高血压合并多重危险因素及靶器官损害患者的治疗指南葛世俊

高血压合并多重危险因素及靶 器官损害患者的治疗指南 葛世俊 宁波市李惠利医院心内科 BMJ 2003;326:1419 A strategy to reduce cardiovascular disease by more than 80% 减少心血管疾病 80%以上的策略 polypill策略 : 同时针对四种危险因素 : low density lipoprotein cholesterol blood pressure serum homocysteine platelet function) 方法 :meta-analyses of randomised trials and cohort studies and a meta- analysis of 15 trials of low dose (50-125 mg/day) aspirin 结果 : Polypill组成 : 1. a statin (for example, atorvastatin (daily dose 10 mg) or simvastatin (40 mg); 2. three blood pressure lowering drugs (for example, a thiazide, a blocker, and an angiotensin converting enzyme inhibitor), each at half standard dose; 3. folic acid (0.8 mg); 4. aspirin (75 mg). 估计 : Polypill减少缺血性心脏病 88%(84% to 91%) .减少中风 80% (71% to 87%). 三分之一 55岁或以上人群能得益 .平均延长 无缺血性心脏病和中风寿命 11年 . 降压抗动脉粥样硬化：降低心血管病超过 80% BMJ. 2003;326:1419 0% 20% 40% 60% 80% 100% 0% 20% 40% 60% 80% 100% 风险降低 (%) 缺血性心脏病 46% 降压药 他汀 阿司匹林 叶酸 总计 卒中 降压药 他汀 阿司匹林 叶酸 总计 61% 32% 16% 88% 63% 17% 16% 24% 80% 风险降低 (%) 该论文意义在于提出了多重危险因素干预 的概念 (multifactorial interventions ) 多重危险因素干预的理由主要有 : 1、心血管疾病的主要敌人是动脉粥样硬化 2、 心血管危险因素有聚集性 3、干预单一危险因素效果并不理想 Most Patients Have Overlapping CV Risk Factors Of all Hypertensives 65% have dyslipidemia 16% have type 2 diabetes 45% are overweight / obeseOf all Dyslipidemics 48% have hypertension 14% have type 2 diabetes 35% are overweight / obese Of all Type 2 Diabetics 60% have hypertension 60% have dyslipidemia 90% are overweight / obese Hypertension Type 2 Diabetes Dyslipidemia Multiple comorbidities increases risk 400-700% 1 Based on Framingham risk 高血压人群中，动脉粥样硬化的发生率更高 Prevention and Control (2005) 1, 315 PDAY研究 (Pathobiological Determinants of Atherosclerosis in Youth Study) 全球 15个国家的 18个临床中心 1277名因外伤死亡的人群（年龄 15-34岁） P 115 mmol/l (1.3 mg/dl) Therefore, treatments witha low-dose aspirin have favourable benefit/risk ratios only if given to patients above a certain threshold of total cardiovascular risk (1520% in 10 years). To minimize the risk of haemorrhagic stroke, antiplatelet treatment should be started after achievement of BP control. 2007 Guidelines for the Management of Arterial Hypertension Subclinical organ damage 、 L