钙拮抗剂降压治疗地位进展课件

1、钙拮抗剂降压治疗地位进展钙拮抗剂降压治疗地位进展 从循证证据和国际治疗指南的角度从循证证据和国际治疗指南的角度影响不同种类降压药物治疗地位的决定因素影响不同种类降压药物治疗地位的决定因素 禁忌症禁忌症 循证医学证据循证医学证据 不良反应和治疗持续性不良反应和治疗持续性 效益效益/ /费用费用 种族种族各类降压药物的禁忌症各类降压药物的禁忌症(ESC/ESH,2007)(ESC/ESH,2007)噻嗪类利尿剂 痛风 代谢综合症、糖耐量减低 妊娠-阻滞剂 哮喘、 外周血管病、代谢综合症 糖耐量异常、慢阻肺 A-V阻滞(2或3度) 运动员和强体力活动者 二氢吡啶类CCB 快速性心律失常、心力衰竭 非

2、二氢吡啶类CCB A-V阻滞(2或3度) 心力衰竭 ACEI和ARB 妊娠、高血钾症 双侧肾动脉狭窄醛固酮拮抗剂 肾功能衰竭 高血钾症 绝对(强制) 相对(可能) BP-Lowering Treatment Trialists (WHO/ISH, 2003)Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.0.51.02.0Relative RiskBlood Pressure Lowering Treatment Trialists Collaboration. Lanc

3、et. 2003;362:1527-1535.BP-Lowering Treatment TrialistsComparisons of Different Active Treatments RR (95% CI) Favours first listed Favours second listed0.51.02.0Relative RiskBP difference(mm Hg) 1.09 (1.00,1.18) ACEI vs. D/BB 0.93 (0.86,1.01) CA vs. D/BB 1.12 (1.01,1.25) ACEI vs. CA2/01/01/1BPLTT (20

4、03): StrokeComparisons of different active treatmentsBlood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.Odds ratio for CHDACE IsSystolic BP difference between groups (mmHg) Verdecchia et al 2005CCBsRelationship Between Odds Ratio for CHD and Achieved BP Differences

5、CCBs and CV OutcomesNew Meta-Analysis (ACC, 2009)在在BPLTT的基础上，纳入了的基础上，纳入了2003年以后发表的年以后发表的临床试验：临床试验：ACTION, ASCOT-BPLA, CAMELOT, CASE-J, FEVER, INVEST, MOSES, HICOLE, VESPACCBs and CV OutcomesNew Meta-Analysis (ACC, 2009)CCB vs. ACEI OR ( 95% CI )Stroke 0.87 (0.78-0.97)MI 1.06 (0.98-1.18)无强制指征无强制指征Sta

6、ge 1 HypertensionThiazide-type diuretics for most. May consider ACEI, ARB, BB,CCB, or combination.Stage 2 Hypertension2-drug combination for most ( thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)JNC-7：降压治疗流程：降压治疗流程JNC Recommendations for an Initial Antihypertensive AgentCommittee Year Recomm

7、endationJNC 1 1977 Thiazide-type diureticJNC 2 1980 DiureticJNC 3 1984 Thiazide-type diuretic or BBJNC 4 1988 Diuretic or BB or CCB or ACEIJNC 5 1993 Diuretic or BBJNC 6 1997 Diuretic or BBJNC 7 2003 Thiazide-type diuretic, either alone or in combination with ACEI.ARB,BB,or CCB 各类降压药物治疗高血压的地位各类降压药物治

8、疗高血压的地位 利尿剂 -阻滞剂 ACEI CCB ARB -阻滞剂(ESC/ESH, 2007) 利尿剂-阻滞剂钙拮抗剂ACE抑制剂血管紧张素II受体拮抗剂两药低剂量联合治疗两药低剂量联合治疗2007ESH/ESC2007ESH/ESC指南推荐的降压治疗模式指南推荐的降压治疗模式 -blockersAngiotensin receptorantagonistsThiazide diureticsCalcium antagonistsACE inhibitors-blockers合理的降压联合治疗方案合理的降压联合治疗方案A: ACE Inhibitor or Angiotensin Rece

9、ptor Blocker B: -BlockerC: Calcium Channel Blocker D: Diuretic (Thiazide)BHS IV (2001) Recommendations for Blood Pressure Lowering DrugsNICE / BHS (2006)Management of Hypertension In hypertensive patients aged 55 or over, or Black patients of any age, first-choice initial therapy should be a dihydro

10、pyridine calcium channel blocker; a thiazide-type diuretic is an alternative.NICE / BHS (2006)Management of HypertensionJapanese Guidelines for the Management of Hypertension(JSH, 2004 and 2009) 对对大多数高血压患者，推荐钙拮抗大多数高血压患者，推荐钙拮抗剂作为初始治疗或联合治疗的药物，除剂作为初始治疗或联合治疗的药物，除了禁忌症和不能耐受治疗的患者。了禁忌症和不能耐受治疗的患者。心血管病预防指南心血管病预防指南(WHO/ISH,2007)(WHO/ISH,2007)降压药物的选择降