降压治疗的策略和目标课件.ppt

1、降压治疗策略与目标降压治疗策略与目标回顾与进展回顾与进展降压治疗策略研究的重点降压治疗策略研究的重点l 血压水平与心血管危险l 降压治疗与心血管危险控制 治疗益处及来源(why)治疗对象(who)治疗目标水平(what)治疗方案(which)Lancet 2002,360:1903Stroke mortality(floating absolute risk and 95%CI)2561286432168421120140160180Usual sysytolic bloodPressure(mmHg)Usual diastolic bloodPressure(mmHg)25612864321

2、68421708010011090Stroke mortality(floating absolute risk and 95%CI)A:Systolic blood pressureB:Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59YearsAge at rist:80-89Years70-79Yaes60-69years50-59YearsIHD mortality(floating absolute risk and 95%CI)2561286432168421120140160180Usual

3、 sysytolic bloodPressure(mmHg)Usual diastolic bloodPressure(mmHg)2561286432168421708010011090IHD mortality(floating absolute risk and 95%CI)A:Systolic blood pressureB:Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsAge at rist:80-89Years70-79Yaes60-69years50-59Ye

4、ars40-49yearsLancet 2002,360:1903CauseAge atNumber ofOf deathrisk(years)deathsStroke40-494140.36(0.32-0.40)50-5913720.38(0.35-0.40)60-6929390.43(0.41-0.45)70-7943270.50(0.48-0.52)80-8926360.67(0.63-0.71)IHD40-4913220.49(0.45-0.53)50-5955940.50(0.49-0.52)60-69104500.54(0.53-0.55)70-79108520.60(0.58-0

5、.61)80-8956490.67(0.64-0.70)Other40-493860.43(0.38-0.48)vascular50-5913770.50(0.47-0.54)60-6925490.53(0.51-0.56)70-7932270.64(0.61-0.67)80-8922510.70(0.65-0.75)0.250.350.50.71.0A:usual systolic blood pressure(115 mmHg)Hazard ratio(95%CI)for 20 mmHgLower usual systolic blood pressureLancet 2002,360:1

6、903CauseAge atNumber ofOf deathrisk(years)deathsStroke40-493480.35(0.30-0.40)50-5912430.34(0.32-0.37)60-6926460.40(0.38-0.42)70-7939150.48(0.45-0.51)80-8923400.63(0.58-0.69)IHD40-4911140.47(0.43-0.51)50-5949450.52(0.50-0.55)60-6992890.56(0.54-0.58)70-7997270.62(0.60-0.64)80-8950680.70(0.65-0.74)Othe

7、r40-493160.43(0.37-0.50)vascular50-5911400.48(0.44-0.52)60-6922200.49(0.46-0.53)70-7928530.61(0.57-0.66)80-8919760.71(0.64-0.79)0.250.350.50.71.0B:usual diastolic blood pressure(75 mmHg)Hazard ratio(95%CI)for 10 mmHgLower usual diastolic blood pressureLancet 2002,360:1903脑卒中脑卒中 冠心病冠心病SBP 89%93%DBP 8

8、3%73%PP 37%43%MAP 100%97%Mid BP 100%100%Lancet 2002,360:1903血压分级 患者 ESRD数目 年龄校正后的 校正后的RR (n=322554)(n=814)每10万人年发生率 (95%CI)理想 61089 51 5.3 1.0正常 81621 86 6.6 1.2(0.8-1.7)正常高值 73798 134 11.1 1.9(1.4-2.7)高血压 1级（轻度）85684 275 21.0 3.1(2.3-4.3)2级（中度）23459 158 43.6 6.0(4.3-8.4)3级（重度）5464 73 96.1 11.2(7.7-

9、16.2)4级（极重度）1429 37 187.1 22.1(14.2-34.3)Klag MJ,Whelton PK,Randali BL et al,New Eng J Med.1996;334:14-18.分类 收缩压(mmHg)舒张压(mmHg)正常血压 120 和 80高血压前期 120-139 或 80-89高血压1级 140-159 或 90-99高血压2级 160 或 100 分类收缩压(mmHg)舒张压(mmHg)理想血压 120 80正常血压 120-129 80-84正常高值 130-139 85-891级高血压(轻度)140-159 90-992级高血压(中度)160-

