进一步改善轻中高血压治疗施仲伟课件

HomeHealthMonitoringReducesCardiovascularDiseaseRisk

InMedicallyUnderservedCommunities

AlfredA.Bove,MD,PhDTempleUniv.MedicalSchoolPhiladelphia,PaTelemedicinestudyReportedonMarch30,2009atACC2009ObjectiveLowerCardiovascularDiseaseRiskinUrbanandRuralUnderservedCommunitiesCompareAnursemanagementprogram–4officevisitsinoneyearvs.NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineStudySubjectsRuralandUrbanSubjectsFraminghamriskscore>10%NoovertCVDAge20~75MalesandFemalesKnownPCP(PersonalCareProvider)PrimaryEnd-Point–5%orGreaterinCVDRiskat1year

25%-NM,37.5%-TStudyProtocol388SubjectscompletedthestudyOneYearResultsAmongpatientswithstage1hypertensionwhousedthetelemedicinereportingsystem,SBPreductionwassignificantlylower.ConclusionsandImplicationsAnursemanagementprogramcanreduceCVDriskinmedicallyunderservedcommunities,HowevercostforthismanagementisprohibitiveTelemedicineprovidesadditionalbenefitforBloodPressuremanagement,particularlyinpatientswithmildtomoderateHBPImplicationsNurseManagedCVDriskreductionpotentiallycansignificantlyreduceCVDmorbidityandmortalityHowevercostforthismanagementisprohibitiveTelemedicineprovidesalowcostcomplementaryriskreductiontoolAutomatedremindersviawebandtelephonePHRforarchivingdataandprovidingportabilityTimelyfeedbackandadviceforriskmanagement专家即刻评论"ThisisoneofseveralstudiesdemonstratingthatthecombinationofsomeformofWeb-basedtechnologyplushumaninterventioniseffectiveinloweringbloodpressure."DanielW.Jones,MDpastpresidentofAHADeanofUnivMississippiSchoolofMedicine互联网技术和医务人员干预的结合，能有效降低血压。上海瑞金医院施仲伟家庭血压监测、互联网交流和药剂师参与对高血压控制的影响JAMA2008,299(24):2857-2867internet-mediatedopen-labelcrossovertrialofcalciumchannelblockersforhypertension

互联网为中介开放交叉钙拮抗剂治疗高血压研究i-TECHO试验RyuzakiM,etal.JHypertens,25(11):2352-2358回顾：另外一项以互联网为治疗辅助的研究上海瑞金医院施仲伟入选患者55名门诊高血压患者入选标准：收缩压>140mmHg或舒张压>90mmHg或者目前正在使用抗高血压药物RyuzakiM,etal.JHypertens,25(11):2352-2358上海瑞金医院施仲伟我国轻中度高血压患者比例较高Amongpatientswithstage1hypertensionwhousedthetelemedicinereportingsystem,SBPreductionwassignificantlylower.轻中度高血压多中心比较研究RobertaRomito,MariaIdaPansini,FrancescoPerticone,JClinHypertens.AutomatedremindersviawebandtelephoneIkuoSAITO,TakaoSARUTA,HypertensionResearch.硝苯地平控制片降压疗效卓越、平稳持久、不良反应少，适合轻中度高血压的治疗Currentmedicalresearchandopinion;2003;19,3:226-237JournalofPreventiveMedicine，2003；NoovertCVD轻中度高血压多中心比较研究：结论NoovertCVD研究目的：比较硝苯地平控释片和氨氯地平的疗效LEAD试验：不良反应发生率

拜新同低于非洛地平缓释片EuropeanHeartJournal(2007)28,1462–1536.37(2):84-89internet-mediatedopen-labelcrossovertrialofcalciumchannelblockersforhypertension

互联网为中介开放交叉钙拮抗剂治疗高血压研究Bove,MD,PhD轻中度高血压：

两种CCB降低DBP的疗效相当Bove,MD,PhD研究目的及方法研究目的：比较硝苯地平控释片和氨氯地平的疗效试验设计：随机、开放、交叉研究观察时间：每例患者均使用两种药物各6周以上部分患者先给予氨氯地平，至少6周后换为硝苯地平剩下患者先给予硝苯地平，至少6周后换为氨氯地平接受两种药物治疗过程中，监测家庭自测血压情况RyuzakiM,etal.JHypertens,25(11):2352-2358上海瑞金医院施仲伟RyuzakiM,etal.JHypertens,25(11):2352-2358RyuzakiM,etal.JHypertens,25(11):2352-2358i-TECHO：硝苯地平控释片控制清晨血压

