# # Media Debate on Diagnostic Criteria of Hypertension

1 13 years 10/3 months 13 days, the China Clinical Practice Guide, which was formulated by the National Cardiovascular Center, the Chinese Medical Doctor Association, the Hypertension Committee of the Chinese Medical Doctor Association, the Cardiovascular Branch of the Chinese Medical Association, and the Hypertension Committee of the Cross-Strait Medical and Health Exchange Association, was released, and the diagnostic threshold of hypertension in adults in China was changed from ≥/kloc. As soon as the news came out, it immediately rushed to the hot search. Overnight, many people suddenly had high blood pressure. However, last night, the National Health Commission responded to the heated discussion. "Healthy China" announced that the state has standardized the procedures for establishing diagnostic standards for diseases such as hypertension. In other words, the country has not adjusted the diagnostic criteria of adult hypertension. The discussion about the diagnostic criteria of hypertension in the past two days was very enthusiastic, and some experts from all walks of life supported it, while others clearly expressed their opposition.

Let's take a look at the debate about the diagnostic criteria of hypertension in the media with me.

Red star depth | 130/80 or 140/90? The Debate of "Normal High Value" Behind "Hypertension" of 200 Million People

According to Oriental IC

Red Star journalist Hu Wuyang reports from Beijing.

Editor Qiu Tian

According to chinese journal of cardiology WeChat official account 165438+ 10/3, the Clinical Practice Guide of Hypertension in China (hereinafter referred to as the guide) was issued. The guideline suggests that the diagnostic threshold of hypertension in adults in China should be lowered from ≥ 140/90mmHg to ≥ 130/80 mmHg. The guideline was jointly formulated by the National Cardiovascular Center, the Chinese Medical Doctor Association, the Hypertension Committee of the Chinese Medical Doctor Association, the Cardiovascular Branch of the Chinese Medical Association, and the Hypertension Committee of the Cross-Strait Medical and Health Exchange Association. After the relevant news was reported by the media, it caused widespread concern.

165438+1October15th, National Health Commission announced that at present, the national diagnostic criteria for adult hypertension have not been adjusted. Guides and knowledge issued by professional organizations, trade associations and individuals are the research results of experts, and are not used as national disease diagnosis standards.

Red Star News reporter found that at present, the pre-release link of the guide in Chinese Journal of Cardiology has expired. According to the official WeChat account information mentioned above, the guide will be officially published in the issue 1 1 of Chinese Journal of Cardiology 2022 on1on October 24th.

Will the standard change affect the geometry? According to the Guide, the national survey data show that among the adults aged 65,438+08 and above in China, SBP (systolic blood pressure) is 65,438+030 ~ 65,438+039 mmHg and/or DBP (diastolic blood pressure) is 80~89 mmHg, accounting for 23.2%, and the estimated total number is nearly 243 million. According to the guideline, according to the starting standard of antihypertensive drug therapy recommended by the latest international guideline, among adults aged 35 and above in China, 22.7% of people with SBP 130~ 139 mmHg and/or DBP80~89 mmHg need antihypertensive drug therapy, and the total number is estimated to be 39.9 million.

Chen Hui, a professor and chief physician of Fujian Institute of Cardiovascular Diseases, learned about the formulation of the guidelines. After the publication of the Guide, she also had an exchange with Cai Jun, the founder and chief expert of the Guide and a professor at Fuwai Hospital of China Academy of Medical Sciences of the National Cardiovascular Center. She told the Red Star journalist that the original intention of the guidelines was good, but the revision of the clinical guidelines involved a wide range and required a response from the National Health and Family Planning Commission. Research shows that strengthening blood pressure reduction is good for human body, especially for the elderly, so we hope to pay attention to normal high-value people.

However, Chen Hui believes that the revision of hypertension standards is a bit radical, which may go out of shape in the implementation process, leading to the doubling of the number of people taking drugs and increasing the burden of personal and national medical insurance. She believes that we should return to strengthening lifestyle intervention for normal high-value people.

Differences in diagnostic criteria

There have long been different voices in the world.

National Health Commission pointed out that regarding the diagnostic criteria of hypertension, the publicity and education points, prevention and treatment guidelines and clinical pathways issued by the national health administrative department in 2005, 20 10, 20 17 were all clear: the diagnostic criteria of hypertension in adults are: blood pressure exceeds 140/90mmHg for three consecutive times in the same day.