10、179 100-1093级高血压(重度)160 110单纯收缩期高血压 140 90110110119120129130139140149150159160+SBP,mm Hg%of men302520151050Adjusted relative risk5432107070747579808485899094100+DBP,mm Hg%of men302520151050Adjusted relative risk32.521.510.509599MRFIT:Arch Intern Med 1993;153:598正常血压者临界血压者正常血压者临界血压者90%10%47%53%降压治疗临床

11、试验荟萃分析结果降压治疗临床试验荟萃分析结果T=treatmentC=controlNon-fatal eventsFatal eventsTCTCTCTCNumbers individuals020040060080010001200%reductionin oddsStroke39%CHD16%Vascular deaths21%All other deaths2%0.080.060.040.020012345Years after randomizationIschemic StrokeHemorrhagic StrokePlacebo TreatmentActive Treatment

12、Cumulative Stroke RateSHEP study:JAMA 2000;284:2651.82.310.90.811.41.10.50.60.3600.511.522.5EWPHESTOPSHEPSyst-EurUKPDSPlaceboTherapyTrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.0

13、1.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82All cardiovascular end points199:289137:18674:94410:56932%SD 52P=0.001Fatal and non-fatal stroke103:15944:7745:59195:29537%SD 62P=0.00125%SD 82P=0.004SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.96Fatal and non-fatal MI(including sudden death)90:11259:77

14、33:44182:233Eur Heart J 1999:1(suppl):p3Eur Heart J 1999:1(suppl):p3TrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82Total mortality2

15、13:242133:13761:82397:46117%SD 62P=0.008Cardiovascular mortality90:11259:7733:44182:23325%SD 82P=0.005PROGRESS:PROGRESS:预防脑卒中再发预防脑卒中再发随访时间（年）随访时间（年）发生事件患者的比例发生事件患者的比例安慰剂组安慰剂组 治疗组治疗组危险下降危险下降28%(95%的可信限的可信限 17-38%)P0.0001Lancet 2001;358:1033-410.200.150.100.050.001234 平均下降 脑卒中 3540%心肌梗死 2025%心力衰竭 50%T

16、rialsNumber ofOdds ratios Diferecevents/paitients(95%Cls)(SD)OldNewMIDAS/NICS/VHAS15/135815/1353STOP2/CCBs369/2213362/2196NORDIL228/5471153/3157INSIGHT152/3164153/3157ALLHAT/Aml 2203/152551256/9048ELSA 17/115713/1177CCBs without CONVINCE2984/286182030/22341-3.1%(3.2)2P=0.31Heterogeneity P=0.95CONVIN

17、CE319/8297337/8179All CCBs3303/369152367/30520-2.3%(2.9)2P=0.42 Heterogeneity P=0.95UKPDS59/35875/400STOP2/ACEIs369/2213380/2205CAPPP190/5493184/5492ALLHA/Lis2203/152551314/3044ANBP2210/3039195/3044HYVET/AD30/42627/431All ACEIs3061/267842175/20626-0.4%(3.1)2P=0.89Heterogeneity P=0.90LIFE 431/4588383

18、/4605SCOPE266/2460259/2477All ARBs697/7048642/7082-9.2%(5.9)2P=0.09Heterogeneity P=0.42ALLHAT/Dox851/15268514/9067All trias 4489/532795698/67295-1.8%(2.1)2P=0.38Heterogeneity P=0.96 New drugs betterOld drugs better0123Total mortalityStaessen JA.J Hypertens 2003,21:1055TrialsNumber ofOdds ratios Dife

19、recevents/paitients(95%Cls)(SD)OldNewMIDAS/NICS/VHAS7/135810/1353STOP2/CCBs221/2213212/2196NORDIL115/5471131/5410INSIGHT52/316460/3157ALLHAT/Aml 992/15255592/9048ELSA 8/11574/1177CCBs without CONVINCE1438/309471039/246852.0%(4.4)2P=0.64Heterogeneity P=0.59CONVINCE143/8297152/8179All CCBs1581/3924411

20、91/328642.7%(4.1)2P=0.51 Heterogeneity P=0.68UKPDS32/35848/400STOP2/ACEIs221/2213226/2205CAPPP95/549376/5492ALLHA/Lis992/15255609/9054ANBP282/303984/3044HYVET/AD23/42622/431All ACEIs1539/231461365/191262.2%(4.3)2P=0.61Heterogeneity P=0.50LIFE 234/4588204/4605SCOPE152/2460145/2477All ARBs386/7048349/

