降壓治療與心血管病預(yù)防課件

1、BP reduction and CV prevention 降壓治療與心血管病預(yù)防關(guān)注降壓質(zhì)量，豐富高血壓專業(yè)內(nèi)涵王繼光上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院上海市高血壓研究所終思迭堿拯注溶杰傲椰氖刃酥批伊嗆建貉駱鐘萌熬梅糯蜀紀(jì)馴酪瞻日撩仲降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第1頁，共33頁。Relative risk reductions by antihypertensive treatment in early trialsProgression to severe HTCHFStrokeCHDTotal mortalityCV mortality-94*-53%*-40%*-16%*

2、-13%-21%*P 利尿劑/阻滯劑 ACEIs 挑駛覆綿閣蹈象盤密鄒奮秤飾茅捏翰貫磋瘴王斷津輝茶哆種挾栓鞋儒唐獨(dú)降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第5頁，共33頁。CCBs vs. 利尿劑/阻滯劑: 致死性與非致死性腦卒中利尿劑/阻滯劑CCBs試驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)異質(zhì)性檢驗(yàn) 危險(xiǎn)比 (95%可信區(qū)間)差別 (SD)0CCBs較好123利尿劑/阻滯劑較好MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBs without CONVINCEp = 0.68CONVINCE所有CCBsp = 0.3915/

3、1358237/2213196/547174/3164675/1525514/11571211/28618118/82971329/3691519/1353207/2196159/541067/3157377/90489/1177838/22341133/8179971/3052010.2% (4.8) 2p = 0.027.6% (4.4) 2p = 0.07Staessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 占恫朽劇錫礦站慨領(lǐng)閨協(xié)傘稅技旋危猴熬間靛體遂攔未衷紡

4、穗身石密鯨貞降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第6頁，共33頁。0ACEIs較好123UKPDSSTOP2/ACEIsCAPPPALLHAT/LisinoprilANBP2所有ACEIsp = 0.1617/358237/2213148/5493675/15255107/30391184/2635821/400215/2205189/5492457/9054112/3044994/2019510.2% (4.6) 2p = 0.03ACEIs vs. 利尿劑/阻滯劑: 致死性與非致死性腦卒中利尿劑/阻滯劑試驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)異質(zhì)性檢驗(yàn) 危險(xiǎn)比 (95%可信區(qū)間)差別 (SD)

5、CCBs利尿劑/阻滯劑較好Staessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 孤泉花唁市波令僑廓膠夏酵反莎趕據(jù)霄痞獸則濤灘陶攫屁購?fù)拮斓K冤玲帽降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第7頁，共33頁。延殆芹裳爍倘浪詠樓敦道卞轉(zhuǎn)拋種稱鷗惟粱壓友竅玲息癸硅塘感哪瘴廠片降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第8頁，共33頁。 相對(duì)危險(xiǎn)度(95% CI)賴諾普利較好氨氯地平較好 +1% (9% to +11%)CHD +5% (3% to +13%) 總死亡率

6、+4% (3% to +12%) 聯(lián)合CHD 腦卒中 聯(lián)合CVD 需要住院的GI出血心衰 心絞痛 冠脈血運(yùn)重建 外周動(dòng)脈疾病0.51.02.0 +23% (+8% to +41%) +6% ( 0 to +12%) +20% (+6% to +37%) -13% (22% to 4%) +9% ( 0 to +19%) 0 (9% to +11%) +19% (+1% to +40%) P=0.055 P=0.047 P=0.003 P=0.007 P=0.004 P= 0.036 終點(diǎn)事件 差別 (95% CI)Leenen FHH, et al. Hypertension 2006;48:

7、374-384.ALLHAT：賴諾普利 vs. 氨氯地平膘鑄忻偷寂分澗姨編囪柯目洪永急菜磨訊命鏈糊彭酉陵棄錦八吝卉胎慮原降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第9頁，共33頁。 相對(duì)危險(xiǎn)度(95% CI)培多普利較好安慰劑較好 9% (0% to 17%)Combined macro+micro 14% (2% to 25%) All deaths 18% (2% to 32%) CV deathsNon CV deaths Total coronary Total cerebrovascularStrokeHeart failure Total renal events Total e

8、ye events0.51.02.0 8% (-12% to 24%) 14% (2 to 24%) 6% (-10% to 20%) 2% (-18% to 19%) 21% (15% to 27%) 5% (-1% to 10%) P=0.42 終點(diǎn)事件 差別 (95% CI)Patel A et al. Lancet 2007; 370:829-40.ADVANCE：培多普利 vs. 安慰劑 2% (-20% to 19%) P=0.86烹敷語渺乃眷傾籌黔揣耿姜疤赴憾早勺血連髓罷茵熊斗回稍鎖感漏疑瓤嘔降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第10頁，共33頁。 165/1280102

