降压治疗中的J-Curve现象.ppt

降压治疗中的J-Curve现象,上海交通大学医学院附属瑞金医院 上海市高血压研究所 王继光 ,CV events,BP,血压与心血管风险的J 形曲线关系,Observational studies Randomized controlled trials The strategy to avoid J-curve,PSC: Stroke mortality and usual BP,80-89 y,70-79 y,60-69 y,50-59 y,Age at risk:,Stroke mortality (floating absolute risk and 95% CI),256,128,64,32,16,8,4,2,1,120,140,160,180,Usual SBP (mm Hg),80-89 y,70-79 y,60-69 y,50-59 y,Age at risk:,70,80,90,100,110,2,1,4,8,16,32,64,128,256,Systolic blood pressure,Diastolic blood pressure,Usual DBP (mm Hg),Prospective Studies Collaboration. Lancet 2002; 360: 190313.,80-89 years,70-79 years,60-69 years,50-59 years,40-49 years,256,128,64,32,8,4,2,1,!,!,!,!,!,!,70,80,90,100,110,!,!,!,!,Diastolic blood pressure,Age at risk:,16,256,128,64,32,8,4,2,1,120,140,160,180,!,!,!,!,!,!,!,!,16,PSC: IHD mortality and usual BP,IHD mortality (floating absolute risk and 95% CI),Usual SBP (mm Hg),Usual DBP (mm Hg),Prospective Studies Collaboration. Lancet 2002; 360: 190313.,APCSC: stroke and usual BP,64.0,32.0,16.0,8.0,4.0,2.0,1.0,0.5,0.25,110,120,130,140,150,160,170,Usual systolic blood pressure (mmHg),l,l,l,l,l,l,l,Age at risk 70 years 60-69 years 60 years,Hazard ratio and 95% CI,Asia Pacific Cohort Studies Collaboration. J Hypertens 2003;21:707716.,P for heterogeneity = 0.002,澳洲,亚洲,Hazard ratio,+10 mmHg: 1.22 (1.18-1.26),+10 mmHg: 1.31 (1.26-1.35),Mean usual SBP (mmHgl),APCSC: 收缩压与冠心病事件,Asia Pacific Cohort Studies Collaboration. J Hypertens 2003;21:707716.,MI或卒中发病率(%),MI Stroke,60,60 to 70,70 to 80,80 to 90,90 to 100,100 to 110,110,0,5,10,15,20,25,30,35,随访期间的平均舒张压 (mm Hg),MI and stroke by average follow-up DBP in INVEST,Messerli FH et al. Ann Intern Med 2006;144:88493.,高血压合并冠心病患者降压治疗,130/80,缺血性心脏病心衰,130/80,STEMI,不稳定性心绞痛或NSTEMI,130/80 or 120/80,稳定性心绞痛,not 60 mm Hg,slowly,130/80,合并冠心病危险因素,特别注意,降压速度,降压治疗目标血压(mm Hg),冠心病不同阶段,Rosendorff C et al. Circulation 2007.,not 60 mm Hg,not 60 mm Hg,not 60 mm Hg,not 60 mm Hg,slowly,slowly,slowly,slowly,130/80 or 120/80,Observational studies Randomized controlled trials The strategy to avoid J-curve,血压与心血管风险,7,6,5,4,3,2,1,0,100,110,120,130,140,150,160,170,180,190,200,SBP (mm Hg),Relative Benefit,1.00,0.85,0.70,0.55,0.40,0.25,0.10,0.3,VALISH: 血压,Ogihara T, et al. Hypertension. 2010;56:196-202.,VALISH: 心血管事件,Ogihara T, et al. Hypertension. 2010;56:196-202.,NAVIGATOR: Mean Sitting BP,McMurray JJ et al. N Engl J Med 2010.,NAVIGATOR: Primary & secondary outcomes,McMurray JJ et al. N Engl J Med 2010.,ACCORD: Systolic pressures (mean + 95% CI),Average : 133.5 Standard vs. 119.3 Intensive, Delta = 14.2,Mean # Meds Intensive: 3.2 3.4 3.5 3.4 Standard: 1.9 2.1 2.2 2.3,N Engl J Med 2010;362:1575-85.,ACCORD: Primary & secondary outcomes,N Engl J Med 2010;362:1575-85.,Systole,Diastole,2nd shoulder,1st shoulder,增强压力 Augmentation Pressure (AP),脉压 (PP),射血期,(msec),舒张期,Incisura,Start of the Wave,中心动脉压力波形,P1,AIx = AP / PP,0,80,85,90,95,100,105,0,3,6,12,24,36,Final,HOT: Diastolic BP (% patients reaching target),Target 80 mm Hg,Target 85 mm Hg,Target 90 mm Hg,DBP (mm Hg),74%,80%,43%,85%,52%,57%,67%,75%,56%,71%,83%,86%,57%,86%,73%,55%,Follow-up (months),74%,80%,43%,85%,52%,57%,67%,75%,56%,71%,83%,86%,57%,86%,73%,55%,74%,80%,43%,85%,52%,60%,57%,67%,75%,56%,71%,83%,86%,75%,57%,86%,73%,55%,Hansson L, et al. Lancet 1998; 351: 175562.,0,5,10,15,20,25,Major CV events/ 1000 patient years,Target DBP mm Hg,p=0.005 for trend, 90, 85, 80,HOT: Major CV events in patients with diabetes at randomisation,Hansson L, et al. Lancet 1998; 351: 175562.,Observational studies Randomized controlled trials The strategy to avoid J-curve,24-h 动态血压 (1),180,160,140,120,100,80,60,40,SD24=15.5 mmHg,day SD=9.2 mmHg,night SD=8.9 mmHg,(9.2 x 14) + (8.9 x 6) SDdn = = 9.1 mmHg 14 + 6,12,14,16,18,20,22,0,2,4,6,8,10,Hours,Bilo G et al. J Hypertens 2007; 25: 2058-66.,(SDd x Hrd) + (SDn x hrn) SDdn = hrd + hrn,长期血压监测,泡沫细胞,脂纹,中层病变,粥瘤,纤维斑块,复合病变/破裂,动脉粥样硬化,35-45岁 45-55 岁 55-65岁 65岁,Stiffness Visual explanation,Quality Carotid Stiffness,正常凋亡率： 3%,维持内皮层稳定,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” approach,选择有效药物，实现降压达标 选择长效降压药物，控制24小时血压 选择能够长期坚持使用的药物，长期、平稳控制血压 选择作用于血管