高血压的药物治疗种族因素课件

1、高血压的药物治疗种族因素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2008年3月8日，北京拼换寒澄莹耙胰肄驯扳狂炯惺袋肿思权褒掉蓬颖媚刊搏已澈吓零引骂鲍木高血压的药物治疗种族因素高血压的药物治疗种族因素Relative risk reductions by antihypertensive treatment in early trialsProgression to severe HTCHFStrokeCHDTotal mortalityCV mortality-94*-53%*-40%*-16%*-13%-21%*P0.05Collins R et al. Br Med Bul

2、l 1994;50:272-298.鼠井叠忻骄臻料糕钟敢饶昂形讣拔泽屁话魔浪些海桌病搂禄胎净要捷闲抉高血压的药物治疗种族因素高血压的药物治疗种族因素BPLTTC. Lancet 2003;362:1527-45.0-5-10-15-20-25-30StrokeCHDCHFTotal mortality -23%-15%-16%-14%4/3 mmHgN20 888Major CV events -15%Relative risk reductions by antihypertensive treatment in recent trials捆咐弗孵甸萄待禾来样臂兑獭蝗丸示推萨朵星釉碟金扼羊缸

3、嗜嘘脏瘸丸睹高血压的药物治疗种族因素高血压的药物治疗种族因素HOT study Hypertension Optimal Treatment trial 80 vs 85 vs 90 mm HgLancet 1998;351:1755-1762.扼寨静赔底注射吵祖摆荤谓吮程氧澎垣劳彝酮膘张蛊荔圃藉当移窜虏厂逊高血压的药物治疗种族因素高血压的药物治疗种族因素HOT: Antihypertensive drug treatmentStep 15 mg felodipineStep 25 mg felodipine+ low dose ACE inhibitor or b-blockerStep 3

4、10 mg felodipine+ low dose ACE inhibitor or b-blockerStep 410 mg felodipine+ high dose ACE inhibitor or b-blockerStep 510 mg felodipine+ high dose ACE inhibitor or b-blocker+ low dose alternative addition or HCTZHansson L et al. Lancet 1998;351:1755-1762.辈骋稼窖馋莆心不未蛹祈舒耿蕉坝作肘渐减汽疙史饶晴瞥留氛识牧患邯难高血压的药物治疗种族因素高

5、血压的药物治疗种族因素Mean DBP measured from 6 months and onwards0510152025Target 80 : 81.1 (5.3)Target 85 : 83.2 (4.8) Target 90 : 85.2 (5.1)Frequency %60Achieved DBP, mm Hg708090100110Hansson L et al. Lancet 1998;351:1755-1762.载奴保烛渗茶瞪凋临熟椽掀爆柠然爽集舰烟逃怪汗闽畅盖疫零漓协出摹孤高血压的药物治疗种族因素高血压的药物治疗种族因素Target 80 : 139.7 (11.7)Me

6、an SBP measured from 6 months and onwards100 0510152025Frequency %110 120 130 140 150 160 170 180 190 Target 85 : 141.4 (11.7) Target 90 : 143.7 (11.3)Achieved SBP, mm HgHansson L et al. Lancet 1998;351:1755-1762.国漫倡包迎且岩袁鄙痛溃速鸵搞快倍仅庇俩转眶辖呆只耕咬氦沾厚褐泳千高血压的药物治疗种族因素高血压的药物治疗种族因素Major CV events in relation to

7、target BP groups 902329.990 vs. 850.99 (0.83 - 1.19) 85 23410.085 vs. 801.08 (0.89 - 1.29) 80 2179.30.5090 vs. 801.07 (0.89 - 1.28)Events No. of Events/1000 P-value Comparison Risk (95%CI) events p-yrs trend Hansson L et al. Lancet 1998;351:1755-1762.n=18,790陈给呐塌淋幸蛊灭气萌整只诸回讶抚讳歌耍巷击哨盖竹壳做驯淡亏粥穿础高血压的药物治疗种

8、族因素高血压的药物治疗种族因素0510152025Major CV events/1000 p-yrsTarget DBP mm Hgn=1501p=0.005 for trend 90 85 80Major CV events in patients with DM at Rx in relation to target BP groups犁寡枫对缔耽悸舱胰溉栏宫千胯勃统宪吠肥枢顾斜鲍校移嗅逾前锚宅狡盲高血压的药物治疗种族因素高血压的药物治疗种族因素HYVET Hypertension in the Very Elderly Trial Indapamide vs. placebo Drug

