高血压治疗的坚持与改变.ppt

高血压治疗的坚持与改变,上海交通大学医学院附属瑞金医院 上海市高血压研究所 王继光 ,“Quality first” From ambiguous to clear recommendations,The “Quality First” approach,降低整个动脉系统的血压（中心动脉压vs肱动脉血压） 降低24小时血压（晨峰血压） 不宜太低，不宜太快（应遵循个体化原则） 多重危险因素干预（降脂、降糖、戒烟）,Systolic pressures (mean + 95% CI),Average : 133.5 Standard vs. 119.3 Intensive, Delta = 14.2,Mean # Meds Intensive: 3.2 3.4 3.5 3.4 Standard: 1.9 2.1 2.2 2.3,Diastolic Pressures (mean + 95% CI),Mean # Meds Intensive: 3.2 3.4 3.5 3.4 Standard: 1.9 2.1 2.2 2.3,Primary & secondary outcomes,Also examined fatal/Nonfatal HF (HR=0.94, p=0.67), a composite of fatal coronary events, nonfatal MI and unstable angina (HR=0.94, p=0.50) and a composite of the primary outcome, revascularization and unstable angina (HR=0.95, p=0.40),Primary outcome Nonfatal MI, Nonfatal Stroke or CVD Death,Total stroke,HR = 0.89 95% CI (0.73-1.07),HR = 0.59 95% CI (0.39-0.89) NNT for 5 years = 89,Mean Sitting BP,McMurray JJ et al. N Engl J Med 2010.,Extended and core CV outcomes,Placebo 693 events (14.8%) Valsartan 672 events (14.5%),Placebo 377 events (8.1%) Valsartan 375 events (8.1%),McMurray JJ et al. N Engl J Med 2010.,Exploratory outcomes: CV & total mortality,Placebo 327 events (7.0%) Valsartan 295 events (6.4%),Placebo 116 events (2.5%) Valsartan 128 events (2.8%),McMurray JJ et al. N Engl J Med 2010.,McMurray JJ et al. N Engl J Med 2010.,Adverse events of interest,*MedDRA preferred terms include: hypotension, dizziness (including dizziness exertional, dizziness postural), syncope, presyncope and shock (not otherwise specified),IDACO: 晨峰血压的预测价值,Li Y, et al. Hypertension 2010; in press.,The “Quality First” approach,选择有效药物，实现降压达标 选择长效降压药物，控制24小时血压 选择能够长期坚持使用的药物，长期、平稳控制血压 选择作用于血管的降压药物,“Quality first” From ambiguous to clear recommendations,Possible combinations of antihypertensive drugs,J Hypertens 2007;25:1105-87.,Thiazide diuretics,ACEIs,ARBs,CCBs,-blockers,-blockers,JNC指南推荐的降压治疗起始药物,NICE/BHS (2006)：降压药物推荐,A: ACEI or ARB B: -阻滞剂 C: CCB D: 利尿剂 (噻嗪类),* 与其它联合治疗方案相比，阻滞剂与利尿剂联合治疗方案会增加新发糖尿病风险,National Collaborating Centre for Chronic Conditions. Hypertension: management of hypertension in adults in primary care: partial update. London: Royal College of Physicians, 2006.,ACCOMPLISH: 主要终点及组成,复合CV发病率/死亡率 心血管死亡率 心梗 中风 不稳定心绞痛住院 冠状动脉成形术 猝死复苏成功,危险比 (95%),Aml / Ben 较好,0.80 (0.720.90) 0.80 (0.62-1.03) 0.78 (0.62-0.99) 0.84 (0.65-1.08) 0.75 (0.50-1.10) 0.86 (0.74-1.00) 