245 million people were fine on the first day. How did they become hypertensive overnight? However, overnight, their blood pressure
245 million people were fine on the first day. How did they become hypertensive overnight? However, overnight, their blood pressure returned to normal.
On June165438+1October 14, the epidemic situation in COVID-19 continued to climb, and the number of infected people approached the 5000 mark. He used to be the chief physician/professor of cardiovascular medicine in Southern Hospital of Southern Medical University, and made house calls every Monday afternoon and Wednesday morning.
On this day, I felt different as soon as I arrived at the clinic. After the static button was pressed in some areas of Guangzhou, the hospital was much deserted. 165438+1October 13 night, several central urban areas in Guangzhou introduced measures to strengthen prevention and control, making it more difficult for citizens to travel. However, on June 14, people lined up at the entrance of the clinic.
Several people came because of "anxiety". 165438+ 10/3, National Cardiovascular Center, Chinese Medical Doctor Association, Cardiovascular Branch of Chinese Medical Association and other academic institutions jointly formulated and promulgated the Clinical Practice Guide of Hypertension in China. Compared with the current hypertension-related guidelines at home and abroad, the biggest concern of the new guidelines is to reduce the diagnostic criteria of hypertension from ≥ 140/90mmHg to ≥ 130/80mmHg.
The news quickly fermented on the Internet. China is a country with high blood pressure. According to China's population base, this standard change will add about 245 million "patients". The blood pressure values of these people who met in Chun Qing were all between 130/80mmHg and 140/90mmHg. After seeing the tour guide, he quickly asked the doctor for help.
Subsequently, National Health Commission's official media "Healthy China" clearly stated that the diagnostic criteria of hypertension had not changed, and it was still ≥ 140/90mmHg. 200 million "hypertensive patients" returned to normal blood pressure overnight, and the topic of "lowering the diagnostic standard of hypertension" gradually subsided. But this group of 200 million people is at a critical point. How to manage the dispute over the diagnostic criteria of hypertension? Why is it so difficult to reach a unified understanding because of the small difference in the mercury standard of 10 mm?
A "new" patient who is anxious about blood pressure
"Doctor, am I already hypertensive?" A patient has asked this question to him before he paid attention to sitting on the stool in the consulting room.
Zeng Chun Qing was very happy with the arrival of these people. His answer to patients is that blood pressure value130/80mmhg ~140/90mmhg is an early manifestation of hypertension, but it is not recommended to take medicine directly, especially since the guidelines have just been published and have not been certified by the state, so there is no need to be too anxious. It is suggested to change to a healthy lifestyle, including low-salt diet, strengthening exercise, controlling weight, ensuring adequate sleep and avoiding it. If after 3-6 months, the patient's blood pressure is still above 130/80mmHg, we can fully communicate with the patient according to the patient's risk stratification, inform him of the possible harm caused by the increase of blood pressure and the possible advantages and disadvantages of receiving antihypertensive drugs, and then decide whether to start antihypertensive drug treatment as appropriate.
Image source: Picture Network _502495629
Every headline reporter noticed that although National Health Commission has made it clear that the diagnostic criteria of hypertension have not changed, people at the "tipping point" still hope to find a more intuitive statement from doctors.
165438+ 10/7, the reporter visited a public hospital in Chengdu and found that clinicians were more cautious about this topic. An outpatient doctor said, "The Health and Health Commission has spoken, and it is certain to determine whether it is hypertension according to the standard of 140/90mmHg, and then decide whether to take medicine." The doctor also said that the number of people who came to see a doctor increased slightly in recent days, but few people actually prescribed medicine, mostly for consultation.
In the outpatient area, a man in his fifties is waiting to see a doctor. According to it, hypertension was previously diagnosed and controlled by taking medicine, but the systolic blood pressure hovered around 133 for a long time. Once the standard is revised, it means that he has "changed back" to a hypertensive patient. After learning the news, he rushed to the hospital at the first time and asked if he needed medication. But in the end, the patient got the suggestion that "medication is not needed for the time being" and the doctor said that "it is good to take it (130/80mmHg standard) as a health reminder first".