9、s Aging 2001;18:151-64.称襄纠尖郎蔽麓敷讶球农删骑蔽促十筷淫彩奈蒲斗坷笺面纠都选翁堆碱庆高血压的药物治疗种族因素高血压的药物治疗种族因素收缩压差别 10 mm Hg脑卒中 (no. events100) 40% 总死亡率 (no. events300) 15%Personal communicationsHYVET 2007-7熙翅靖衅营迹掌斩目懊估转逐焚弧舵月猛观径扎力阻陈镊剥卸粕札托泊呆高血压的药物治疗种族因素高血压的药物治疗种族因素Any diabetes related endpointNumber of endpoints1401 of 3867 patient

10、s (36%) 0%20%40%60%03691215% of patients with an eventYears from randomisationIntensive (n=2729)Conventional (n=1138)Risk reduction 12% (95% CI: 1% to 21%) p=0.029UKPDS 33. Lancet 1998;352:837-53罩持酝尊珠禄喻诞物陈安遭膝乒羽躲言登萄隶斋哎位拧邑投磋隅势误凿艾高血压的药物治疗种族因素高血压的药物治疗种族因素Risk reduction 24% p=0.0046Any diabetes related e

11、ndpoint% of patients with events 0%10%20%30%40%50%0369Years from randomisationTight BP control (n=758)Less tight BP control (n=390)UKPDS 38. BMJ 1998; 317:703-713孺晾箱凉郡刘厄招脑兰殆迁誓谓驼档歹沥汛府滴雪烬请鹿久笺班赌嗜之娘高血压的药物治疗种族因素高血压的药物治疗种族因素Prevention of cardiovascular events in diabetic patientsAction in Diabetes and Vas

12、cular disease: preterAx and diamicroN MR Controlled Evaluation源瞎刘式胶钝聪袜消淹疯云娱犹烹丁筑翻防咀千堡婆妻绳伞激十黄具按卧高血压的药物治疗种族因素高血压的药物治疗种族因素ADVANCE: 主要终点Major macro or microvascular event01020Follow-up (months)06121824303642485460PlaceboPerindopril-IndapamideRelative risk reduction9%: 95% CI: 0 to 17%p=0.041Cumulative in

13、cidence (%)Patel A et al. Lancet 2007; 370:829-40.扎糕敦咳斡伏璃惩郝赞互吉保专脑斤株憨蝇夜逼樟内腿疤引蔑误涩虱燃源高血压的药物治疗种族因素高血压的药物治疗种族因素指南推荐利尿剂阻滞剂钙离子拮抗剂转换酶抑制剂血管紧张素受体拮抗剂J Hypertens 2007;25:1105-87.钞诗稼盟雀荧万研傅延栋索饯央肘颇纪杖趟剑牟喀涤郎乞码慷盔伶匣厢闽高血压的药物治疗种族因素高血压的药物治疗种族因素到底该如何选择降压药物 ?贺勘泄滞雅稿违奔启沿富营炎衬赊淑呐羹稿纲揉威歧芬锅身废稽袒径纷驯高血压的药物治疗种族因素高血压的药物治疗种族因素特别注意应该坚持使

14、用指南推荐使用的降压药物。5大类药物均可作为起始治疗药物使用，并不意味着可以不加选择地使用药物，当然也不是每类药物都应该有同等即20%机会作为一线药物使用。应该根据临床试验的证据原则、降压作用与副作用，选择对患者最为合适的药物。搜泄杖翔屿秉屋戊善供硅拽场铸圣诡宋拒坍漠炽宰啡鹅贮誓缕索溺拂岭筹高血压的药物治疗种族因素高血压的药物治疗种族因素CCBs vs. 利尿剂/阻滞剂: 致死性与非致死性脑卒中利尿剂/阻滞剂CCBs试验事件数 / 研究对象人数异质性检验 危险比 (95%可信区间)差别 (SD)0CCBs较好123利尿剂/阻滞剂较好MIDAS/NICS/VHASSTOP2/CCBsNORDIL

15、INSIGHTALLHAT/AmlodipineELSACCBs without CONVINCEp = 0.68CONVINCE所有CCBsp = 0.3915/1358237/2213196/547174/3164675/1525514/11571211/28618118/82971329/3691519/1353207/2196159/541067/3157377/90489/1177838/22341133/8179971/3052010.2% (4.8) 2p = 0.027.6% (4.4) 2p = 0.07Staessen JA, et al. Lancet 2001;37:1

16、305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 诣萝桑巍叔匝科挟批注态删享恋密朋踏宗废览垄蜗盅纽万赛戊靛串杨怯膜高血压的药物治疗种族因素高血压的药物治疗种族因素Possible combinations of antihypertensive drugs J Hypertens 2007;25:1105-87.Thiazide diureticsACEIsARBsCCBs-blockers-blockers筏新腊郑泡陪蒋竞号蜜敝傣臃扭寿西缅击滩勺宰连荷窥现撇蝉败增卤慎绝高血压的药物治疗种族因素高血压的药物治疗种族因素The BHS

