Seven‐action approaches for the management of hypertension in Asia – The HOPE Asia network
亚洲高血压管理的七种行动方法 – HOPE Asia 网络

4.2. Strict BP control 4.2. 严格的血压控制

Previous studies have shown that the slope of the association between BP and cardiovascular events is steeper in Asians than Westerners. ³⁹ Data from the recent STEP (Strategy of Blood Pressure Intervention in the Elderly Hypertensive Patients) trial, conducted in China, showed that strict BP control (SBP 110–130 mmHg) was superior to standard BP control (SBP 130–150 mmHg) for preventing cardiovascular events. ⁴⁰ The findings of this study are relevant for hypertension management in Asia, ^{41 , 42 , 43} and suggest that elderly Asians would benefit from strict BP control to reduce cardiovascular risk.
先前的研究表明，亚洲人血压与心血管事件之间的关联斜率比西方人更陡峭。 ³⁹ 最近在中国进行的STEP（老年高血压患者血压干预策略）试验的数据显示，在预防心血管事件方面，严格的血压控制（SBP 110-130 mmHg）优于标准血压控制（SBP 130-150 mmHg）。 ⁴⁰ 这项研究的结果与亚洲的高血压管理有关， ^{41 , 42 , 43} 并表明亚洲老年人将受益于严格的血压控制以降低心血管风险。

A recent Blood Pressure Lowering Treatment Trialists’ Collaboration (BPLTTC) meta‐analysis, which includes data from the Systolic Blood Pressure Intervention Trial (SPRINT), has been released. ⁴⁴ The results showed that a 5‐mmHg reduction in office SBP reduced the risk of total cardiovascular disease by 10%, the risk of stroke and heart failure by 13%, and the risk of coronary artery disease by 8%. ⁴⁴ In addition, these benefits of BP lowering were seen in individuals aged up to 85 years. ⁴⁵ In the STEP study, a 5‐mmHg reduction in office SBP was associated with an 18% reduction in total cardiovascular disease risk, a 23% reduction in the risk of stroke and coronary artery disease, and a 58% reduction in heart failure risk. These findings showing greater reductions in cardiovascular risk in the STEP study than in SPRINT and the BPLTTC (Table 2), suggest that strict BP control is probably more effective for cardiovascular disease prevention in Asians than in Westerners.
最近的一项降血压治疗试验者合作 （BPLTTC） 荟萃分析已经发布，其中包括来自收缩压干预试验 （SPRINT） 的数据。 ⁴⁴ 结果显示，办公室 SBP 降低 5 mmHg 可使总心血管疾病风险降低 10%，卒中和心力衰竭风险降低 13%，冠状动脉疾病风险降低 8%。 ⁴⁴ 此外，在85岁以下的人群中也看到了降低血压的这些好处。 ⁴⁵ 在 STEP 研究中，办公室 SBP 降低 5 mmHg 与总心血管疾病风险降低 18%、卒中和冠状动脉疾病风险降低 23% 以及心力衰竭风险降低 58% 相关。这些发现显示，与SPRINT和BPLTTC相比，STEP研究的心血管风险降低幅度更大（表2），这表明严格控制血压对亚洲人的心血管疾病预防可能比西方人更有效。

4.3. Home BP‐guided hypertension management
4.3. 家庭血压引导的高血压管理

Individuals with masked hypertension or poorly controlled hypertension are at increased risk of target organ damage and cardiovascular disease. ^{19 , 38 , 46} Masked hypertension is more prevalent in Asia than in Western countries due to higher rates of abnormal patterns of BP variability, including exaggerated early morning BP surge and non‐dipper/riser phenotypes of nocturnal BP. ⁴⁷
隐匿性高血压或高血压控制不佳的个体患靶器官损伤和心血管疾病的风险增加。 ^{19 , 38 , 46} 由于血压变异的异常模式发生率较高，包括清晨血压升高和夜间血压的非北斗/上升表型，隐蔽性高血压在亚洲比西方国家更为普遍。 ⁴⁷

Three prospective observational studies conducted in Asia (Ohasama, J‐HOP [Japan Morning Surge Home Blood Pressure], and HONEST [Home blood pressure measurement with Olmesartan Naive patients to Establish Standard Target blood pressure]) showed that morning hypertension detected using HBPM is associated with a higher risk of cardiovascular disease, regardless of office BP. ⁴⁸ In addition to the average home BP, day‐to‐day variability in home BP is associated with cardiovascular disease risk, especially in those with increased arterial stiffness. ^{49 , 50 , 51 , 52} A recent analysis of data from the J‐HOP study demonstrated that greater morning‐evening difference in home SBP (especially ≥20 mmHg), ⁵³ and peak home SBP over 14 days were associated with cardiovascular disease. ⁵⁴
在亚洲进行的三项前瞻性观察性研究（Ohasama、J-HOP [日本早晨激增家庭血压]和 HONEST [对奥美沙坦未成年患者进行家庭血压测量以建立标准目标血压]）表明，无论办公室血压如何，使用 HBPM 检测到的早晨高血压与更高的心血管疾病风险相关。 ⁴⁸ 除了平均家庭血压外，家庭血压的日常变化也与心血管疾病风险相关，尤其是在动脉硬度增加的患者中。 ^{49 , 50 , 51 , 52} 最近对 J-HOP 研究数据的分析表明，14 天内家庭 SBP（尤其是 ≥20 mmHg） ⁵³ 和家庭 SBP 峰值的早晚差异更大与心血管疾病有关。 ⁵⁴