1.75 (0.73-4.17),Ben / HCTZ较好,Jamerson K et al. N Engl J Med 2008;359:2417-28.,ASCOT-BPLA：一、二级终点,0.50,0.70,1.00,1.45,主要终点 非致死性MI(包括症状MI)+致死性冠心病 次要终点 非致死性MI(除外无症状MI)+ 致死性冠心病 总的冠心病终点事件 总的心血管病事件和操作 总死亡率 心血管病死亡率 致死性和非致死性脑卒中 致死性和非致死性心力衰竭,2.00,Unadjusted Hazard ratio (95% CI) 0.90 (0.79-1.02) 0.87 (0.76-1.00) 0.87 (0.79-0.96) 0.84 (0.78-0.90) 0.89 (0.81-0.99) 0.76 (0.65-0.90) 0.77 (0.66-0.89) 0.84 (0.66-1.05),Dahlf B et al. Lancet 2005:366;895-906.,氨氯地平 培哚普利较好,阿替洛尔 苄氟噻嗪较好,相对危险度 (95% CI),赖诺普利较好,氨氯地平较好,+1% (9% to +11%),CHD,+5% (3% to +13%),总死亡率,+4% (3% to +12%),联合CHD,脑卒中,联合CVD,需要住院的GI出血,心衰,心绞痛,冠脉血运重建,外周动脉疾病,0.5,1.0,2.0,+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,终点事件,差别 (95% CI),Leenen FHH, et al. Hypertension 2006;48:374-384.,ALLHAT：赖诺普利 vs. 氨氯地平,Months,Number at risk,Valsartan,Amlodipine,7596,7649,7497,7499,7458,7458,7332,7319,7205,7177,6905,6853,7065,7016,6727,6680,6141,6078,3840,3864,1532,1520,6562,6504,% of patients with 1st event,7 6 5 4 3 2 1 0,VALUE: 致死及非致死心肌梗死,0 6 12 18 24 30 36 42 48 54 60 66,缬沙坦组,氨氯地平,HR = 1.19; 95% CI = 1.02-1.38; P = 0.02,Julius S et al. Lancet. June 2004;363.,19,CCBs vs. 利尿剂/阻滞剂: 致死性与非致死性脑卒中,0,1,2,3,MIDAS/NICS/VHAS STOP2/CCBs NORDIL/Diltiazem INSIGHT/Nifedipine GITS ALLHAT/Amlodipine ELSA/Lacidipine CCBs without CONVINCE p = 0.68 CONVINCE/Verapamil SR All CCBs p = 0.39,15/1358 237/2213 196/5471 74/3164 675/15255 14/1157 1211/28618 118/8297 1329/36915,19/1353 207/2196 159/5410 67/3157 377/9048 9/1177 838/22341 133/8179 971/30520,10.2% (4.8) 2p = 0.02,7.6% (4.4) 2p = 0.07,CCBs较好,利尿剂/阻滞剂较好,利尿剂/阻滞剂,试验,事件数 / 研究对象人数,异质性检验,危险比 (95%可信区间),差别 (SD),CCBs,Staessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76., 80, 40,0,+ 40%,Syst-China: Fatal and non-fatal endpoints,Liu LS et al. J Hypertens 1998;16:1823-1829.,Placebo (n=1141),Total mortality CV mortality Stroke mortality All CV events Fatal and non-fatal stroke,Active treatment (n=1253),Placebo better,82 44 20 94 59,61 33 10 74 45,Active treatment better,-39,-39,-58,-37,-38,82 44 20 94 59,61 33 10 74 45,FEVER： 主要终点事件,Liu LS et al. J Hypertens 2005;23:2157-2172.,0,2,4,6,8,10,0,6,12,18,24,30,36,42,48,54,60,26.8%,HCTZ 非洛地平+HCTZ,随访时间（月）,主要终点（%）,Chinese Hypertension Intervention Efficacy (CHIEF)：General design,Hypertensive patients at high CV risk (n=12,000),Amlodipine 2.5 mg/d +telmisartan 40 mg/d,Amlodipine 2.5 mg/d +amiloride 1.25/ HCTZ 12.5 mg/d,Primary endpoint: CV death,