This "pre-hypertension" patient is not the only one who was panicked when he heard that the standard of hypertension was lowered. The chief physician of a third-class hospital in Sichuan told reporters that in recent days, more than a dozen former patients have called or registered in outpatient clinics to ask if they need to use antihypertensive drugs. Their blood pressure ranges from 130/80mmHg to 140/90mmHg. The doctor didn't choose to prescribe medicine for every patient. For most people, he still gives life advice such as eating less salty food, not smoking or drinking, not staying up late and exercising more. For patients with clinical complications, prescribe antihypertensive drugs.
In this regard, Guo Zaixin, an expert in the drafting group of the guide and vice president of the People's Hospital of Hebei Province, wrote in the official account "Guo's Heart Frontier" that it is normal for different scholars and different academic institutions to have different academic views. It is very common that "the public says that the public is right, and the woman says that the woman is right". We don't have to make a fuss about this dispute over the diagnostic criteria for hypertension. From a professional point of view, there are reasons and grounds for advocating or opposing the downward adjustment of diagnostic criteria for hypertension, which will not be discussed in detail here. However, whether it is for or against, the starting point and fundamental motivation are the same, all of which are to better control blood pressure and minimize the harm of high blood pressure to the lives and health of Chinese residents.
Guo said that in real life, most people with blood pressure at this level think that their blood pressure is normal, and few people will pay attention to and interfere with their blood pressure. After the promulgation of the new guidelines, it has also aroused widespread concern among the general public, which is a good thing. It is good to let everyone know their own "situation", let everyone know that experts are arguing fiercely about whether they are patients or not, let everyone know that they may be patients, at least "close contacts" of patients, and let everyone know that their risk of cardiovascular and cerebrovascular diseases has increased in the future. If so, more people will consciously take the initiative to eat less and exercise more to lose weight, quit smoking, limit alcohol and salt, live a regular life and stay up late less, relax and get enough sleep.
Zeng Chun Qing also agreed with the concept of "advancing" the frontier of hypertension diagnosis/prevention in the document. In recent years, more and more research evidence shows that controlling the blood pressure of high-risk hypertensive patients below 130/80mmHg will bring better benefits to patients. It is also based on relevant clinical research evidence that the diagnostic criteria of hypertension was revised to 130/80mmHg in 20 17 years in the United States.
The Guidelines for the Prevention and Treatment of Hypertension in China (revised 20 18) has also been supplemented appropriately, and it is proposed that the diagnosis of hypertension is divided into two steps, that is, the average blood pressure of hypertensive patients falls below 140/90 mmHg; Tolerance patients and some high-risk and above patients can be further reduced to below 130/80mmHg.
Image source: Guidelines for prevention and treatment of hypertension in China (revised on 20 18).
The diagnostic criteria of hypertension have been controversial for many years.
In the medical field, guidelines are an important basis for disease prevention and treatment. The best doctors can usually combine the guidelines with clinical practice perfectly, and the medical practice rules are based on the guidelines, and at the same time, they can solve patients' problems individually with enough experience.
Since 1976, the Joint Committee on Prevention, Diagnosis, Evaluation and Treatment of Hypertension (JNC) has been issuing JNC hypertension guidelines under the management of the National Institutes of Health (NIH) and its affiliated National Heart, Lung and Blood Institute (NHLBI). The study was initiated by the National Institutes of Health and NHLBI. From 1977 to 2003, the expert group published the JNC guide seven times at the pace of updating every four years on average.
However, after the introduction of JNC7 in 2003, doctors waited ten years to update the guidelines. On 20 14, the expert group of JNC8 announced JNC8 as a member of the Eighth National Committee without any official endorsement. This guideline raises the diagnostic threshold of hypertension patients over 60 years old to 150/90mmHg.
20 17 1 1 month, after many delays, the new American hypertension guidelines originally scheduled to be released in 20 14 were finally released. Guidelines for prevention, detection, evaluation and management of hypertension in adults (referred to as ACC/AHA guidelines, or new guidelines in the United States) 48 1 page, jointly formulated by American College of Cardiology (ACC), American Heart Association (AHA) and other1kloc-0/academic groups.