Thus, identifying and treating masked hypertension phenotypes seems particularly important for cardiovascular risk reduction in Asian populations. This can be facilitated by the use of HBPM. However, current usage of this important tool varies across Asia. ¹⁶ Although HBPM devices are practical to use and affordable, but in the real world they are usually ignored even many patients got one of their own. Therefore, strategies are needed to improve HBPM usage, and there are local guidelines to increase utilization and support the correct usage of HBPM in Asia. ^{19 , 55} Region‐wide differences in hypertension prevalence, control, and management practices in Asia highlight the importance of information sharing to facilitate best practices while taking relevant regional aspects into account.
因此，识别和治疗隐蔽性高血压表型对于降低亚洲人群的心血管风险似乎尤为重要。这可以通过使用HBPM来促进。然而，目前这一重要工具的使用情况在亚洲各地各不相同。 ¹⁶ 尽管HBPM设备使用实用且价格实惠，但在现实世界中，它们通常被忽略，甚至许多患者也拥有自己的设备。因此，需要制定策略来改善HBPM的使用，并且有当地的指导方针来提高利用率并支持亚洲HBPM的正确使用。 ^{19 , 55} 亚洲地区在高血压患病率、控制和管理实践方面的区域差异凸显了信息共享的重要性，以促进最佳实践，同时考虑相关的区域因素。

Development of HBPM devices capable of measuring nocturnal BP along with other information and communication technology‐based strategies are key developments in the widespread implementation of anticipation medicine strategies to detect and prevent cardiovascular events in patients with hypertension. ³⁸
能够测量夜间血压的 HBPM 设备以及其他基于信息和通信技术的策略的开发是广泛实施预测医学策略以检测和预防高血压患者心血管事件的关键发展。 ³⁸

4.4. Reducing morning home BP as the first target and nighttime BP as the second target for high‐risk patients
4.4. 降低高危患者的早晨家庭血压作为第一目标，降低夜间血压作为第二目标

Reducing morning home BP and nighttime BP are actionable targets that could help to improve BP control in the Asian region. Morning BP just before antihypertensive dosing is important because this is when the BP‐lowering effects of the previous morning's dose are at their lowest. Morning BP surge is greater in Japanese versus Western patients with hypertension. ⁵⁶
降低早晨家庭血压和夜间血压是可行的目标，有助于改善亚洲地区的血压控制。在抗高血压给药前进行晨降压很重要，因为这是前一天早上给药的降压效果最低的时候。与西方高血压患者相比，日本高血压患者的晨血压飙升更大。 ⁵⁶

Based on data obtained using wearable BP monitoring devices, morning SBP measured in accordance with guideline recommendations was most closely associated with left ventricular mass measured using cardiac magnetic resonance imaging in medicated patients with hypertension. ⁵⁷ In addition, in the J‐HOP Study, high morning SBP measured by using HBPM (especially SBP ≥135 mmHg) was stronger predictor of stroke than evening BP measured just before going to bed. ⁴⁹ For high‐risk patients with a history of stroke or diabetes, the pathological SBP threshold is lower, at about 125 mmHg. ^{58 , 59}
根据使用可穿戴血压监测设备获得的数据，根据指南建议测量的早晨 SBP 与使用心脏磁共振成像测量的高血压药物患者的左心室质量最密切相关。 ⁵⁷ 此外，在 J-HOP 研究中，使用 HBPM 测量的清晨高 SBP（尤其是 SBP ≥135 mmHg）比睡前测量的晚间血压更能预测卒中。 ⁴⁹ 对于有卒中或糖尿病病史的高危患者，病理 SBP 阈值较低，约为 125 mmHg。 ^{58 , 59}

