从高血压到心力衰竭挑战与对策课件幻灯

从高血压到心力衰竭 挑战与对策,1. McKee et al. N Engl J Med. 1971;285:1441-1446. 2. Levy D. JAMA 1996;275:1557-1562.,高血压: 心力衰竭的主要危险因素 Framingham Heart Study,Framingham 随访研究的资料显示，高血压 是心力衰竭发生的主要危险因素。 约90%的心力衰竭患者，在发生心力衰竭前 曾有高血压史。,Lloyd-Jones et al. Circulation 2002;106: 3068-3072.,3343 men and 4199 women followed for 25 years no HF at baseline,血压水平与心力衰竭危险,Years,Normal LV Subclinical Clinical heart LV structure remodeling LV dysfunction failure & function,Heart failure,Obesity Diabetes,HTN,Smoking Dyslipidemia Diabetes,MI,LVH,Diastolic dysfunction,Years/months,Systolic dysfunction,Death,Vasan RS et al. Arch Intern Med. 1996;156:1789-1796.,HTN = Hypertension MI = Myocardial Infarction LVH = Left ventricle hypertrophy,高血压如何进展到心力衰竭,因心力衰竭首次住院患者 左心室射血分数,HF BY EF LEVEL,N=1399,EF40%,EF 40-49%,EF50%,心力衰竭预后：人群研究,随访(年) 死亡率(%),HF-REF HF-PEF,Olmsted(1998) 5.0 65 65 Framingham(1999) 6.2 75 46 Helsinki(1997) 4.0 54 43,心力衰竭预后：临床研究荟萃分析 (Somaratne, 2008),17项研究，24501例，平均治疗随访47个月 38%患者死亡，RF-REF 40%，HF-PEF 32%,降压治疗有效降低心、脑血管病事件 17项临床试验荟萃分析,-50,-40,-30,-20,-10,0,Heart failure1,Fatal/Nonfatal stroke1,Fatal/Nonfatal CHD1,Risk reduction (%),1. Moser and Herbert. J Am Coll Cardiol. 1996; 2. Collins R et al. Lancet 1990.,Vascular deaths,-52%,-38%,-16%,-21%,HYVET: Heart Failure,placebo active,- Placebo _ Active,Stroke,Systolic BP Difference Between Randomized Groups (mm Hg),Systolic BP Difference Between Randomized Groups (mm Hg),0.25,0.50,0.75,1.00,1.25,1.50,CHD,A = CA vs placebo; B = ACE inhibitor vs placebo; C = more intensive vs less intensive blood- pressure-lowering; D = ARB vs control; E = ACE inihibitor vs CA; F = CA vs diuretic or -blocker; G = ACE inhibitor vs diuretic and -blocker. Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,RR of Outcome Event,RR of Outcome Event,BP-Lowering Treatment Trialists,A = CA vs placebo; B = ACE inhibitor vs placebo; C = more intensive vs less intensive blood- pressure-lowering; D = ARB vs control; E = ACE inihibitor vs CA; F = CA vs diuretic or -blocker; G = ACE inhibitor vs diuretic and -blocker. Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,BP-Lowering Treatment Trialists,ACEI vs. placebo CA vs. placebo More vs. less ARB vs. control ACEI vs. D/BB CA vs. D/BB ACEI vs. CA,219/8233 104/3382 54/7494 302/5935 547/12498 732/23425 502/10357,269/8246 88/3274 72/13394 359/5919 809/18652 850/29734 609/10345,-5/-2 -8/-4 -4/-3 -2/-1 +2/0 +1/0 +1/+1,0.82 (0.69-0.98) 1.21 (0.93-1.58) 0.84 (0.59-1.18) 0.84 (0.72-0.97) 1.07 (0.96-1.19) 1.33 (1.21-1.47) 0.82 (0.73-0.92),Heart Failure,Events/participants,1st Listed,2nd Listed,Difference in BP (Mean, mmHg),Relative risk (95% CI),Relative Risk,Favours 1st listed,Favours 2nd listed,1. Table adapted from Blood Pressure Lowering Trialists Collaboration. Lancet. 2003;362:1527-1535. 2. Gottdiener JS et al. Ann Intern Med. 2002;137:631-639.,ACEI = ACE inhibitor CA = calcium antagonist ARB = angiotensin receptor blocker D/BB = diuretic or beta blocker,Effects of antihypertensive treatment on the development of HF in hypertensive patients,ALLHAT: 住院心力衰竭发生率,Davis BR, et al. Circulation 2008;118:,Chlorthalidone,Lisinopril,Amlodipine,ALLHAT: 住院HF-REF发生率,Davis BR, et al. Circulation 2008;118:,Chlorthalidone,Amlodipine,Lisinopril,ALLHAT-HF: 住院HF-PEF发生率,Davis BR, et al. Circulation 2008;118:,Chlorthalidone,Amlodipine,Lisinopril,Lewis et al. N Engl J Med. 2001;345:851-860.,Proportion With Death From Any Cause (%),Follow-up (months),0.6,0.5,0.4,0.3,0.2,0.1,0.0,0,6,12,18,24,30,36,42,48,54,Amlodipine,Placebo,Irbesartan,IDNT: No Significant Difference in Death From Any Cause,0,6,12,18,24,30,36,42,48,54,Follow-up (mo),60,30,0,10,20,Irbesartan Amlodipine Control,RRR 37% p 0.001,RRR 23% p = 0.15,Subjects (%),Lewis EJ et al. N Engl J Med 2001;345(12):851-60.,IDNT: Time to CHF,Meta-regression analysis: Relation between odds ratios for CHF and differences in achieved SBP between randomized groups,Verdecchia P, et al. Eur Heart J. 2009;30:679-688., 病程早期 阻止病情进展和逆转靶器官结构与功能损害, 病程中晚期 预防心、脑血管病和肾脏病终点事件,降压治疗目标的演进与转移: 不同病程阶段的目标,Devereux R, et al. JAMA. 2004;292:2350-2356,Hazard Ratio: 0.58 (0.38-0.86) p .008,LIFE-ECHO substudy Impact on LVH regression on outcomes,Long-term antihypertensive tre