On the other side of the ocean, the diagnostic criteria of hypertension have changed dramatically. There is a heated discussion on whether to lower the diagnostic standard of hypertension in the world, but few institutions and academic groups really follow up this standard. Supporters say that lowering the diagnostic criteria can move the intervention threshold of hypertension forward and reduce the further increase of blood pressure and the occurrence of hypertension complications; Opponents believe that it may lead to a substantial increase in the number of patients, which not only greatly increases the medical burden in related fields, but also easily causes unnecessary panic.
Yang, deputy director of the Cardiovascular Department of the Second Affiliated Hospital of Nanchang University, pointed out in an interview that the controversy about the diagnostic criteria of hypertension has been heard for several years, but for the actual diagnosis and treatment of domestic doctors, the new standards set by ACC and AHA in the United States have not had much impact.
In his view, the standards proposed by American hypertension guideline 20 17 have certain reference value for the diagnosis and treatment of hypertension in China, but we also need to recognize the differences between Chinese and American populations. "For example, patients in our country tend to take medicine or even intravenous drip during the process of seeing a doctor, which may be more common than patients in other countries, so (lowering the diagnostic criteria of hypertension) will have a greater impact on public psychology."
It should be pointed out that the new guidelines define people with blood pressure130 ~139/80 ~ 89 mmhg as hypertensive patients, which is also supported by clinical research evidence. According to the research of Sun Yingxian's team in the First Affiliated Hospital of China Medical University, compared with people with blood pressure < 120/80mmHg, the total risk of CVD in people with blood pressure130 ~139/85 ~ 89mmhg is 1.56 times, of which stroke is the most common.
Although there is no clear conclusion on how to define and deal with the population whose blood pressure is130 ~139/80 ~ 89 mmhg, it is generally believed that the risk of cardiovascular and cerebrovascular diseases in this population can not be ignored, and lifestyle changes such as no smoking, no drinking and no exercise are worth recommending. In addition, if the patient also suffers from some complications other than hypertension, cardiovascular and cerebrovascular diseases and diabetes.
Image source: Clinical Practice Guide of Hypertension in China
Yang also expressed similar views to reporters. The 243 million "critical point" people in the gap between the two sets of standards need not worry too much or even panic. It doesn't mean that patients who have been diagnosed with hypertension have to take drug intervention immediately. The human body itself also has certain self-regulation ability.
He also mentioned that "blood pressure value is only a reference factor for doctors to judge whether patients with hypertension need to start drug treatment. In addition, it is necessary to observe whether the patient has physical injuries or complications caused by high blood pressure, and then decide whether to seek medical treatment. "
Now, the diagnostic standard of 130/80mmHg has been raised again, and many well-known experts came out to oppose it for the first time. Liu, honorary chairman of China Hypertension Alliance and professor of Fuwai Hospital of China Academy of Medical Sciences, told China that other disease standards can be adjusted, because that is an academic issue, and hypertension is not. Hypertension is the only cardiovascular chronic disease prevention and treatment project listed in the national management at present. The formulation of standards is not only an academic dispute, but also closely related to people's livelihood. Easy adjustment will have a subversive impact. "According to this standard, the scope is too wide. People who used to engage in high-risk occupations such as pilots were suddenly diagnosed with hypertension. Can they continue to work in their original jobs? If something goes wrong, who is responsible? "
Zeng also raised a puzzle from the clinician's point of view: If the blood pressure of a young non-high-risk hypertensive patient is maintained at around 120/8 1mmHg after six months of non-drug intervention, is it necessary to prescribe drugs? In this case, can medication definitely bring greater benefits to patients? Further clinical research is needed to confirm it.
"I think this should also be one of the reasons why the Health and Health Commission temporarily does not change the diagnostic criteria. In addition, if we want to change this standard, it will bring some social problems, which should be considered comprehensively; However, I think the guide can arouse public attention to hypertension, which is of positive significance. In the future, more attention will be paid to patients with blood pressure ranging from 130/80 mmHg to 140/90 mmHg. Once said.