Another important feature of hypertension in Asian populations is high nighttime BP, which is commonly associated with high salt sensitivity and salt intake. Nocturnal hypertension, including isolated nocturnal hypertension with well‐controlled office and/or morning BP, is a risk factor for organ damage and cardiovascular disease even. ^{60 , 61 , 62 , 63} Nocturnal hypertension is often found in high‐risk patients with comorbidities such as diabetes, chronic kidney disease and sleep apnea. ^{64 , 65} Furthermore, high nighttime BP, especially the riser pattern of nocturnal BP, is a risk factor for the development of heart failure, ^{64 , 66} and partly explains the higher B‐type natriuretic peptide seen in hypertensive patients. ⁶⁷ Another important consideration is sleep duration, which should be ≥6 hours, with control of nighttime BP, to reduce the risk of cardiovascular disease. ⁶⁸
亚洲人群高血压的另一个重要特征是夜间血压高，这通常与高盐敏感性和盐摄入量有关。夜间高血压，包括单纯性夜间高血压，办公室和/或晨血压控制良好，是器官损伤和心血管疾病的危险因素。 ^{60 , 61 , 62 , 63} 夜间高血压常见于患有糖尿病、慢性肾病和睡眠呼吸暂停等合并症的高危患者。 ^{64 , 65} 此外，夜间血压高，尤其是夜间血压的上升模式，是心力衰竭发生的危险因素， ^{64 , 66} 部分解释了高血压患者中较高的 B 型利钠肽。 ⁶⁷ 另一个重要的考虑因素是睡眠时间，应≥6小时，并控制夜间血压，以降低患心血管疾病的风险。 ⁶⁸

In cases where the patient's BP is uncertain or labile, or where there is nonadherence to HBPM, 24‐hour ABPM is recommended for confirming the level of BP control. ¹⁸ Nocturnal HBPM devices are also clinically available. ^{60 , 63} In addition, wrist‐type nocturnal HBPM devices that cause less sleep disturbance have now been validated and are available for use in clinical practice. ^{69 , 70} Thus, both ABPM and nocturnal HBPM are useful to detect nocturnal hypertension, especially in high‐risk patients. ^{71 , 72 , 73}
如果患者的血压不确定或不稳定，或者不依从 HBPM，建议使用 24 小时 ABPM 来确认血压控制水平。 ¹⁸ 夜间 HBPM 设备在临床上也可用。 ^{60 , 63} 此外，引起较少睡眠障碍的手腕式夜间 HBPM 设备现已得到验证，可用于临床实践。 ^{69 , 70} 因此，ABPM 和夜间 HBPM 都有助于检测夜间高血压，尤其是在高危患者中。 ^{71 , 72 , 73}

Seasonal changes in BP and vascular properties, especially home BP control status in relation to room temperature also need to be considered. ^{74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82} Morning BP increases to a greater extent in the winter (colder temperatures) and is associated with organ damage, while nighttime BP is increased in the summer (warmer temperatures). ⁸¹ Compared with evening home BP, morning home BP might be a better predictor of winter‐onset cardiovascular events, ⁸³ and the winter morning BP surge partly explains the increased risk of cardiovascular events in the winter. ⁸⁴ Therefore, BP surges during winter should be an important target of a home BP‐guided approach to hypertension management.
还需要考虑血压和血管特性的季节性变化，尤其是与室温相关的家庭血压控制状态。 ^{74 , 75 , 76 , 77 , 78 , 79 , 80 , 81 , 82} 早晨血压在冬季（较低温度）增加的程度更大，并且与器官损伤有关，而夜间血压在夏季（较高温度）增加。 ⁸¹ 与傍晚在家血压相比，早晨在家血压可能是冬季发病心血管事件的更好预测指标， ⁸³ 冬季早晨血压飙升部分解释了冬季心血管事件风险增加的原因。 ⁸⁴ 因此，冬季血压飙升应成为家庭血压指导的高血压管理方法的重要目标。

4.5. Choice of preferred antihypertensive agents
4.5. 首选降压药的选择

Preferred antihypertensive agents for Asian patients with hypertension are calcium channel blockers (CCBs, which have a sodium‐independent BP‐lowering effect), ⁸⁵ renin‐angiotensin system (RAS) inhibitors, and sodium‐excreting agents (eg, diuretics). For strict BP control without decreasing drug adherence, single‐pill combinations are preferred, where feasible.
亚洲高血压患者的首选降压药是钙通道阻滞剂（CCB，具有钠非依赖性降压作用）、 ⁸⁵ 肾素血管紧张素系统（renin-angiotensin system， RAS）抑制剂和钠排泄剂（如利尿剂）。为了在不降低药物依从性的情况下严格控制血压，在可行的情况下，首选单药组合。