21、7082-10.6%(8.1)2P=0.15Heterogeneity P=0.59All trias 2104/501152349/560230.5%(3.1)2P=0.87Heterogeneity P=0.53 New drugs betterOld drugs better0123Total mortalityTrialsNumber ofOdds ratios Diferecevents/paitients(95%Cls)(SD)OldNewMIDAS/NICS/VHAS37/135839/1353STOP2/CCBs637/2213636/2196NORDIL453/5471466

22、/5410INSIGHT397/3164383/3157ALLHAT/Aml 3941/152552432/9048ELSA 33/115727/1177CCBs without CONVINCE5498/286183983/223413.6%(2.4)2P=0.14Heterogeneity P=0.78CONVINCE365/8297364/8179All CCBs5863/369154347/305203.4%(2.3)2P=0.15 Heterogeneity P=0.86UKPDS78/358107/400STOP2/ACEIs637/2213586/2205CAPPP401/549

23、3438/5492ALLHA/Lis3941/152552514/9054ANBP2429/3039394/3044All ACEIs*5486/263584039/201952.6%(3.6)2P=0.59Heterogeneity P=0.006LIFE 588/4588508/4605SCOPE268/2460242/2477All ARBs856/7048750/7082-14.3%(5.5)2P=0.004Heterogeneity P=0.69ALLHAT/Dox2245/152681592/9067All trias*7627/5285310728/66864-1.4%(4.8)

24、2P=0.69Heterogeneity P0.0001 New drugs betterOld drugs better0123Total mortalityStaessen JA.J Hypertens 2003,21:1055收缩压下降与收缩压下降与CVD危险汇萃相关分析危险汇萃相关分析Staessen JA.J Hypertens 2003,21:1055All cardiovascular eventsDifference(referecne minus experimental in systolic pressure(mmHg)0510152025-51.501.251.000.

25、750.500.25Odd ratio(experimental/reference)p 0.0001STONEUKPDS L vs HPART2/SCATHOPEPATSSHEPPROGRESS/ComSTOP1RCT70-80HEPEWPHEMRC2MRC1ATMHSyst-EurSyst-ChinaRENAALPROGRESS/PerSTOP2/ACEISHOT L vs HINSIGMTHOT M vs HMIDAS/NICS/VHASNORDILCAPPISTOP2/CCBsUKPDS C vs AALLHAT0510152025-51.501.251.000.750.500.25O

26、dd ratio(experimental/reference)ALLHAT/Lis bLACKSALLHAT/Lis 65 yALLHAT/LisALLHAT/AmlCONVINCEABCD/NT L vs HDIABHYCARANBP2IDNT2LIFE/ALLSCOPEPREVENTELSAAASK L vs HNICOLELIFE/DMLIFE:LIFE:收缩压差值的意义收缩压差值的意义 CVD事件 0.85(0.76-0.96)0.93(0.85-1.02)Stroke 0.74(0.63-0.88)0.87(0.79-0.95)0.11 MI 1.05(0.86-1.28)0.93

27、(0.85-1.02)0.28Diabetic patients(3 mmHg)CVD事件 0.73(0.57-0.95)0.84(0.77-0.91)Stroke 0.78(0.54-1.13)0.78(0.71-0.85)0.99 MI 0.81(0.54-1.22)0.85(0.78-0.93)0.82Staessen:Eur Heart J 2003;24:504AASK ANBP2 ASCOT ALLHAT BENEDICT CONVINCE DIAB-HYCAR ELSA HYVET LIFE PHYLLIS PRIME PROGRESS RENAAL SCOPE SHELLACE

28、I vs CCB 1.12 1.01-1.250510152025303514121086420Stroke Rate in Placebo Group(per 1000 pt-yr)Stroke Prevented(per 1000 pt-yr)Lever AF.J Hypertens 1995;13(6):571Stroke0.80(0.65-0.98)CHD0.81(0.67-0.98)CHF0.78(0.53-1.15)0510152025Major CV events/1000 patient yearsTarget DBP mm Hgp=0.005 for trend 90 85

29、80 降压治疗与心血管危险控制降压治疗与心血管危险控制基本观点基本观点l 临床试验证实长期有效降压治疗能减少30%-50%心脑血管病发生率。l 降压治疗的益处主要来自血压降低。l 益处大小受患者心血管危险程度、血压控制目标 水平、治疗方案降压以外有利作用或不利作用的 影响。q高血压患者：140/90 mmHgq糖尿病和慢性肾脏疾病患者：130/80 mmHgq高血压患者140/90 mmHgq糖尿病患者130/80 mmHgJNC-7JNC-7：降压治疗流程：降压治疗流程生活方式改变生活方式改变血压未达到控制目标值血压未达到控制目标值(140/90),糖尿病和慢性肾脏病糖尿病和慢性肾脏病(18