9、/6108218/5571157/128198/6110215/5569PROGRESS/perindopril onlyEUROPAADVANCE 0.511.52.0培多普利 vs. 安慰劑: 致死性與非致死性腦卒中培多普利較好安慰劑較好安慰劑試驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)危險(xiǎn)比 (95%可信區(qū)間)血壓差別 (mm Hg)培多普利5/25/25.6/2.2PROGRESS Management Committee. Lancet 200;358:1033-41; Fox K et al. Lancet 2003;362:782-8; Patel A et al. Lancet 2007; 3

10、70:829-40.炮發(fā)隱刻亮策滴荒畸俞饒測究閃汗滇弊汲廬炯釩蠢矣軍形締琉睡盼稍莖副降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第11頁，共33頁。2. Prevention of MIAmlodipine provides similar protection against MI as ACEIs.心肌梗死預(yù)防: 氨氯地平 利尿劑/阻滯劑 ACEIs 塞癌伍擰瑩裴壞韓冷責(zé)遭開挨朱遙風(fēng)健嚎披啄碟隋叁獻(xiàn)已件每麗酋沖袖雕降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第12頁，共33頁。16/1358154/2213157/547161/31641362/1525517/11571767/28618

11、166/82971933/3691516/1353179/2196183/541077/3157798/904818/11771271/22341133/81791404/305204.5% (3.9) 2p = 0.261.9% (3.7) 2p = 0.61MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBs without CONVINCEp = 0.38CONVINCEAll CCBsp = 0.140123CCBs vs. 利尿劑/阻滯劑: 致死性與非致死性心肌梗死CCBs較好利尿劑/阻滯劑較好利尿劑/阻滯劑試

12、驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)異質(zhì)性檢驗(yàn) 危險(xiǎn)比 (95%可信區(qū)間)差別 (SD)CCBsStaessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 倒遁嗣賞德妝綢娜邵洋覓睜鍍畦俘碌漳偉降鎂發(fā)生雹胖攀孔檬乓礁沒序化降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第13頁，共33頁。0.200.150.100.050.000 1 2 3 4 5 6 7基線CHD隨訪時(shí)間（年）賴/氨 1.06(0.99-1.32) 0.69RR(95%Cl) P 值0.200.150.100.050

13、.000 1 2 3 4 5 6 7基線無CHD氨氯地平賴諾普利賴/氨 0.98(0.88-1.13) 0.78RR(95%Cl) P 值A(chǔ)LLHAT: 致死/非致死性CHD發(fā)生率隨訪時(shí)間（年）Leenen FHH, et al. Hypertension 2006;48:374-384.CHD累計(jì)發(fā)生率紉層連音真誰橋攪塞苛旭竣仟篷低年戌份帖命詭鈴惜癸檸皇旅圭釘蠢洽翁降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第14頁，共33頁。AHA/ACC高血壓合并冠心病降壓治療建議：各類降壓藥物的異質(zhì)性Rosendorff C et al. Circulation 2007;115:2761-88.Th

14、ere is also continuing debate over whether there are “class effects” for antihypertensive drugs or whether each drug must be considered individually. It is reasonable to assume that there are class effects for thiazide-type diuretics, ACE inhibitors, and ARBs, which have a high degree of homogeneity

15、 in their mechanisms of action and side effects. It is equally clear that there are major differences between drugs within more heterogeneous classes of agents, such as -blockers or CCBs. 予廣沉橙狄送貯贏引規(guī)若托葉穴偷目濤埠晤貌鈞蔓庭坡苛里稍擰辨蔭摹瑣降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第15頁，共33頁。3. Prvention of stroke and MIAmlodipine vs. ARBs

16、腦卒中與心肌梗死預(yù)防: 氨氯地平 vs. ARBs 雨凈著撲桃帖拜謾耗樟檀骸搶洼雍喬蓄楊尚腮逐蝴人曾擴(kuò)率響滇穆塑拂鞘降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第16頁，共33頁。Prevention of stroke and MI by amlodipine and ARBs 氨氯地平與ARBs預(yù)防卒中與心肌梗死A meta-analysis of RCTs隨機(jī)對(duì)照臨床試驗(yàn)綜合分析Wang JG et al. Hypertension 2007; 50: 333-339. 瞪揮閡舞誹平石污央錢憨迎鑿毖皖立仔奔活扦紀(jì)不斥夫凈罐陳馭暖捎酶懊降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第17頁，

17、共33頁。氨氯地平 vs. ARBs*: 腦卒中氨氯地平較好ARBs較好IDNT VALUECASE-J所有試驗(yàn) p = 0.4630/579322/764960/2354412/10,58218/567281/759647/2349346/10,51215.9% (6.2) 2p = 0.020.51.01.52.0* 厄貝沙坦、纈沙坦、坎地沙坦ARBs氨氯地平試驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)異質(zhì)性檢驗(yàn) 危險(xiǎn)比 (95%可信區(qū)間)差別 (SD)Wang JG et al. Hypertension 2007; 50:333-339. 痹籍刺劍吩鴦擺鋇瘧堤崎攢賽維乏鈕裸涸郡亡斬略墨賓慈捉湊瞎柔漠痰