An expert who did not want to be named said that the recent hypertension is not news in academic circles, but old news. The United States made an adjustment on 20 17, but there are disputes and differences on whether China will follow up the adjustment. Objectively speaking, according to the current domestic standards, there are about 200 million people with hypertension, and about 654.38 billion people have standardized treatment by doctor's advice; At the same time, in the face of the situation of 130/80mmHg, doctors usually suggest strengthening exercise and improving eating and living habits, and only recommend drug intervention if there is no improvement for a period of time. We can't think that patients with hypertension will double overnight, and drug use will increase several times overnight.
Primary doctors still have a headache for the low level of diagnosis and treatment of hypertension.
Hypertension and diabetes are two serious chronic diseases in China at present. Once diagnosed in China, it is basically necessary to take medicine all the year round, and most of them are irreversible.
The available data show that the diagnosis and treatment of hypertension in China is not optimistic. China Cardiovascular Health and Disease Report 202 1 released on June 23rd this year mentioned that there are 245 million hypertensive patients in China, but the awareness rate, treatment rate and control rate of hypertension in China are 5 1.6%, 45.8% and 16.8% respectively.
Sun Ningling, former chief physician of hypertension department of Peking University People's Hospital, told China Newsweek that the awareness rate of hypertension in the United States is already very high, the treatment rate can reach 70%, and the disease control rate can reach 50% ~ 60%. Even if the diagnostic criteria are lowered, it can basically cover new patients. Comparatively speaking, according to the existing standards, the control rate of hypertension in China is only 15.3%, less than 6% in rural areas, and there are many hypertensive patients who need treatment. After the downward adjustment, the domestic hypertension control rate will drop to 3%, and the treatment of antihypertensive drugs will cause a run on existing medical resources.
In this case, if the standards are lowered, doctors and medical institutions at the grassroots level will face greater difficulties. On 17, when the reporter contacted Dr. Zhang, who worked in 18 and worked in a primary public hospital, in his view, one of the major problems in the diagnosis and treatment of hypertension in China at present is that the "three rates" are not high, and it is difficult for some patients to adjust their understanding of the dangers of hypertension through changes in standards; In other words, even under the current diagnostic criteria of hypertension, the clinical diagnosis and treatment of patients with hypertension are not perfect.
For example, doctors will advise some patients with abnormal blood pressure to control their blood pressure below 140/90mmHg through drug treatment, measure their blood pressure every day and take medicine, and then go to the hospital to review and adjust the dose after blood pressure is stable. However, there are also many patients who will not follow the doctor's advice and stop taking drugs or reduce the amount after the discomfort disappears.
There are still more patients who are unaware of the potential harm of hypertension. Dr. Zhang told reporters that his clinic has also encountered hypertensive patients whose systolic blood pressure has exceeded 200mmHg, but the other party did not accept the doctor's drug treatment advice.
"The doctor can only persuade, but some patients will not accept your opinion anyway. Their concept is not to take medicine as long as they are not uncomfortable, which has led to complications when many patients come to see a doctor again. " Doctor Zhang said.
In addition, hypertension is a typical chronic disease, and the number of patients in China exceeds 200 million. It is more difficult to follow up patients in primary hospitals with limited human and financial resources. According to Dr. Zhang's feeling, at present, the problem of "late detection" of hypertensive patients is more prominent than the problem of "overdose", and most of them go to the hospital after symptoms or abnormal physical examination indicators appear.
At the same time, as Hu Dayi, chief physician of Cardiology Department of Peking University People's Hospital, said, primary doctors are facing the challenge of performance appraisal. For example, the assessment of community doctors is the compliance rate of blood pressure. After lowering the standard, it means more patients, so he has to use more drugs to keep the compliance rate.
Dai, a grass-roots doctor in Zhejiang, said in an interview that according to the current local regulations, the standardized management rate of local hypertension population should reach more than 6 1%. Among them, 45% people still need to reach the control rate, even if their blood pressure control results are within a reasonable range.
