高血压并糖尿病患者需要更严格地控制血压.ppt

高血压并糖尿病患者需要更严格地控制血压,王 文 中国高血压联盟 卫生部心血管病防治研究中心 中国医学科学院阜外心血管病医院,中国35-64岁人群队列人群31728人（1992-2002） 基线血压(mmHg)与10年总心血管事件 发病的相对危险(RR),SBP 110 110- 120- 130- 140- 150- 160- 170- 180-,DBP 75 75- 80- 85- 90- 95- 100- 105- 110-,人数比例(%) 21 20 21 11 13 5 4 2 3,RR,Change of Treatment in Hypertension,Subjects BP(mmHg) 1950s- Malignant Hypertension 200 / 120 1960s- Severe Hypertension 180/110 1970s- Moderate Hypertension 160/100 1980s- Mild Hypertension 140/90 1990s- Older Systolic Hypertension 140/130 / 85 2005- DM，CHD，STK 130 / 80,血压水平定义,血压 (mmHg) SBP DBP 正常血压 120 80 正常高值 120139 8089 高血压 140 和/或 90 2005: CHL 标准;,108/903,96/1059,55/1005,10.3%,7.8%,4.9%,BP,Vascular events(%) 非高血压者的心血管事件,Yeas,Fig 7. Cumulative incidence of vascular events for 10 years in 2967 men from Framingham Heart Study,PROGRESS国际结果,治疗组 对照组 危险下降% 脑卒中事件: 高血压(n=2916) 163 235 32 非高血压(n=3187) 144 185 27 重要血管事件: 高血压(n=2916) 240 331 29 非高血压(n=3187) 218 273 24,糖尿病平均收缩压(mmHg)与脑卒中发生率(%),UKPDS: 4801例糖尿病 (50-54岁) 随访10年,SBP,14.4,20.3,22.2,23.8,29.1,36.2,0,5,10,15,20,25,30,35,40,总死亡(%),UKPDS: 糖尿病m SBP水平与死亡率关系 （随访10年）,UKPDS-38: 强化降压与糖尿病大血管及微血管事件,（R Turner, UK BMJ 1998;317:703) 对象 (入选间期19771991年) 1148例高血压伴2DM,758例强化降压, 390例非强化降压治疗, 随访8.4年。 治疗： 强化降压400例ACEI，358例阻滞剂； 非强化390例，避免ACEI/阻滞剂,UKPDS-38：基线特征,强化降压（n758） 非强化（n390） 平均年龄（岁） 56.4 56.5 男 （） 54 56 BMI（kg/m2） 29.8 29.3 SBP（mmHg） 15920 16018 DBP (mmHg) 9410 949 吸烟（） 23 22 降压治疗史（） 66 67,UKPDS-36： 2DM随访10年SBP与事件（1/1000人年）,SBP DM并发症 死于DM 总死亡 心梗 卒中 微血管病 外周血管病 心衰 (mmHg) 120 22.9 4.3 6.9 9.4 5.7 120-129 28.5 5.7 12.8 10.3 1.8 7.2 0.6 1.3 130-139 37.7 10.0 15.9 13.8 3.6 9.3 1.5 3.0 140-149 45.4 10.8 19.2 16.2 6.0 11.1 1.4 3.5 150-159 53.3 15.5 24.5 19.3 8.3 11.6 1.8 5.1 160 58.3 19.9 29.4 21.6 11.0 14.6 2.8 6.4 (5054岁，4801人)（BMJ，2000，321：412）,UKPDS-36: SBP与10年事件,UKPDS-38：血压差别12/5mmHg (144/82 vs 156/87 mmHg),UKPDS-38：终点事件（强化 VS 非强化）,UKPDS-38：有关糖尿病临床终点,UKPDS-38：血管性死亡 （心梗、猝死、卒中、周围血管病、肾衰）,UKPDS-38：微血管终点(眼底激光)、 心梗/猝死、卒中事件,ADVANCE: a factorial randomised trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes,Effects of a fixed combination of the ACE inhibitor, perindopril, and the diuretic, indapamide on major vascular events,ADVANCE：Baseline characteristics,Blood pressure reduction, 2.2 mmHg (95% CI 2.0-2.4); p0.001, 5.6 mmHg (95% CI 5.2-6.0); p0.001,Diastolic,Systolic,Placebo,Perindopril-Indapamide,Mean Blood Pressure (mmHg),65,75,85,95,105,115,125,135,145,155,165,Follow-up (Months),R,6,12,18,24,30,36,42,48,54,60,SBP,ADVANCE BP reduction in context: UK Prospective Diabetes Study,UK Prospective Diabetes Study,All-cause mortality,Follow-up (months),0,10,0,6,12,18,24,30,36,42,48,54,60,Cumulative incidence (%),Relative risk reduction 14%: 95% CI 2-25% p=0.025,5,Deaths,Cardiovascular,Follow-up (months),6,12,18,24,30,36,42,48,54,60,Placebo,Perindopril-indapamide,Non-cardiovascular,Follow-up (months),6,12,18,24,30,36,42,48,54,60,Placebo,Perindopril-indapamide,Relative risk reduction 18%; p=0.027,Relative risk reduction 8%; p=0.41,5%,5%,Cumulative incidence (%),Effects by age, sex, BP and HbA1c Combined primary endpoint,Phomogeneity