降压治疗研究新动态回顾与展望

降压治疗研究新动态回顾与展望第1页/共24页降压治疗研究新动态

回顾与展望第2页/共24页

◆

80岁以上高龄高血压(HYVET)◆高血压前期(TROPH,PHARAO)◆心房颤动(ADVANCEposthoc)新动态(一):扩展降压治疗获益人群第3页/共24页1.00.90.80.70.60.50.40.30100200300400500600700800900100011001200DaysControlRamiprilSurvivalfunctionPHARAOStudy:PrimaryEndpointDevelopmentofHypertensionHazardratio0.656(0.533-0.807)LudersS,etal.JHypertens.2008;26:1487-1496第4页/共24页*********************************************************************604020090100120130140160170180190200220230240PrehypertensionUncertaintyRange~55–75%ofthegeneralpopulation%ofscreenedpopulationNormotensionPrehypertensionMaskedHypertensionSustainedHypertensionMixedpopulationwithWhiteCoatHypertensionandSustainedHypertension(FPs&TPs)MaskedHypertension(officeBP<140/90mmHg)(FNs)第5页/共24页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5.3/2.3mmHg。心房颤动患者降压治疗后总死亡率与心血管死亡率分别降低14%与18%，NTT42。EurHeartJ.2009;March12.onlinepublication.第6页/共24页TheACTIVESteeringCommittee.AmHeartJ.2006;151:1187-93AtrialfibrillationClopidogrelTrialwithIrbesartanforpreventionofVascularEvents第7页/共24页

◆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第8页/共24页100806040200<120120-139140-15960100806040200<7070-7980-8990Achievedsystolicbloodpressurelevels(mmHg)Achieveddiastolicbloodpressurelevels(mmHg)Age-andsex-adjustedincidencerateCKD:Ptrend=0.004Non-CKD:Ptrend<0.0001CKD:Ptrend=0.001Non-CKD:Ptrend<0.0001CKDNon-CKDIncidencerate(1000person-years)PROGRESS-CKDSubstudy:SBPandCVD第9页/共24页WASIDTrial(Warfarin-AspirinSymtomaticIntracranialDisease)RelationshipBetweenBloodPressureandStrkeRecurrenceinPatientsWithIntracranialArterialStenosisTuranTN,etal.Circulation.2007;115:2969-2975第10页/共24页10.90.80.70.60.50.40.30.20.10012345Follow-up(yrs)P<0.000110.90.80.70.60.50.40.30.20.10012345Follow-up(yrs)ProbabilityofIschemicStrokeP<0.000110.90.80.70.60.50.40.30.20.10012345Follow-up(yrs)ProbabilityofIschemicStrokeinTerritory10.90.80.70.60.50.40.30.20.10012345Follow-up(yrs)P<0.0065ProbabilityofIschemicStrokeinTerritoryP<0.0001ProbabilityofIschemicStroke<=119120-139140-159>=160SBP<=119120-139140-159>=160SBPDBP<=7980-89>=90DBP<=7980-89>=90TuranNT,etal.Circulation.2007;115:2969-2975WASIDHazardRatiosforIschemicStrokeAccordingtoSBPandDBP第11页/共24页 No.ofevents/patients Median Favors Favors Hazardratio Pfor Per-Ind Placebo Bloodpressure Per-Ind placebo (95%CI)