疗效优于氨氯地平硝苯地平控释片组氨氯地平组*P<0.05vs.氨氯地平**血压（mmHg）60801001201401601338113180收缩压舒张压RyuzakiM,etal.JHypertens,25(11):2352-2358上海瑞金医院施仲伟重视轻中度高血压的治疗我国轻中度高血压患者比例较高JournalofPreventiveMedicine，2003；37(2):84-89亚洲国际心血管病合作研究（interASIA）：2000~2001年中国35~74岁成年人群统计2007年欧洲高血压指南：

血压不高的患者同样可能处于高危状态GiuseppeMancia,Co-Chairperson,GuyDeBacker,etal.EuropeanHeartJournal(2007)28,1462–1536.155例原发性轻中度高血压患者年龄35~75岁基线舒张压95~105mmHg未用降压药物的患者：硝苯地平控释片组78.9%；氨氯地平组78.5%Currentmedicalresearchandopinion;2003;19,3:226-237轻中度高血压多中心比较研究研究方案及给药方法Currentmedicalresearchandopinion;2003;19,3:226-237洗脱期安慰剂积极治疗期1~2周2周6周6周轻中度高血压：

两种CCB降低SBP的疗效相当组间比较P=NSCurrentmedicalresearchandopinion;2003;19,3:226-237拜新同氨氯地平积极治疗期随访时间（周）血压值（mmHg）轻中度高血压：

两种CCB降低DBP的疗效相当Currentmedicalresearchandopinion;2003;19,3:226-237组间比较P=NS拜新同氨氯地平积极治疗期随访时间（周）血压值（mmHg）Currentmedicalresearchandopinion;2003;19,3:226-2372007年欧洲高血压指南：

血压不高的患者同样可能处于高危状态研究目的：比较硝苯地平控释片和氨氯地平的疗效Philadelphia,PaSchoolofMedicineCurrentmedicalresearchandopinion;2003;19,3:226-237对于轻中度高血压患者，拜新同有效降压，而且并未将血压降得过低Poole-WilsonPA,etal.Bove,MD,PhDCurrentmedicalresearchandopinion;2003;19,3:226-237硝苯地平控释片联合治疗组血压达标率优于氨氯地平组RyuzakiM,etal.SchoolofMedicine2007年欧洲高血压指南：

血压不高的患者同样可能处于高危状态388Subjectscompletedthestudy服用拜新同的患者停药率低于氨氯地平Implications轻中度高血压：

两种CCB降低SBP的疗效相当JHypertens,25(11):2352-2358收缩压>140mmHg或舒张压>90mmHg轻中度高血压：

拜新同组患者的停药率低于氨氯地平组因不良反应停药的患者（%）Currentmedicalresearchandopinion;2003;19,3:226-237轻中度高血压多中心比较研究：结论对于轻中度高血压患者，拜新同有效降压，而且并未将血压降得过低服用拜新同的患者停药率低于氨氯地平Currentmedicalresearchandopinion;2003;19,3:226-237基线血压不同，拜新同®的降压疗效不同Poole-WilsonPA,etal.Lancet2004;364:849–57.MJBrown,etal.Lancet2000;356:366.注：INSIGHT使用拜新同30-60mg；ACTION拜新同60mg120130140150160170180INSIGHT试验N=6321例ACTION试验N=7665例707580859095100105收缩压舒张压138mmHg173mmHg138mmHg132mmHg82mmHg99mmHg80mmHg76.5mmHgmmHgmmHgINSIGHT试验N=6321例ACTION试验N=7665例ADVANCE-Combi：早期血压达标，硝苯地平控释片组优于氨氯地平组#：组间比较差异有统计学显著性IkuoSAITO,TakaoSARUTA,HypertensionResearch.2006.29:789-796.ADVANCE-Combi试验：硝苯地平控释片联合治疗组血压达标率优于氨氯地平组提高舒张压达标率76.8％50.2％提高收缩压达标率43.9％提高整体达标率组间比较P值均<0.001硝苯地平控释片联合治疗组氨氯地平联合治疗组IkuoSAITO,TakaoSARUTA,HypertensionResearch.2006.29:789-796.69.8％48.5％75.1％50.0％61.2％34.6％轻中度高血压患者：

