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

1、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,影响不同种类降压药物治疗地位的决定因素,禁忌症 循证医学证据 不良反应和治疗持续性 效益/费用 种族,各类降压药物的禁忌症(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,SBP differen

2、ce between randomized groups (mmHg,Relative risk of outcome event,BP-Lowering Treatment Trialists (WHO/ISH, 2003,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535,0.5,1.0,2.0,Relative Risk,RR (95% CI,BP Difference(mm Hg,FavorsFirst Listed,FavorsSecond Listed,Major

3、 CV events,CV mortality,Total mortality,1.02 (0.98, 1.07,2/0,ACEI vs D/BB,1.03 (0.95, 1.11,2/0,ACEI vs D/BB,1.00 (0.95, 1.05,2/0,ACEI vs D/BB,1.04 (0.99, 1.08,1/0,CA vs D/BB,1.05 (0.97, 1.13,1/0,CA vs D/BB,0.99 (0.95, 1.04,1/0,CA vs D/BB,0.97 (0.92, 1.03,1/1,ACEI vs CA,1.03 (0.94, 1.13,1/1,ACEI vs C

4、A,1.04 (0.98, 1.10,1/1,ACEI vs CA,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535,BP-Lowering Treatment TrialistsComparisons of Different Active Treatments,RR (95% CI,Favours first listed,Favours second listed,0.5,1.0,2.0,Relative Risk,BP difference (mm Hg,1.09

5、(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. CA,2/0,1/0,1/1,BPLTT (2003): StrokeComparisons of different active treatments,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535,0.2,1.8,2.0,15,10,5,5,Odds ratio for CHD,ACE Is,Systolic B

6、P difference between groups (mmHg,Verdecchia et al 2005,0,Relationship Between Odds Ratio for CHD and Achieved BP Differences,CCBs and CV Outcomes New Meta-Analysis (ACC, 2009,在BPLTT的基础上，纳入了2003年以后发表的临床试验： ACTION, ASCOT-BPLA, CAMELOT, CASE-J, FEVER, INVEST, MOSES, HICOLE, VESPA,CCBs and CV Outcomes

7、New 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,Stage 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

8、, or CCB,JNC-7：降压治疗流程,JNC Recommendations for an Initial Antihypertensive Agent,Committee Year Recommendation,JNC 1 1977 Thiazide-type diuretic JNC 2 1980 Diuretic JNC 3 1984 Thiazide-type diuretic or BB JNC 4 1988 Diuretic or BB or CCB or ACEI JNC 5 1993 Diuretic or BB JNC 6 1997 Diuretic or BB JNC

9、 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 从JNC-6(1997)到JNC-7(2003,利尿剂 b-阻滞剂 ACEI CCB ARB -阻滞剂,用于起动和持续治疗的合适降压药物 (ESC/ESH, 2007,利尿剂 b-阻滞剂 钙拮抗剂 ACE抑制剂 血管紧张素II受体拮抗剂,2007ESH/ESC指南推荐的降压治疗模式,b-blockers,Angiotensin receptor antagonists,Thiazide diuretics,Calcium antagonists,ACE inhibitors,blockers,欧洲高血压治疗指南(ESC/ESH,2007) 合理的降压联合治疗方案,Younger (55yr) a thiazide-type diuretic is an alternative,NICE / BHS (2006) Management of Hypertension,Japanese Guidelines for the Management of Hypertension (JSH, 2004 and 2009