According to CBN, at present, China Hypertension Union, Hypertension Branch of China Health Care Association for the Promotion of International Exchanges, Hypertension Branch of China Geriatrics Association, National Health Commission Key Laboratory of Hypertension Diagnosis and Treatment, and Shanghai Hypertension Research Institute, which have not participated in the above guidelines, have jointly submitted statements to National Health Commission, expounding relevant positions and giving relevant suggestions.

The Red Star News reporter noticed that the prevention and treatment guideline issued on 20 10 is the "Guidelines for Prevention and Treatment of Hypertension in China". The latest version of this guide was revised in 20 18. The authors are China Hypertension Prevention and Control Guidelines Revision Committee, Hypertension Alliance (China), Cardiovascular Branch of Chinese Medical Association, Hypertension Professional Committee of Chinese Medical Doctor Association, Hypertension Branch of China Medical Care International Exchange Promotion Association, and Hypertension Branch of China Geriatrics Association. Both editions are led by Liu, Dean of Fuwai Hospital of China Academy of Medical Sciences, Director of Beijing Institute of Hypertension and former President of World Hypertension Union.

According to the relevant guidelines at home and abroad, the standard of ≥ 160/95mmHg proposed by the World Health Organization in 1977 was changed to ≥ 140/90mmHg in 1997, which has been widely adopted by all countries in the world and has been used so far.

The guidelines of American Heart Association (ACC)/ American Heart Association (AHA) on hypertension in 20 17 took the lead in lowering the diagnostic standard of hypertension to ≥ 130/80 mmHg. However, few institutions and academic groups follow this standard. The American Diabetes Association has always adhered to the diagnostic criteria of ≥ 140/90 mmHg. The guidelines for hypertension management issued by the European Society of Cardiology (ESC)/ European Society of Hypertension (ESH) in 2018 and the international practice guidelines for hypertension issued by the International Society of Hypertension (ISH) ISH)2020 all maintain the diagnostic criteria of ≥ 140/90mmHg.

In May 2022, the Cardiology Society of Taiwan Province Province in China and the Hypertension Society of Taiwan Province Province jointly published the Guide to Hypertension in Taiwan Province Province in 2022, which lowered the diagnostic standard of hypertension to 130/80mmHg. Professor Jiang, a professor at the Veterans General Hospital of Chinese Taipei, once pointed out at a cross-strait academic seminar that with the deepening of related research, there are also differences in the setting of hypertension in the world. Different academic organizations have different antihypertensive goals, which can be roughly divided into three groups: active antihypertensive, traditional antihypertensive and passive antihypertensive.

Guo, an expert in the drafting group of the Guide and vice president of Hebei Provincial People's Hospital, wrote on the official account of personal WeChat that it is normal for different scholars and academic institutions to have different academic views. There are reasons and grounds for the downward adjustment of this standard, but its starting point is consistent with the fundamental motivation, that is, to better control blood pressure and minimize the harm of hypertension to the lives and health of Chinese residents.

People whose blood pressure is130-139/80-89 mmhg are a very noteworthy group. Guo believes that the controversy caused by the guideline is a good thing, because ordinary people can pay attention to their blood pressure health and care that they may be patients. "If so, more people will consciously take the initiative to eat less and exercise more to lose weight, quit smoking, limit alcohol and salt, stay up late regularly, relax and get enough sleep."

Definition of normal high value

Blood pressure is not a single constant value.

However, lower than the diagnostic criteria does not mean that blood pressure is normal. Normal blood pressure is usually defined as

Generally speaking, it is only recommended to start antihypertensive drug treatment for high-risk groups with SBP 130 ~ 139 mmHg internationally. Another major adjustment of the guidelines is that for people whose blood pressure is130-139mmhg/80-89mmhg with 0-2 cardiovascular risk factors, if their blood pressure is still not up to standard after lifestyle intervention for 3-6 months, it is recommended to start antihypertensive drug treatment immediately.

Chen Hui explained that human blood pressure itself is not a single constant value. The currently used 140/90mmHg is also the result of population survey. This value is suitable for most people, but for some individuals, the diagnosis of hypertension may not be valid.

Chen Hui believes that doctors should first strengthen the education of normal high-value people between 130/80mmHg and 140/90mmHg to see if it can be reversed through lifestyle intervention, which is also emphasized in the previous guide.

"Any level of hypertension, first of all, non-drug treatment, healthy lifestyle can not meet the standard and then consider drug treatment, which is a principle of hypertension treatment. However, if 130/80mmHg becomes the standard in this guide, pharmaceutical companies will take this opportunity to publicize that everyone above this standard will take medicine. This will lead to a large increase in the number of drug users, and both individuals and national medical insurance will be under pressure. " Chen Hui said.

