ACP/AAFP：６０歳以上高血圧ガイドライン

６０歳以上において

• 収縮期血圧 150mmHg以上は基本的に全員、150mmHg 未満を目標、死亡率、卒中、心血管イベントリスク減少示す
• 卒中やTIA既往の場合は、１４０mmHg未満目標として、卒中再発リスク減少
• 心血管リスク高い場合個別評価に基づき、１４０mmHg未満目標として、卒中・心イベントリスク減少

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CLINICAL GUIDELINES |17 JANUARY 2017

Pharmacologic Treatment of Hypertension in Adults Aged 60 Years or Older to Higher Versus Lower Blood Pressure Targets: A Clinical Practice Guideline From the American College of Physicians and the American Academy of Family Physicians
Amir Qaseem, et. al.; for the Clinical Guidelines Committee of the American College of Physicians and the Commission on Health of the Public and Science of the American Academy of Family Physician
http://annals.org/aim/article/2598413/pharmacologic-treatment-hypertension-adults-aged-60-years-older-higher-versus

対象：全臨床医を読者対象、６０歳以上高血圧成人全員をターゲット

Recommendation 1:

ACP and AAFP recommend that clinicians initiate treatment in adults aged 60 years or older with systolic blood pressure persistently at or above 150 mm Hg to achieve a target systolic blood pressure of less than 150 mm Hg to reduce the risk for mortality, stroke, and cardiac events. (Grade: strong recommendation, high-quality evidence).
ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

Recommendation 2:

ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in adults aged 60 years or older with a history of stroke or transient ischemic attack to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for recurrent stroke. (Grade: weak recommendation, moderate-quality evidence).
ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

Recommendation 3:

ACP and AAFP recommend that clinicians consider initiating or intensifying pharmacologic treatment in some adults aged 60 years or older at high cardiovascular risk, based on individualized assessment, to achieve a target systolic blood pressure of less than 140 mm Hg to reduce the risk for stroke or cardiac events. (Grade: weak recommendation, low-quality evidence).
ACP and AAFP recommend that clinicians select the treatment goals for adults aged 60 years or older based on a periodic discussion of the benefits and harms of specific blood pressure targets with the patient.

喘息誤診はかなり多い ・・・ というJAMA誌の報告

　喘息はその病態上症状・所見出現と消失を繰り返すので、安定時、特に、症状jのない昼間の診察室で診断をするのは困難。一方的に「誤診」と騒がれると、困った事態に陥るだろう。そもそも診断基準なるものが存在しないわけで・・・。ただ、気流制限や可逆性のエビデンスを客観的に提示する必要はある。気流制限などメカニクス上正常で、無症状の緩解期継続する症例に対し、継続加療するのは薬剤過剰投与ともなる


　ここでの誤診とは、「 no evidence of acute worsening of asthma symptoms, reversible airflow obstruction, or bronchial hyperresponsiveness after having all asthma medications tapered off and after a study pulmonologist established an alternative diagnosis. 」であり、通常の誤診とはちょっと違う気がする。

　筆者であるAaronは、１回喘息可能性あるとされる症例のうち、少なくとも２０％程度はその症状は消失すると述べている。もう一つは、検証期間中に気道閉塞証拠を一度も示せない症例を誤診の範疇となりゅ。さらに、「咳喘息」の存在は薬剤メーカーの啓発活動のせいかかなり普及し、咳嗽継続というだけで喘息と辛酸されている症例に多く遭遇する。ここでは「咳喘息」も誤診と判断されている可能性がある

・・・そういう問題を具有する報告でもある。