降压治疗中的JCurve现象

1、降压治疗中的降压治疗中的j-curve现象现象上海交通大学医学院附属瑞金医院上海交通大学医学院附属瑞金医院上海市高血压研究所上海市高血压研究所王继光王继光cv eventsbp血压与心血管风险的血压与心血管风险的j 形曲线关系形曲线关系nobservational studiesnrandomized controlled trialsnthe strategy to avoid j-curve psc: stroke mortality and usual bp80-89 y70-79 y60-69 y50-59 yage at risk:stroke mortality(floating

2、absolute risk and 95% ci)2561286432168421120140160180usual sbp (mm hg)80-89 y70-79 y60-69 y50-59 yage at risk:7080901001102148163264128256systolic blood pressurediastolic blood pressureusual dbp (mm hg)prospective studies collaboration. lancet 2002; 360: 190313.80-89 years70-79 years60-69 years50-59

3、 years40-49 years25612864328421!708090100110!diastolic blood pressureage at risk:1625612864328421120140160180!80-89 years70-79 years60-69 years50-59 years40-49 yearssystolic blood pressureage at risk:16psc: ihd mortality and usual bpihd mortality(floating absolute risk and 95% ci)usual sbp (mm hg)us

4、ual dbp (mm hg)prospective studies collaboration. lancet 2002; 360: 190313.apcsc: stroke and usual bp 64.032.016.0 8.0 4.0 2.0 1.0 0.5 0.25110120130140150 160 170usual systolic blood pressure (mmhg)lllllllage at risk 70 years60-69 years60 to 7070 to 8080 to 9090 to 100100 to 110 11005101520253035随访期

5、间的平均舒张压随访期间的平均舒张压 (mm hg)mi and stroke by average follow-up dbp in investmesserli fh et al. ann intern med 2006;144:88493.高血压合并冠心病患者降压治疗高血压合并冠心病患者降压治疗130/80缺血性心脏病心衰缺血性心脏病心衰130/80stemi不稳定性心绞痛或不稳定性心绞痛或nstemi130/80 or 120/80稳定性心绞痛稳定性心绞痛not 60 mm hgslowly130/80合并冠心病危险因素合并冠心病危险因素特别特别注意注意降压降压速度速度降压治疗目标降压治

6、疗目标血压血压(mm hg)冠心病不同阶段冠心病不同阶段rosendorff c et al. circulation 2007.not 60 mm hgnot 60 mm hgnot 60 mm hgnot 60 mm hgslowlyslowlyslowlyslowly130/80 or 120/80nobservational studiesnrandomized controlled trialsnthe strategy to avoid j-curve 血压与心血管风险血压与心血管风险76543210100110120130140150160 170 180 190 200sbp

7、(mm hg)relative benefit1.000.850.700.550.400.250.100.3valish: 血压血压ogihara t, et al. hypertension. 2010;56:196-202.valish: 心血管事件心血管事件ogihara t, et al. hypertension. 2010;56:196-202.navigator: mean sitting bpmcmurray jj et al. n engl j med 2010.navigator: primary & secondary outcomes valsartan valsart

8、an events events (%/yr)(%/yr)placeboplaceboevents (%/yr)events (%/yr)hr (95% ci)hr (95% ci)p pprimary - extended672 (2.62)693 (2.69)0.96 (0.86-1.07)0.43primary core cv375 (1.40)377 (1.40)0.99 (0.86-1.14)0.85fatal and nonfatal mi138 (0.51)140 (0.51)0.97 (0.77-1.23)0.83fatal and nonfatal stroke105 (0.

9、38)132 (0.48)0.79 (0.61-1.02)0.07mcmurray jj et al. n engl j med 2010.accord: systolic pressures (mean + 95% ci)average : 133.5 standard vs. 119.3 intensive, delta = 14.2mean # meds intensive: 3.2 3.4 3.5 3.4 standard: 1.9 2.1 2.2 2.3n engl j med 2010;362:1575-85.accord: primary & secondary outcomes

10、 intensive intensive events (%/yr)events (%/yr)standardstandardevents (%/yr)events (%/yr)hr (95% ci)hr (95% ci)p pprimary208 (1.87)237 (2.09)0.89 (0.73-1.07)0.20total mortality150 (1.28)144 (1.19)1.07 (0.85-1.35)0.55cardiovascular deaths60 (0.52)58 (0.49)1.06 (0.74-1.52)0.74nonfatal mi126 (1.13)146

11、(1.28)0.87 (0.68-1.10)0.25nonfatal stroke34 (0.30)55 (0.47)0.63 (0.41-0.97)0.03total stroke36 (0.32)62 (0.53)0.59 (0.39-0.89)0.01n engl j med 2010;362:1575-85.systolediastole2nd shoulder1st shoulder增强压力增强压力augmentation pressure (ap)脉压脉压(pp)射血期射血期(msec)舒张期舒张期 incisurastart of the wave中心动脉压力波形中心动脉压力波形

12、p1aix = ap / pp080859095100105036122436finalhot: diastolic bp (% patients reaching target)target 80 mm hgtarget 85 mm hgtarget 65岁age: 24d: 7.0 mmd: 605 mqcs: 1.9age: 45d: 7.5 mmd: 281 mqcs: 4.0patientd: 6.3 mmd: 124 mqcs: 6.9normalhighvery high25rfqcs - 1215quality carotid stiffness正常凋亡率： 3%维持内皮层稳定

13、过度凋亡发生粥样硬化 对抗动脉硬化内皮细胞凋亡和动脉硬化形成斑块、斑块破裂内皮的连续性the “quality first” approachn选择有效药物，实现降压达标选择有效药物，实现降压达标n选择长效降压药物，控制选择长效降压药物，控制24小时血压小时血压n选择能够长期坚持使用的药物，长期、平稳控制血压选择能够长期坚持使用的药物，长期、平稳控制血压n选择作用于血管的降压药物选择作用于血管的降压药物在观察研究中，将不同血压水平者进行对比，血压较高者心在观察研究中，将不同血压水平者进行对比，血压较高者心血管风险也较高。血管风险也较高。在降压治疗临床试验中，在将血压降低到在降压治疗临床试验中，在将血压降低到140/90 mm hg以以下后进一步降低血压时，对特定的患者、特定并发症或特定下后进一步降低血压时，对特定的患者、特定并发症或特定的降压方式，都可