Controversy about standard adjustment

Not only clinical research, but also national conditions should be considered.

As for the basis for lowering the standard, the recommendations in the Guide cite a number of domestic and foreign studies, indicating that based on observational research evidence, harm exists; Based on the clinical trial evidence, the intervention is effective. But then the academic circles issued different voices.

Liu, director of the Institute of Beijing Hypertension Union and former president of the World Hypertension Union, said recently that there is no high-quality evidence that drug treatment will achieve obvious benefits when the blood pressure is in the range of130 ~139 mmhg/80 ~ 89 mmhg.

Wang Jiguang, chairman of China Hypertension Alliance and professor of Ruijin Hospital affiliated to Shanghai Jiaotong University School of Medicine, also pointed out in an interview with CBN reporter that up to now, no published randomized controlled clinical study at home and abroad has confirmed that it can benefit non-high-risk patients with blood pressure130-139/80-89 mmhg, and no study has confirmed the safety of drug treatment for these people. Wang Jiguang said that lowering the diagnostic criteria of hypertension is not only not suitable for China's national conditions, but may also cause serious health hazards to people at risk of hypotension.

The adjustment of American ACC/AHA20 17 hypertension guidelines is also controversial internationally. For example, on 20 18, the British Medical Journal (BMJ) published a cooperative study between the National Cardiovascular Center of the United States and Yale University. It is believed that if the new definition of American hypertension guidelines is used, both Chinese and American health systems will be overwhelmed and unsustainable.

Chen Hui explained that the United States lowered the standard of hypertension guidelines to 130/80mmHg, mainly because there are a large number of obese people in the United States, and the risk factors affecting hypertension have been difficult to control. In order to better meet the standard of blood pressure and reduce the complications of heart, brain and kidney, the standard of hypertension in the United States is lower than that in other countries. At the same time, this is also related to the relatively better medical resources in the United States. But this standard is too radical for other countries, and most countries are using the standard of 140/90mmHg.

From the perspective of cost-effectiveness, Zhao Dong, a professor of anzhen hospital affiliated to Capital Medical University, introduced at the press conference that most people with blood pressure levels of 130~ 139 mmHg and/or 80~89 mmHg are young and middle-aged. Lowering diagnostic criteria embodies the concept of moving forward and strengthening initial prevention, otherwise it will miss the key opportunity to reduce the harm of cardiovascular diseases caused by hypertension. It is an important window period to reduce the adverse consequences of hypertension by lifestyle intervention for people with blood pressure130 ~139/80 ~ 89 mmhg and starting antihypertensive drug treatment when non-drug treatment fails. Although the downward adjustment of the diagnostic criteria for hypertension may lead to an increase in the cost of early treatment (based on the current national medical insurance and centralized drug procurement policy, this increase is completely affordable), in the long run, the high cost of treatment for serious complications in the future is expected to drop significantly, which is cost-effective on the whole.

The reporter has not paid attention to the basic articles or specific calculation process of the evaluation evidence of health economics given in the Guide.

Chen Hui said that China's national conditions are different from those of the United States. There are not as many obese people in China as in the United States, and normal high-value people can be treated with non-drugs. At the same time, China's medical resources are relatively insufficient, and the medical insurance affordability is limited. "The formulation of clinical guidelines should not only consider clinical research, but also consider national conditions, such as the affordability of national medical care and the health level of the people."

The share price of pharmaceutical companies once rose sharply.

Are there any benefits behind it?

The formulation of a medical guide needs to invite experts from all aspects and departments. According to the full text of the guideline, the members of the guideline working group include not only clinicians and experts in the cardiovascular field, but also experts and patient representatives in the fields of nephrology, endocrinology, urology, vascular surgery, psychiatry, epidemiology, nursing, clinical pharmacy and health economics. Red Star News reporter noticed that there are four decision makers in the external audit team.

Cai Jun, the founder of the Guide, said in an interview with the media recently that the lowering of the diagnostic threshold for hypertension was decided by the unanimous vote of 50 top experts in cardiovascular field in China. According to Economic Observer, a core member of the guideline formulation committee also said that "the vast majority of experts voted in favor".

Red Star journalists learned from relevant people that before and after the publication of the guideline, relevant discussions and symposiums were held in the domestic cardiovascular field.

On Monday165438+1October 14, the stock prices of antihypertensive drugs companies such as Huahai Pharmaceutical, Renfu Pharmaceutical and Rundu Shares rose sharply. In this regard, some netizens questioned the interests of pharmaceutical companies.