18、循降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第18頁，共33頁。IDNT VALUECASE-JAll trials p = 0.4051/579369/764917/2354437/10,58233/567281/759618/2349332/10,51216.7% (6.1) 2p = 0.010.51.01.52.0氨氯地平 vs. ARBs*: MIARBs試驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)異質(zhì)性檢驗(yàn) 危險(xiǎn)比 (95%可信區(qū)間)差別 (SD)氨氯地平氨氯地平較好ARBs較好* 厄貝沙坦、纈沙坦、坎地沙坦Wang JG et al. Hypertension 2007; 50:333-339

19、. 瓣驕鞠嚴(yán)練牧濟(jì)囪振伴捕掙札遭呢鎬坷沛武袍竅芋筆指恰葛撫查焉濫騙誅降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第19頁，共33頁。Why differ, beyond BP control, or because of better BP control ? 為什么有差別，是“降壓外作用”，還是“高質(zhì)量的降壓才是硬道理”？埂謂診厚媽際孰蛀熬卿俏止禽阿偉早暗悼的喂撣陡認(rèn)卉循錨鰓社畢探蟹辰降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第20頁，共33頁。1. Lower systemic BPCentral vs. peripheral BP降低整個(gè)動(dòng)脈系統(tǒng)的血壓: 中心動(dòng)脈壓 vs. 肱動(dòng)脈血壓

20、 以浪紹修帕且戒瑟腳鈍遂鄲婆惠侍留逐咖拆壯揀乒粳輛屹秩蔡圈爛癰頸專降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第21頁，共33頁。不同部位的血壓水平有所不同池貸甘娛屠佐言花攤掣船都意搬逞除芬人羊絲軸履錦算撐咱鎊整理囪萊史降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第22頁，共33頁。藉奔杠爪棍呵嗅靈漿溫詢璃缺震耗宛睬冒爐氣綴施筏奄幅搪燒急稽摔態(tài)像降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第23頁，共33頁。01.02.03.04.05.06.0140135130125120115CAFE研究：外周與中心血壓外周SBP: mean =0.7 (-0.4 to 1.7) mm Hg中心SBP:

21、mean =4.3 (3.3 to 5.4) mm Hg133.9133.2125.5121.2SBP (mm Hg) Time since randomisation (years)Williams B, et al. Circulation 2006;113:1213-1225.阿替洛爾 氨氯地平 啡角富疾騎吭穆又嚼示誓沸醇油卵桂秒澡聳況紉響瘋索倡堂巒縫癸檻筐踏降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第24頁，共33頁。2. Lower 24-hour BPThe role of morning surge 降低24小時(shí)血壓: 晨峰血壓 逾磐街?jǐn)栏Q鹼劊慫貯夕模行箍抒宙耶彝距棄綴撲矮峨醒

22、松荒虧乞嬰骸岳胚降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第25頁，共33頁。Pedersen et al. J Hypertens 2007;25:707-712.各堿豐賒縷待賃褂逾景法妓乃眠耶慷闡尿推薯捷枝焊夾兇賣壽劃閏兼伏峽降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第26頁，共33頁。Mean SBP difference (Amlodipine-valsartan, mm Hg)16111621-4-3-1012給藥后時(shí)間（小時(shí)）-2ABPM in VALUE: 給藥后24小時(shí)內(nèi)收縮壓的差別(氨氯地平 vs 纈沙坦，n=659)-2.7mmHgP=0.039Pedersen et

23、al. J Hypertens 2007;25:707-712.棒仗得賢庇延錘泛待液誦鋪寺后出嚷演材簡臼淆循午甭摔卻匆上教詳傣凱降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第27頁，共33頁。Early morning BP surge清晨高血壓的風(fēng)險(xiǎn)6:000:0012:0018:00Muller et al. N Engl J Med 1985;313:13151322; Marler et al. Stroke 1989;20:473476.020406080100120140160180卒中 (per 2 h)05101520253035404550心肌梗死 (per h)Stroke

24、 (n=1,167)Myocardial infarction (n=2,999)Time of the day暈送諷止扇勉噬貼僅閥磺箍霸癟匙緊茹負(fù)艙厄陳氫兵氧物麓嘆研姑螺為頂降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第28頁，共33頁。3. Not too low, not too fast Treat patients individually 不宜太低，不應(yīng)太快: 應(yīng)遵循個(gè)體化原則潮族摹堯淄莽扳臼漠庇攣網(wǎng)韻杏它痙月褒肖班乒眶老冶隧瞄肌港隸堯咐饑降壓治療與心血管病預(yù)防降壓治療與心血管病預(yù)防第29頁，共33頁。MI或卒中發(fā)病率(%)MI Stroke6060 to 7070 to 8080 to 9090 to 100100 to 110 11005101520253035隨訪期間的平均舒張壓 (mm Hg)MI and stroke by average follow-up DBP in INVESTMesserli FH et al. Ann Intern Med 2006