ACEI与ARB.pptx

ACEI与ARB,山东省立医院心内科 韩伟中,.,Introduction,The reninangiotensinaldosterone system (RAAS） maintaining haemodynamic stability in the human body through regulation of arterial blood pressure, water and electrolyte balance,Current concept of the RAAS,RAAS: an important therapeutic target,direct renin inhibitor (DRI), ACEI ARB aldosterone antagonist (AA),ACEI/ARB on hypertension,THE BLOOD PRESSURE INDEPENDENT EFFECT: ACEI, ARB OR BOTH?,Anti-hypertensive therapy has been shown to reduce the risk of stroke (3540%), myocardial infarction (2025%) and heart failure ( 50%) blood pressure independent effect, whereby the observed cardio vascular benefit exceeds the benefits that would be attributed to the observed reduction of blood pressure alone,HOPE, EUROPA, PEACE there was an 18% relative reduction in cardiovascular mortality, MI, and stroke, despite the achievement of only modest blood pressure reductions,Only ACEI,2007, Journal of Hypertension, meta analysis which included over 26 trials , demonstrated that despite comparable blood-pressure-dependent effects on overall risk of coronary events, stroke, and heart failure between ACEIs and ARBs ACEIs were associated with an additive 9% relative risk reduction of coronary events, independent of a reduction in blood pressure,ARB-MI Paradox,2004, VALUE, a multinational study of over 15 000 high-risk hypertensive patients randomized to valsartan or amlodipine who were followed over a mean of 4.2 years for time to the primary endpoint a composite of cardiovascular mortality and morbidity,ARB-MI Paradox,At its conclusion, there was no difference noted in the primary endpoint. VALUE received a considerable amount of attention for the secondary endpoint findings on rate of MI between the valsartan group (4.8%) and amlodipine group (4 .1%) accounting for a 19% relative increase in risk of MI,Debate,A publicized editorial in a 2004 issue of the British Medical Journal by Verma and Strauss The debate played out in a 2006 issue of Circulation, in which two groups of authors debated the ARB-MI Paradox,) there was no major difference in the composite primary outcome of MI, stroke, cardiovascular death, or all-cause death II) analysis of the endpoint of MI alone did not reveal an incremental risk of MI between the ARB and ACEI,These findings allayed concerns that ARB use increased the risk of cardiovascular outcomes It also failed to demonstrate a cardioprotective effect Despite the fact that patients in the telmisartan arm had consistently lower mean blood pressure measurements (0.9/0.6 mmHg) than with ACEI,Possible mechanisms,New Progress,included a total of 37 randomized controlled trials, with 147 020 patients followed on average for 3.3 years comparing cardiovascular outcomes between ARB therapy and control therapies,CONCLUSION,ARBs and ACEI both modulate RAS activity and angiotensin II effects Blood-pressure independent effect which appears to belong to the ACEI class, not ARB,CONCLUSION,ARB appear to have a neutral effect upon modifyi