30、0 orDBP 110No other riskfactors12 risk factors3 or more riskfactors or TODor diabetesACCV HIGH RISKV HIGH RISKV HIGH RISK V HIGH RISKHIGH RISKHIGH RISKHIGH RISK MEDIUM RISK MEDIUM RISKMEDIUM RISKLOW RISKSBP 120129 orDBP 8084SBP 130139 orDBP 8589 V HIGH RISKV HIGH RISKAVERAGE RISKLOW RISK LOW RISKAVE

31、RAGE RISKMEDIUM RISK HIGH RISK HIGH RISK q收缩压和舒张压水平(13级)q男性 55岁q女性 65岁q吸烟q血脂异常(TC 6.5 mmol/L,或LDL-C4.0 mmol/L,或HDL-C男1.0,女1.2 mmol/L)q早发心血管病家族史(发病年龄男 55岁，女 38 mm,Cornell 2440 mmmms 超声心动图:LVMI男 125,女 110 g/m2)超声有动脉壁增厚 (颈动脉IMT 0.9 mm)或粥样斑块证据 血肌酐轻度升高 (男115 133,女107 124 mmol/L)尿微量白蛋白 (30 300 mg/24h;白蛋白/

32、肌酐男 22,女31mg/g)q空腹血糖 7.0 mmol/Lq餐后血糖 11.0 mmol/Lq缺血性卒中q脑出血q短暂性脑缺血发作q心肌梗死q心绞痛q冠状动脉血运重建q充血性心力衰竭q糖尿病肾病q肾脏损害(血肌酐男133,女124 mol/L)q蛋白尿(300 mg/24h)q出血或渗出q视乳头水肿Very High RiskHigh RiskMedium RiskLow RiskStratify riskMediumMonitor BP&otherrisk factors for at least 3 monthsSBP 140or DBP 90Begin drugtreatmentSB

33、P 140and DBP 140or DBP 90Consider drugtreatmentSBP 140and DBP 90Continueto monitor 利尿剂 -阻滞剂 ACEI CCB ARB -阻滞剂 利尿剂-阻滞剂钙拮抗剂ACE抑制剂血管紧张素II受体拮抗剂o患者对某类药物的降压疗效和不良反应o药品价格o患者心血管危险因素状况o 存在TOD、心脑血管病、肾脏病和糖尿病o存在有益或限制某类降压药使用的合并症o与其它药物相互作用的可能性 l 合理的血压目标水平l 适宜的降压药物l 最佳的联合治疗方案？l 恰当的费用/效益比值Diuretics-blockers AT1-rece

34、ptor blockers -blockersCalcium antagonistsACE inhibitors合理的降压联合治疗方案合理的降压联合治疗方案 利尿剂 -阻滞剂 ACEI CCB ARB 不同点 HOT ALLHAT 起始药物 CCB 利尿剂 联合药物 阻滞剂或ACEI 交感抑制剂或阻滞剂 剂量递增 先联合後递增 先递增後联合 血胰岛素(mIU/L)9.65 11.00 9.25 8.96 0.01空腹血糖(mmol/L)5.29 5.42 5.17 5.10 0.001 血甘油三酯(mmol/L)1.52 1.95 1.58 1.66 0.001 HDL-C(mmol/L)1.

35、39 1.31 1.36 1.35 0.001 HCT/blocker ARB/CCB前 后 前 后p 建立在硬终点事件临床试验基础上的循证医学，对临床实践具有重要的指导意义。然而，临床试验显示的是治疗药物或治疗方案在特定人群中的平均效果，其结论是一种总体评价。临床医师面临的是生物个体多样化的具体患者，不可能采用同一种治疗模式，需要多种降压治疗模式。HOT治疗方案为我们提供了有重要示范意义的治疗模式。多种降压治疗模式的多种降压治疗模式的临床意义临床意义结结 论论 长期有效抗高血压治疗能显著降低心血管危险。降压治疗的益处主要来自血压降低，益处大小受患者心血管危险程度、血压控制目标水平、治疗方案降压以外有利作用或不利作用的影响。抗高血压治疗尚需进一步提高治疗益处和扩展治疗群体。