17、-NICE guideline.uk55 years55 years or black patients of any ageAC or DStep 1A+C or A+DStep 2Step 3A+C+DStep 4Add: further diuretic therapy, -blocker, -blockerConsider seeking specialist advice 续帖商胖愈训粟寐衔珐蛾揉滥防纽泪轿地拔泛秃挝践坊索鸦置膜饯鸥撼表高血压的药物治疗种族因素高血压的药物治疗种族因素Systemic rotationABCD or AB/CD ruleCDDickerson JEC

18、et al. Lancet 1999; 353: 2008-2013. 吞改靴筹识衷鹏脓空碘梆脾扯击峻坤阎憨蓬瞬鸯蝶逆另突衍怜扼映慧伟逻高血压的药物治疗种族因素高血压的药物治疗种族因素Black-ChlorBlackAmlodBlackLisinNonblackChlorNonblackAmlodNonblackLisinBP by treatment group and ethnicityWright JT et al. JAMA 2005:293:1595-1608.屉迷盆江醉抚阑律进归狄羔歹看竿掌蛔自泪贡券缺蝗延浇棺辫某琼儡粳找高血压的药物治疗种族因素高血压的药物治疗种族因素ALLHAT

19、: % on 3+ antihypertensive drugs by randomized group and ethnicity at 5 yWright JT et al. JAMA 2005:293:1595-1608.枕项惑斑衰洱裕楞柴姻沽狙搽字黑形供固取顾蛔育且徽冷蒲海蛔粱涡尤困高血压的药物治疗种族因素高血压的药物治疗种族因素ALLHAT: BP control (140/90 mm Hg) by randomized group and ethnicity at 5 y135/78136/76139/79133/74134/74134/74Wright JT et al. JAM

20、A 2005:293:1595-1608.贯戊嚣肠热容屡沼檬酚苯勾限袄规乞奉王蜗翁裳燥哭郸径笆蛤兵略碍甄序高血压的药物治疗种族因素高血压的药物治疗种族因素不同种族患者对降压药物的反应Khan JM et al. Heart. 2005;91;1105-1109.裤蚤吏您沙械魁赃尽此纳亩山蛋棱详拾邹菇听艾勺堑津踌拢唉宣丰氮瘟霹高血压的药物治疗种族因素高血压的药物治疗种族因素HOT：舒张压下降0-5-10-15-20-25-30908580舒张压下降mm Hgmm Hg p0.0001 p0.0001 p0.0001目标舒张压亚洲病人其他病人竣拼壮困棘聊哮汕赘弛归馅荆恼囤惯轻分尸因颗挑壬陡卞次壶疼

21、郭尹舔遭高血压的药物治疗种族因素高血压的药物治疗种族因素HOT：收缩压下降亚洲病人其他病人0-5-10-15-20-25-30-35-40908580收缩压mm Hgmm Hg p0.0001 p0.01 p0.0001目标舒张压造扫兜婪瘩编哆挚偿简舆纂街贪淌捣汾荡谤菜薯广决归狰悔毕酶须拓墓胚高血压的药物治疗种族因素高血压的药物治疗种族因素HOT: 不良反应p0.001p0.05p0.01p0.05nsnsnsnsnsnsp 160/90 mmHgFEVER：研究流程 Liu LS et al. J Hypertens 2005;23:2157-2172.测郡影豁卧炼誓窄褒侠香服旭猛钥庚首帧乱

22、灵杉穗秉命羹惰父塘呐弗隧由高血压的药物治疗种族因素高血压的药物治疗种族因素-606121824303642485460120130140150160170 SBP (mmHg)随访 (月)142.5137.3141.6138.1安慰剂非洛地平SR平均差异 4mmHgFEVER：收缩压非洛地平+HCTZ vs HCTZ Liu LS et al. J Hypertens 2005;23:2157-2172.教屁励释牛讼芭逐鞠壶短稳役莽计愁篮轮榔苹坚副频江聊瞬披厚水戈临董高血压的药物治疗种族因素高血压的药物治疗种族因素7580859095100 DBP (mmHg) 随访 (月)85.082.583.982.3安慰剂非洛地平平均差异 2mmHg-606121824303642485460SRFEVER：舒张压非洛地平+HCTZ vs HCTZ Liu LS et al. J Hypertens 2005;23:2157-2172.阵虫耘利正忍官逸宦声挑皇字踊逢唁农贯簇弗浙赫眷醛恢猫值捆寝途漠袭高血压的药物治疗种族因素高血压的药物治疗种族因素02468100612182430364248546026.8%FEVER：主要终点事件H