降压治疗研究新动态回顾与展望课件

1、降压治疗研究新动态 回顾与展望 80岁以上高龄高血压 (HYVET) 高血压前期 (TROPH, PHARAO) 心房颤动 (ADVANCE post hoc)新动态(一): 扩展降压治疗获益人群1.00.90.80.70.60.50.40.30100200300400500600700800900100011001200DaysControlRamiprilSurvival functionPHARAO Study: Primary EndpointDevelopment of HypertensionHazard ratio0.656(0.533-0.807)Luders S, et al

2、. J Hypertens. 2008;26:1487-1496* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *604020090100120130140160170180190200220230240PrehypertensionUncertainty Range 55 75% of the general population% of screened populationNormotensionPrehypert

3、ensionMasked HypertensionSustainedHypertensionMixed population with WhiteCoat Hypertension and SustainedHypertension (FPs & TPs)Masked Hypertension (office BP 140/90 mmHg) (FNs)ADVANCE-AF 研究 11140例2型糖尿病，心房颤动占7.6%。 perindopril / indapamide 降压治疗4.3 年， 治疗组血压比对照组降低 5.3 / 2.3 mmHg。 心房颤动患者降压治疗后总死亡率与心 血管死亡

4、率分别降低14%与18%，NTT 42。Eur Heart J. 2009; March 12. online publication.The ACTIVE Steering Committee. Am Heart J. 2006; 151:1187-93Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events 脑卒中史 (PROGRESS再分析, WASID) 糖尿病 (ADVANCE)新动态(二): 心血管高危患者强化血压控制10.90.80.70.60.50.40.30.

5、20.10012345Follow-up (yrs)P0.000110.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)Probability of Ischemic StrokeP0.000110.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)Probability of Ischemic Stroke in Territory10.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)P0.0065Probability of Ischemic Stroke

6、 in TerritoryP0.0001Probability of Ischemic Stroke=160SBP=160SBPDBP=90DBP=90Turan NT, et al. Circulation. 2007;115:2969-2975WASIDHazard Ratios for Ischemic Stroke According to SBP and DBP No. of events/patientsMedianFavorsFavorsHazard ratio P forPer-IndPlaceboBlood pressurePer-Indplacebo(95% CI) tre

7、ndAll renal eventsAll participants1243/55691500/55710.79 (0.73 to 0.85)Baseline systolic blood pressure (mmHg)120134/615167/560113 mmHg0.70 (0.56 to 0.88)0.75120-139367/1736431/1793131 mmHg0.85 (0.74 to 0.97)140-159439/1945563/2003149 mmHg0.75 (0.66 to 0.85)160303/1273339/1215172 mmHg0.81 (0.70 to 0

8、.95)Baseline diastolic blood pressure (mmHg)70208/846240/88166 mmHg0.84 (0.70 to 1.02)0.8570-79387/1748481/175875 mmHg0.77 (0.67 to 0.88)80-89386/1862479/183484 mmHg0.76 (0.66 to 0.87)90262/1113300/109895 mmHg0.81 (0.69 to 0.96)All renal events, macrovascular events, all-cause deathAll participants1

9、781/55692064/5571 0.82 (0.77 to 0.88)Baseline systolic blood pressure (mmHg) 120190/615205/560113 mmHg0.82 (0.68 to 1.00) 0.35120-139527/1736590/1793131 mmHg0.89 (0.79 to 1.00)140-159615/1945771/2003149 mmHg0.77 (0.69 to 0.86)160449/1273498/1215172 mmHg0.81 (0.72 to 0.93)Baseline diastolic blood pre

10、ssure (mmHg)70 304/846352/88166 mmHg 0.85 (0.73 to 1.00) 0.6070-79551/1748637/175875 mmHg0.83 (0.74 to 0.93)80-89554/1852651/183484 mmHg0.81 (0.72 to 0.90)90372/1113424/109895 mmHg0.81 (0.71 to 0.94)0.51.02.0Hazard ration (95% CI)ADVANCE: Baseline BP and Outcome EventsDe Galan BE, et al. J Am Soc Ne

11、phrol. 2009; Feb.18, online10987654100110120130140150160170Achieved systolic blood pressure (mmHg)Annual patient event rate (%)Median systolic bloodPressure (mmHg)106116125135144154168No. of person-Years14314266897411983913849423470ADVANCE: Achieved BP levels and all renal eventsDe Galan BE, et al.

12、J Am Soc Nephrol. 2009; Feb.18, onlineDiureticsACE inhibitorsorARBsCalciumantagonistsInitial Combinations of Medications for Management of Hypertension1086420 0.5 mEq/L Decrease 0.5 mEq/L DecreaseChange in Serum Potassium from BaselinePlaceboChlorthalidoneIncidence Rate(per 100 person-yrs)No. of Cas

13、es5253667No. of Participants1,5791,075179776SHEP Trial: Unadjusted incidence rate of diabetes in year 1 by change in serum potassiumShafi T, et al. Hypertension. 2008;52:1022-29.Thiazide DiureticsSympatheticNervousSystemReninAngiotensinSystemInsulinResistance K+ SupplementBlood FlowNa+/K+ATPaseK+pIn

14、sulinp Glucosep? 噻嗪类利尿剂引起血糖升高的可能机制Carter BL, et al. Hypertension. 2008;52:30-36 强调收缩压目标 多效性作用的单片联合治疗(SPC)新动态(四): 简化降压治疗目标和模式简化降压治疗: STITCH研究(Simplified Treatment Intervention to Control Hypertension)Feldman RD, et al. Hypertension. 2009;53:646-653主要终点(治疗6个月时血压达标患者比例)：STITCH 64.7% vs. CHEP 52.7% p=0.026 次要终点(治疗6个月时SBP和DBP的变化)：STITCH 22.6/10.4 mmHg vs. CHEP 17.5/8.2 mmHg p=0.002/0.03新动态(五): 挑战