The Red Star reporter learned that in terms of funding sources, the Guide indicated that the funds needed for the preparation came from the project of the Disease Prevention and Control Bureau of the National Health and Wellness Committee (T202 1-ZC02) and the medical and health science and technology innovation project of China Academy of Medical Sciences (202 1-I2M- 1-007). The funds are mainly used to pay for labor, materials, travel and conference expenses, and the suggestions in the guide are not affected by the funds.

In terms of conflict of interest, the guide points out that all authors declare that there is no conflict of interest. The core members of the above-mentioned guideline formulation committee interviewed by Economic Observer Network also said that the guideline used all the research funds of its own projects and "never took a penny from pharmaceutical companies".

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How important is managing blood pressure?

1 13 years 10/3 months 13 days, the China Clinical Practice Guide, which was formulated by the National Cardiovascular Center, the Chinese Medical Doctor Association, the Hypertension Committee of the Chinese Medical Doctor Association, the Cardiovascular Branch of the Chinese Medical Association, and the Hypertension Committee of the Cross-Strait Medical and Health Exchange Association, was released, and the diagnostic threshold of hypertension in adults in China was changed from ≥/kloc. As soon as the news came out, it immediately rushed to the hot search. Overnight, many people suddenly had high blood pressure.

However, last night, the National Health Commission responded to the heated discussion. "Healthy China" announced that the state has standardized the procedures for establishing diagnostic standards for diseases such as hypertension. Guides and knowledge issued by professional organizations, trade associations and individuals are the research results of experts, and are not used as national disease diagnosis standards. In other words, the country has not adjusted the diagnostic criteria of adult hypertension.

Debate on the standard of hypertension

The discussion about the diagnostic criteria of hypertension in the past two days was very enthusiastic, and some experts from all walks of life supported it, while others clearly expressed their opposition. According to the report of Physician, Liu Jiaoshou, the former chairman of China Hypertension Union, said that in the adult population with low cardiovascular risk130-139/80-89mmhg, antihypertensive drug therapy can not only effectively reduce cardiovascular risk, but also increase the occurrence of adverse reactions. In addition, taking 130/80 mmHg as the diagnostic cut-off point of hypertension will inevitably bring great impact to China's social and medical security system.

165438+1October 15 Professor Wang Jiguang, chairman of China Hypertension Alliance and director of Shanghai Hypertension Research Institute, also said in an interview with CBN that lowering the diagnostic criteria of hypertension is not only not suitable for China's national conditions, but may also cause serious health hazards to non-hypertensive people.

Yesterday, National Health Commission's article said that in 2005, 20 10, 20 17, the publicity and education points, prevention and treatment guidelines and clinical pathways issued by the national health administrative department were all clear: the diagnostic standard of adult hypertension is: blood pressure exceeds 140/90mmHg three times on the same day.

Professor Ren Ben, director of the Department of Cardiology, Shanghai Chest Hospital, said in an interview that according to the diagnostic criteria of SBP≥ 140 mmHg and/or DBP≥90 mmHg, from 20 18 to 20 15 years, the number of adult hypertensive patients aged 18 and above in China was about 245 million. Such a huge base, but the awareness rate, treatment rate and control rate of hypertension in China are 5 1.6%, 45.8% and 16.8% respectively, which are still at a low level.

According to the national survey data, among the adults 18 and above in China, the estimated total number of130-139/80-89 mmhg is nearly 245 million. If the diagnostic threshold of hypertension is adjusted, the number of patients with hypertension will almost double. The sharp increase in the number of patients will inevitably have a great impact on the social and medical security system in China.

Professor He Ben believes that the goal of hypertension treatment is to reduce its clinical consequences. Blood pressure is a continuous curve, and the degree of blood pressure increase is positively correlated with complications. Hypertension high-risk population refers to the history of hypertension with a clearly diagnosed cardiovascular risk of 10 years, including clinical complications such as cerebral hemorrhage, ischemic stroke, coronary heart disease, chronic heart failure and renal failure, and the assessed risk exceeds 10%. Therefore, the importance of proper blood pressure control cannot be overemphasized. But to find a suitable "tangent point"; It's just that it's neither left nor right. It's hard. Different positions will lead to disputes. From the clinician's point of view, we often see that patients have severe hypertension without knowing it, and the treatment rate and control rate are also very low, and the medication compliance is very poor, which makes us need to pay more attention to the prevention and control of hypertension.