all 0.1,2.0,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Hazard ratio,0.5,1.0,Age (years), 65,325,346,6% (-10 to 19),= 65,536,592,11% (0 to 21),Sex,Male,546,594,10% (-1 to 20),Female,315,344,8% (-7 to 21),SBP (mmHg), 140,309,341,10% (-5 to 23), 140,552,597,9% (-2 to 19),History of hypertension,No,121,136,9% (-17 to 29),Yes,740,802,9% (0 to 18),HbA1c (%), 7.5,406,456,9% (-4 to 20), 7.5,451,481,11% (-1 to 22),All participants,861,938,9% (0 to 17),Coronary events,*2P=0.02,Non-fatal MI or death from coronary heart disease Unstable angina requiring hospitalisation, coronary revascularisation or silent MI,Major coronary heart disease,265,294,11% (-6 to 24),All coronary heart disease,468,535,14% (2 to 24),Other coronary heart disease,283,324,14% (-1 to 27),*,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Hazard ratio,0.5,1.0,2.0,Cerebrovascular events,Major cerebrovascular disease,215,218,2% (-18 to 19),All cerebrovascular disease,286,303,6% (-10 to 20),Other cerebrovascular disease,79,99,21% (-6 to 41),2.0,*,*2P=0.40,Non-fatal stroke or death from cerebrovascular disease Transient ischaemic attack or subarachnoid haemorrhage,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Hazard ratio,0.5,1.0,Renal events,2.0,Hazard ratio,0.5,1.0,New or worsening nephropathy,181,216,18% (-1 to 32),New microalbuminuria,1094,1317,21% (14 to 27),Total renal events,1243,1500,21% (15 to 27)*,*2P=0.01,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Eye events,2.0,Hazard ratio,0.5,1.0,*2P=0.09,New or worsening eye disease,289,286,-1% (-18 to 15),Visual deterioration,2446,2514,5% (-1 to 10),Total eye events,2531,2611,5% (-1 to 10)*,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,ADVANCE Summary,Routine treatment of type 2 diabetic patients with perindopril-indapamide resulted in: 14% reduction in total mortality 18% reduction in cardiovascular death 9% reduction in major vascular events 14% reduction in total coronary events 21% reduction in total renal events,Benefits appeared to be similar in all major subgroups. Treatment was very well tolerated, with few side effects and adherence similar to that with placebo.,*mostly new onset microalbuminuria,Absolute benefits of routine treatment with perindopril and indapamide,脑卒中: ABCD HOT UKPDS,严格降压,常规降压,Relative Risk ( 95% CI ),0.98 (0.402.43),0.80 (0.411.56),0.56 (0.370.90),严格降压与常规降压对糖尿病患者脑卒中事件的影响,心血管总事件： ABCD HOT UKPDS,严格降压,常规降压,Relative Risk ( 95% CI ),0.91 (0.601.37),0.67 (0.451.00),0.69 (0.550.86),严格降压与常规降压对糖尿病患者心血管事件的影响,卒中,DM 终点,DM 死亡,微血管病,UKPDS: 严格降糖与严格降压治疗终点减少(%)的比较 4800例 糖尿病治疗随访10年,*,*,*,*,ACCORD: 糖尿病心血管危险控制研究,目的：比较HbA1c140mmHg的降压效果； 对象：美加77个医疗单位随机10251例2MD伴CVD危险。 终点：主要心血管事件（卒中，心梗，心性死亡） 计划：2001-2009， 提前终止强化降糖试验2008年2月 结果：强化降糖组死亡257例，标准组203例，增加死亡危险 21%,ADVANCE降糖研究,降糖目标：HbAic 6.5 % 达标率 国际65%，中国70% HbAic 组间差别目标 1 % 差值 国际0.7 %, 中国0.8 % 降糖结果： 2008-6-4 ADA会前发布,糖尿病治疗目标,血压：1g/d） 血压低限：120 / 60-70 mmHg（可耐受） HbA1c 7.0% (6.07.0%) TC 4.5 mmol/L BMI 25 kg/m2,糖尿病降压治疗原则,首选ACEI或ARB 要使血压达标，往往需联合治疗，可加钙拮抗剂，利尿剂。 初用ACEI/ARB后24周，复查血钾、肌酐，肌酐升高30则减量或停用。,国家“十一五”科技支撑项目 CHIEF ：高血压综合防治研究,牵头单位：中国医学科学院阜外心血管病医院 课