In the daily management of patients with hypertension, Dai Qile needs to divide patients with hypertension into grade one and grade two according to their blood pressure, waist circumference data, bad living habits and complications, and grade three is high-risk hypertensive patients. For this group of people, Dai Qile needs to be followed up once a month, asking the other party to go to the hospital for regular review and give long-term medication and life guidance. At the same time, it is necessary to establish a special hypertension file for this group of people, and record the drug use, physical examination results and evaluation results one by one. For patients with relatively mild hypertension, the period of going to the hospital for reexamination is relatively long. For example, patients with primary hypertension need face-to-face follow-up every three months.
Image source: Picture Network _50 1793306
If the standard is lowered from 140/90mmHg to 130/80mmHg, the number of hypertensive patients that primary doctors like Dai need to face will greatly increase. Under the same percentage requirement, the number of managers will greatly increase and the management difficulty will also increase.
In the last week, someone around me found Dai and asked, "Does this make me a hypertensive patient?" However, when it comes to medication, this group of people still show resistance, and more are seeking suggestions for lifestyle improvement. "In the face of this group of people, we will not let them take drugs from the beginning, but more adjust from lifestyle changes such as low-salt diet and regular exercise to achieve the effect of lowering blood pressure," Dai said.
More importantly, in the work of primary doctors, people from 130/80mmHg to 140/90mmHg have actually been included in the management scope. In electronic files, they are called "high-risk groups of hypertension". For these people, Dai will also advise them to have regular physical examinations, check their blood pressure and follow up, and tell them to improve their living habits and prevent them from becoming hypertensive.
"From the practical work level, we are not willing to lower the standard because the increased workload will be very large. But from the point of view of medicine and patients, I prefer that for patients with high cardiovascular risk stratification, a certain degree of downward adjustment is a good thing. Especially for young patients with high risk factors, it is more necessary to standardize. Because from the perspective of prevention and treatment, if a person starts to receive intervention from blood pressure 1.30/80 mmHg, no matter lifestyle adjustment or small dose of drugs, it is likely that 1.40 will not be achieved. Whether it is from personal health risks or the medical burden after the development of cerebral infarction, downward adjustment is a good thing. "
However, he also stressed that no matter in Europe, America or at home, it is impossible to simply distinguish whether it is a hypertensive patient or not, and whether to take medicine. "Even if the patient's blood pressure is between130/80 mmHg-140/90 mmHg, it is necessary to combine the risk stratification, whether it is high or low, whether there are complications, and the age of the patient."
Zeng Chun Qing also had some headaches about the low "three rates" of hypertension in China. He believes that even if the diagnostic criteria of hypertension in China change, it may have a positive effect on improving the awareness rate, but it may not have the expected effect on the treatment rate and control rate. Especially in rural or remote areas, people's understanding of disease and health management is still relatively backward, and they are not sensitive enough to the new diagnostic criteria of hypertension. It is still unknown whether they can attach importance to health management due to the decline of diagnostic criteria for hypertension.
Reporter | Lin Xu Libo
Editor | Duan Lian Co-ordinating Editor | Yi Qijiang
Vision | Zou Li
Video clip | Zhang Yi
Typesetting | Duan Lian
Reporter's Notes | Take the discussion of hypertension standards as a "health reminder"
At the beginning of publication, the change of hypertension standard may not be expected to trigger a big discussion involving academia, industry and policy makers.
The more the truth is argued, the clearer it becomes. Whether it is scholars and experts who advocate lowering the standards or the competent authorities who claim that the standards have not changed, their positions have merits. Whether the standard of hypertension has changed involves not only the quality of individual life and body, but also the changes of health economics, medical resources and industrial structure.
Instead of "panicking" because of a medical discussion and worrying that we will become hypertensive patients overnight, we might as well follow the advice of more clinicians and experts and regard this discussion as a friendly health reminder. Taking medicine by injection is second. Paying attention to your body signals in time and maintaining good living habits may be an unexpected gain from this discussion.