摄入目标为 $\mathbf{3\,500{\sim}4\,700\,m g/d\left(2B\right)}$ 。

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临床问题11 如何根据心血管危险分层确定高血压患者启动降压治疗的时机？

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临床问题13 高血压患者是否需要在4 周内实现血压达标？

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临床问题16 高血压合并冠心病患者如何推荐降压药物？

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临床问题17 高血压合并心衰患者，如何推荐首选降压药物？

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临床问题18 高血压合并卒中的患者如何推荐降压药物？

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临床问题21 哪些高血压患者应该服用阿司匹林？

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临床问题22 高血压患者进行降压药物治疗后再次随访需间隔多长时间？

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临床问题23 螺内酯是否应作为难治性高血压患者的第4种药物选择？

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临床问题 24 肾脏去交感神经术（renaldenervation，RDN）适用哪些高血压人群？

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临床问题25 高血压急症的急诊处理原则？

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临床问题26 哪些高血压患者需要进行继发性高血压筛查？

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临床问题27 哪些高血压患者需要筛查原发性醛固酮增多症（简称原醛症）？

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临床问题28 原醛症的初步筛查指标及各项指标的切点值如何推荐？

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临床问题30 原醛症筛查全程是否需要药物洗脱？

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