使用拜新同的患者副作用发生率低患者百分数（%）ArchInternMed.1998;158:2029-2034.LEAD试验：不良反应发生率

拜新同低于非洛地平缓释片RobertaRomito,MariaIdaPansini,FrancescoPerticone,JClinHypertens.2003;5:249–253.拜新同组非洛地平缓释片组拜新同水肿发生率低于氨氯地平水肿发生率（%）AmJCardiol2000;86:1182拜新同60mg组氨氯地平10mg组P<0.05小结互联网高新技术丰富了轻中度高血压治疗方案轻中度高血压患者同样可能是高风险患者，必须重视和积极治疗硝苯地平控制片降压疗效卓越、平稳持久、不良反应少，适合轻中度高血压的治疗ObjectiveLowerCardiovascularDiseaseRiskinUrbanandRuralUnderservedCommunitiesCompareAnursemanagementprogram–4officevisitsinoneyearvs.NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineStudySubjectsRuralandUrbanSubjectsFraminghamriskscore>10%NoovertCVDAge20~75MalesandFemalesKnownPCP(PersonalCareProvider)RyuzakiM,etal.JHypertens,25(11):2352-2358我国轻中度高血压患者比例较高JournalofPreventiveMedicine，2003；37(2):84-89亚洲国际心血管病合作研究（interASIA）：2000~2001年中国35~74岁成年人群统计155例原发性轻中度高血压患者年龄35~75岁基线舒张压95~105mmHg未用降压药物的患者：硝苯地平控释片组78.9%；氨氯地平组78.5%Currentmedicalresearchandopinion;2003;19,3:226-237轻中度高血压多中心比较研究Bove,MD,PhDNursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicine我国轻中度高血压患者比例较高轻中度高血压：

两种CCB降低SBP的疗效相当JHypertens,25(11):2352-2358PrimaryEnd-Point–5%orGreaterinCVDRiskat1yearNursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineJournalofPreventiveMedicine，2003；轻中度高血压多中心比较研究：结论"ThisisoneofseveralstudiesdemonstratingthatthecombinationofsomeformofWeb-basedtechnologyplushumaninterventioniseffectiveinloweringbloodpressure.LEAD试验：不良反应发生率

拜新同低于非洛地平缓释片NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineBove,MD,PhD轻中度高血压多中心比较研究：结论JHypertens,25(11):2352-2358KnownPCP(PersonalCareProvider)ConclusionsandImplicationsEuropeanHeartJournal(2007)28,1462–1536.JHypertens,25(11):2352-2358JHypertens,25(11):2352-2358155例原发性轻中度高血压患者JournalofPreventiveMedicine，2003；IkuoSAITO,TakaoSARUTA,HypertensionResearch.轻中度高血压：

两种CCB降低SBP的疗效相当RobertaRomito,MariaIdaPansini,FrancescoPerticone,JClinHypertens.未用降压药物的患者：硝苯地平控释片组78.服用拜新同的患者停药率低于氨氯地平未用降压药物的患者：硝苯地平控释片组78.NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineBove,MD,PhD#：组间比较差异有统计学显著性Currentmedicalresearchandopinion;2003;19,3:226-237对于轻中度高血压患者，拜新同有效降压，而且并未将血压降得过低轻中度高血压：

两种CCB降低SBP的疗效相当AutomatedremindersviawebandtelephoneBove,MD,PhDImplications观察时间：每例患者均使用两种药物各6周以上RobertaRomito,MariaIdaPansini,FrancescoPerticone,JClinHypertens.我国轻中度高血压患者比例较高NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineIkuoSAITO,TakaoSARUTA,HypertensionResearch.NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicinepastpresidentofAHACurrentmedicalresearchandopinion;2003;19,3:226-2372007年欧洲高血压指南：

血压不高的患者同样可能处于高危状态RyuzakiM,etal.Philadelphia,Pa155例原发性轻中度高血压患者2007年欧洲高血压指南：

血压不高的患者同样可能处于高危状态2003;5:249–253.AmJCardiol2000;86:1182Philadelphia,PaRyuzakiM,etal.SchoolofMedicine部分患者先给予氨氯地平，至少6周后换为硝苯地平#：组间比较差异有统计学显著性RyuzakiM,etal.NoovertCVD155例原发性轻中度高血压患者注：INSIGHT使用拜新同30-60mg；IkuoSAITO,TakaoSARUTA,HypertensionResearch.Bove,MD,PhDJournalofPreventiveMedicine，2003；NursemanagementplusweeklyreportingofCVDriskfactorsviaTelemedicineRyuzakiM,etal.注：INSIGHT使用拜新同30-60mg；AutomatedremindersviawebandtelephoneJournalofPreventiveMedicine，2003；NoovertCVD因不良反应停药的患者（%）SchoolofMedicineCurrentmedicalresearchandopinion;2003;19,3:226-237