CCBs are the most popular antihypertensive drugs in Asia. They have powerful dose‐dependent and salt intake‐independent BP‐lowering effects and reduce BP variability, making them ideally suited as first‐line therapy in Asian populations. ⁸⁵ In addition, sodium‐excreting drugs such as diuretics should be effective in Asians, who have high salt intake and salt sensitivity. Lower serum potassium levels are also seen in patients from some of Asian countries, meaning that thiazide‐like diuretics excrete potassium. Mineralocorticoid receptor (MR) blockers reduce potassium excrete and hence increase serum potassium, and the recently developed selective MR blocker, esaxerenone, has been shown to reduce nighttime and morning BP, and decrease levels of N‐terminal pro B‐type natriuretic peptide (NT‐proBNP). ^{86 , 87 , 88 , 89} Other sodium‐excerting drugs such as angiotensin receptor‐neprilysin inhibitors (ARNI) and sodium‐glucose co‐transporter 2 (SGLT2) inhibitors, both of which are proven therapies for heart failure, are also effective in lowering BP. ^{90 , 91 , 92 , 93 , 94 , 95 , 96 , 97} SGLT2 inhibitors also decrease 24‐hour BP in patients who have both diabetes and hypertension. ^{98 , 99 , 100 , 101} ARNI have recently been launched for the treatment of hypertension in Japan and China. The BP‐lowering effects of ARNI are greater in Asians than in Westerners, ^{91 , 102} highlighting the potential of these agents in Asian populations. However, availability and cost of these drugs are main obstacles for general use.
CCB是亚洲最受欢迎的降压药。它们具有强大的剂量依赖性和盐摄入依赖性降血压作用，并降低血压变异性，使其成为亚洲人群的一线治疗的理想选择。 ⁸⁵ 此外，钠排泄药物（如利尿剂）应该对盐摄入量高和盐敏感性的亚洲人有效。在一些亚洲国家的患者中也可以看到血清钾水平降低，这意味着噻嗪类利尿剂会排泄钾。盐皮质激素受体 （MR） 阻滞剂可减少钾排泄，从而增加血清钾，最近开发的选择性 MR 阻滞剂艾沙烯酮已被证明可降低夜间和早晨血压，并降低 N 末端 B 型利钠肽 （NT-proBNP） 的水平。 ^{86 , 87 , 88 , 89} 其他钠释放药物，如血管紧张素受体脑啡肽酶抑制剂 （ARNI） 和钠-葡萄糖协同转运蛋白 2 （SGLT2） 抑制剂，这两种药物都是经证实的心力衰竭疗法，也可有效降低血压。 ^{90 , 91 , 92 , 93 , 94 , 95 , 96 , 97} SGLT2 抑制剂还可以降低糖尿病和高血压患者的 24 小时血压。 ^{98 , 99 , 100 , 101} ARNI最近在日本和中国推出，用于治疗高血压。ARNI在亚洲人的降血压作用比西方人更大， ^{91 , 102} 这凸显了这些药物在亚洲人群中的潜力。 然而，这些药物的供应和成本是普遍使用的主要障碍。

4.6. Widespread screening to improve awareness
4.6. 广泛筛查以提高认识

Rates of hypertension awareness in some Asian countries/regions are low, meaning that strategies such as screening for hypertension in public places (eg, the workplace or COVID‐19 vaccination centers), and self‐measurement of BP using HBPM at home and/or at work might be useful. ^{103 , 104 , 105} As part of the May Measurement Month initiative, BP was measured in millions of people in several Asian countries/regions. ¹⁰⁶ The prevalence of hypertension in screened populations was found to be 30.6% in East Asia and 47.8% in South‐East Asia and Australasia; corresponding hypertension awareness rates were 59.0% and 66.5%. ¹⁰⁶ Of patients with hypertension in Asia Pacific, only 16.8% to 28.6% were being treated with antihypertensive medication. Of those treated, more than one‐third (33.4% in East Asia and 36.8% in South‐East Asia and Australasia) had uncontrolled BP. ¹⁰⁶ This reinforces the need for effective strategies to both diagnose and treat hypertension in the region.
在一些亚洲国家/地区，高血压意识的发生率较低，这意味着在公共场所（如工作场所或COVID-19疫苗接种中心）筛查高血压以及在家中和/或工作中使用HBPM自我测量血压等策略可能有用。 ^{103 , 104 , 105} 作为 5 月测量月计划的一部分，在几个亚洲国家/地区对数百万人进行了血压测量。 ¹⁰⁶ 在筛查人群中，东亚的高血压患病率为30.6%，东南亚和大洋洲为47.8%;相应的高血压意识率分别为59.0%和66.5%。 ¹⁰⁶ 在亚太地区的高血压患者中，只有16.8%至28.6%的患者正在接受抗高血压药物治疗。在接受治疗的患者中，超过三分之一（东亚为33.4%，东南亚和大洋洲为36.8%）血压不受控制。 ¹⁰⁶ 这加强了在该地区诊断和治疗高血压的有效策略的必要性。

The authors thank Viatris for the grant to support the HOPE Asia Network activities.
作者感谢Viatris为支持HOPE亚洲网络活动提供的赠款。