Patient Mr. Jiang, 77 years old, has a history of hypertension 10 years. At present, his blood pressure is 180/ 106mmHg, accompanied by hyperlipidemia and diabetes. Coronary angiography showed mild coronary artery stenosis, echocardiography showed that the left atrium was obviously enlarged, the interventricular septum was thickened, the left ventricular systolic function was obviously decreased, and the left ventricular ejection fraction was 45%. He Ben said that patients with long-term hypertension, poor control, leading to changes in heart structure and function, accompanied by hyperlipidemia and diabetes, are high-risk cardiovascular patients. He Ben urged patients to eat a low-salt diet, exercise properly, quit smoking and limit alcohol, pay attention to rest, and give medication at the same time. "Patients with hypertension like this need to adjust their treatment plans and treat and improve heart failure through multi-drug combination under the condition of poor blood pressure control; At the same time, lowering blood sugar and lipid also needs to keep up. " He Ben said that such high-risk patients should also self-test and monitor their blood pressure every day at home, make regular follow-up visits, control cardiovascular risk factors and prevent complications.

What will be the impact of changing the guidelines?

Professor He Ben believes that the most important thing in the prevention and treatment of hypertension is to move forward, make early diagnosis and intervention for patients, effectively slow down the progress of the disease and reduce the occurrence of clinical complications such as heart, brain and kidney.

Shao Qin, director of the Department of Hypertension Rehabilitation, Department of Cardiology, Shanghai Chest Hospital, also said that with reference to the guidelines, more people may start to pay attention to their blood pressure as soon as possible, find hypertension as soon as possible, see a doctor in time, and strengthen management at an early stage to prevent the disease from progressing. Doctors will also pay more attention to these patients and see if there are other risk factors for early intervention.

Of course, for patients with blood pressure130-139/80-89 mmhg, that is, the "controversial population" in the revision of this guideline, if there are no clear cardiovascular risk factors, lifestyle intervention can be carried out for 3-6 months instead of taking antihypertensive drugs immediately.

Xiao Liu, a 23-year-old patient, always feels dizzy and chest tightness, especially during exercise or emotional excitement. The clinical blood pressure is 138/88mmHg because no abnormality is found in ECG and echocardiography. By asking about the medical history, the doctor found that the young man often stayed up late in recent months due to work pressure, overeating at night, often losing sleep and having no exercise habits. Although according to the current diagnostic criteria, Xiao Liu is not a "hypertensive patient", his symptoms have sounded the alarm for his health. The doctor told him to improve his lifestyle, adjust his stress, pay attention to rest, eat lightly and exercise properly, including moderate or high-intensity aerobic exercise, 30-60 minutes each time, 5-7 days a week; Resistance training 2~3 times a week. Three months later, Xiao Liu's blood pressure dropped to 12 1/74mmHg, and the symptoms of dizziness and chest tightness were greatly improved.

Expect more people to pay attention to their blood pressure.

With the update of the new hypertension guide, the number of patients who came to the hospital for consultation in the past two days has also increased accordingly. Many citizens placed orders on the e-commerce platform, bought sphygmomanometers and officially began to pay attention to the blood pressure of the whole family.

Patient Xiao Wang's blood pressure is just 130/80mmHg, but there is nothing uncomfortable. He doesn't know whether to take medicine or not. Shao Qin said that such patients should fully evaluate whether there are clinical complications and whether there are more than three cardiovascular risk factors. If it is judged as a non-high-risk patient, lifestyle intervention can be started. "In fact, all patients with hypertension should have lifestyle interventions, such as diet, exercise, decompression, weight loss, smoking cessation and alcohol restriction, whether it is low-risk or high-risk patients; For high-risk patients, it is recommended to start antihypertensive drug treatment immediately. For non-high-risk patients, lifestyle intervention can be carried out for 3 to 6 months. When the effect is not good, consider starting antihypertensive drug treatment. " Shao Qin said.

In a word, preventing and controlling hypertension is one of the core strategies to curb the prevalence of cardiovascular and cerebrovascular diseases. Professor He Ben said frankly that the elderly group is still the protagonist among patients with hypertension in China, and doctors will give patients the most suitable intervention plan according to their personal situation and clinical experience. From another perspective, we can take this opportunity to call on more people to pay attention to their blood pressure as soon as possible and reduce the risk of cardiovascular and cerebrovascular diseases by changing unhealthy lifestyles. This is what doctors and patients want to see.

Xinmin Evening News reporter Zuo Yan