全球药物干预治疗单纯性高血压指南的系统评价

Guidelines Concerning Pharmacological Intervention in Simple Hypertension:A Systematic Review

目的循证评价药物干预单纯性高血压指南,比较指南中药物推荐的异同,分析不同地区、不同质量级别指南中药物推荐频次的差异,探讨药物推荐的证据基础,促进对指南的理解。方法计算机检索MEDLINE、EMbase、CBM、WanFang Data和NGC(National Guideline Clearinghouse)、GIN(Guidelines International Network)、NICE(National Institute for Health and Clinical Excellence)及中国临床指南协作网(Clinical Practice Guideline Network,CPGN)等中英文数据库和指南网站,纳入药物干预单纯性高血压的指南,用指南评价工具(Appraisal of Guidelines for Research and Evaluation,AGREE)中的6个领域(23个条目)评价指南的方法学质量,并通过同类比较分析不同地区和质量级别的指南对药物推荐的异同及特点。结果共纳入27篇药物干预单纯性高血压指南,覆盖6个洲13个国家、3个地区及3个组织,时间跨度为2003～2012年,含A级指南4篇,B级17篇,C级6篇。27篇指南仅在"范围与目的"和"清晰性与可读性"2个领域平均得分>60%,各地区指南在AGREE不同领域的平均得分各有优劣。8篇循证指南在AGREE各领域的平均得分均高于非循证指南。指南对血压的理想、正常、正常高值的划分范围及高血压的分级与标准存在差异。对一线药物,指南首推利尿剂(Diuretics,D),对其他药物推荐与年龄和人种有关,且有地区差异。对二联用药,北美倾向推荐以D为基础的联合方案,亚洲倾向推荐以钙离子拮抗剂(Calcium Channel Blockers,CCBs)为基础的联合方案。结论不同国家或地区药物干预单纯性高血压指南的整体质量不高,AGREE工具6个领域23个条目评分各有高低,循证指南各领域的得分均优于非循证指南。对血压分级及名称的标准存在差异。对一线药物,推荐存在地区差异,且与年龄和人种有关。二联用药推荐组合存在地区差异。

Objective To systematically review simple hypertension guidelines through methods as follows： （a） compare differences and similarities of the recommended drugs; （b） analyze differences of the recommended frequencies in different regions and quality levels; and （c） explore the recommended evidence basis, so as to better understand relevant guidelines. Methods Uncomplicated hypertension guidelines concerning pharmacological interventions were identified （terminated by March 2012） in Ovid, EMbase, Chinese Biomedical Disc （CBM） and WangFang database as well as guideline websites including NGC （National Guideline Clearinghouse）, GIN（Guidelines International Network）, NICE（National Institute for Health and Clinical Excellence） and CPGN （Clinical Practice Guideline Net, guidelines con- cerning pharmacological intervention in simple hypertension were included. A total of 6 domains （involving 23 items） in the Appraisal of Guidelines for Research and Evaluation （AGREE） were applied to assess the methodological quality of the guidelines. A comparative study was performed regarding the recommendations in guidelines from different regions as well as of different methodological qualities. Results A total of 27 guidelines concerning pharmacological intervention in simple hypertension were included, involving 6 continents, 13 counties, 3 regions and 3 international organizations. Publication dates ranged from 2003 to 2012. According to the AGREE instrument ,4, 17 and 6 guidelines were graded as Level A, B and C, respectively. There were only 2 domains, ＂Scope and Purpose＂ and ＂Clarity of Presentations＂, getting high average scores （more than 60%） among all guidelines. The average scores of guidelines in different domains of AGREE varied with regions. There were 8 evidence-based guidelines which got higher average scores in each domain of AGREE than those of non-evidence-based guidelines. Guidelines varied with the standards of classifying ideal, normal, high normal blood pressure and hypertension. Diuretics were the first agent recommended by all guidelines, and the other recommendations were correlated with age and race. There was a tendency to recommend diuretics as basic drugs in two- drug combination therapy in North America, while calcium channel blockers （CCBs） were the most recommended agents in Asian guidelines. Conclusion The overall methodological quality of simple hypertension guidelines is suboptimal in different countries or regions. The 6 domains involving 23 items in AGREE vary with scores, while the scores of evidence- based guidelines are higher than those of non-evidence-based guidelines. There are differences in the standards of classifying ideal, normal, high normal blood pressure and hypertension. The first-line drug recommendations differ in regions and relate to age and race. Two-drug combination therapy regimens also vary with region.