trendAllrenaleventsAllparticipants 1243/5569 1500/5571 0.79(0.73to0.85)Baselinesystolicbloodpressure(mmHg)<120 134/615 167/560 113mmHg 0.70(0.56to0.88) 0.75120-139 367/1736 431/1793 131mmHg 0.85(0.74to0.97)140-159 439/1945 563/2003 149mmHg 0.75(0.66to0.85)≥160 303/1273 339/1215 172mmHg 0.81(0.70to0.95)Baselinediastolicbloodpressure(mmHg)<70 208/846 240/881 66mmHg 0.84(0.70to1.02) 0.8570-79 387/1748 481/1758 75mmHg 0.77(0.67to0.88)80-89 386/1862 479/1834 84mmHg 0.76(0.66to0.87)≥90 262/1113 300/1098 95mmHg 0.81(0.69to0.96)Allrenalevents,macrovascularevents,all-causedeathAllparticipants 1781/5569 2064/55710.82(0.77to0.88)Baselinesystolicbloodpressure(mmHg) <120 190/615 205/560 113mmHg 0.82(0.68to1.00) 0.35120-139 527/1736 590/1793 131mmHg 0.89(0.79to1.00)140-159 615/1945 771/2003 149mmHg 0.77(0.69to0.86)≥160 449/1273 498/1215 172mmHg 0.81(0.72to0.93)Baselinediastolicbloodpressure(mmHg)<70 304/846 352/881 66mmHg 0.85(0.73to1.00)0.6070-79 551/1748 637/1758 75mmHg 0.83(0.74to0.93)80-89 554/1852 651/1834 84mmHg 0.81(0.72to0.90)≥90 372/1113 424/1098 95mmHg 0.81(0.71to0.94)0.51.02.0Hazardration(95%CI)ADVANCE:BaselineBPandOutcomeEventsDeGalanBE,etal.JAmSocNephrol.2009;Feb.18,online第12页/共24页10987654100110120130140150160170Achievedsystolicbloodpressure(mmHg)Annualpatienteventrate(%)MediansystolicbloodPressure(mmHg) 106 116 125 135 144 154 168No.ofperson-Years 1431 4266 8974 11983 9138 4942 3470ADVANCE:AchievedBPlevelsandallrenaleventsDeGalanBE,etal.JAmSocNephrol.2009;Feb.18,online第13页/共24页

◆

降压治疗模式的历史演进

◆优化联合治疗方案◆纠正噻嗪类利尿剂代谢缺点新动态(三):优化降压治疗方案第14页/共24页

降压治疗模式的历史演进

序贯治疗(SequentialMonotherapy)

阶梯治疗(Stepped-care)

联合治疗(Combination)处方联合单片联合第15页/共24页1.41.21.00.80.60.40.20ThiazideBetablockerACEInhibitorCalciumchannelblockerAllClasses1.04(0.88-1.20)1.00(0.76-1.24)1.16(0.93-1.39)1.01(0.90-1.12)Addingadrugfromanotherclass(onaveragestandarddoses)Doublingdoseofsamedrug(fromstandarddosetotwicestandard)IncrementalsystolicbloodpressurereductionRatioofobservedtoexpectedadditiveeffects0.89(0.69-1.09)0.19(0.08-0.30)0.23(0.12-0.34)0.2(0.14-0.28)0.37(0.29-0.45)0.22(0.19-0.25)CombinationTherapyVersusMonotherapyMeta-analysisfrom42trialsWaldDS,etal.AmJMed.2009;122:290-300.第16页/共24页DiureticsACEinhibitorsorARBsCalcium

antagonistsInitialCombinationsofMedicationsforManagementofHypertension第17页/共24页1086420<0.5mEq/LDecrease≥0.5mEq/LDecreaseChangeinSerumPotassiumfromBaselinePlaceboChlorthalidoneIncidenceRate(per100person-yrs)No.ofCases 52 53 6 67No.ofParticipants 1,579 1,075 179 776SHEPTrial:Unadjustedincidencerateofdiabetesinyear1bychangeinserumpotassiumShafiT,etal.Hypertension.2008;52:1022-29.第18页/共24页ThiazideDiuretics Sympathetic Nervous System Renin Angiotensin System Insulin ResistanceK+Supplement BloodFlow Na+/K+ ATPase [K+]p [Insulin]p[Glucose]p?????

噻嗪类利尿剂引起血糖升高的可能机制CarterBL,etal.Hypertension.2008;52:30-36第19页/共24页

◆

强调收缩压目标◆多效性作用的单片联合治疗(SPC)新动态(四