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 difference b

2、etween randomized groups (mmHg)Relative risk of outcome event1.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.25StrokeMajor CVDCHDCVD deathTotal mortality-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024BP-Lowe

3、ring Treatment Trialists (WHO/ISH, 2003)Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.0.51.02.0Relative Risk RR (95% CI)BP Difference(mm Hg)FavorsFirst ListedFavorsSecond ListedMajor CV eventsCV mortalityTotal mortality 1.02 (0.98, 1.07)2/0 ACEI vs D/BB 1.03 (

4、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 CA 1.04 (0.98, 1.10)1/1 ACEI vs CABlood Pressure Lowering Treatment Trialists Col

5、laboration. Lancet. 2003;362:1527-1535.BP-Lowering Treatment TrialistsComparisons of Different Active Treatments RR (95% CI) Favours first listed Favours second listed0.51.02.0Relative RiskBP difference(mm Hg) 1.09 (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. CA2/

6、01/01/1BPLTT (2003): StrokeComparisons of different active treatmentsBlood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.0.40.60.81.01.21.40.21.82.015105-5Odds ratio for CHDACE IsALLHATACEIUKPDS39EUROPAPROGRESSPROGRESSComCAMELOTHOPEPEACECAPPPSTOP-2ACEIANBP-2Systolic

7、 BP difference between groups (mmHg) Verdecchia et al 20050NICSALLHATCCBPREVENTIDNT-2CONVINCEVHASSyst-ChinaSYSTEURCAMELOTSTONENICOLEACTIONNORDILINVESTSTOP-2CCBINSIGHT151050-5CCBsELSARelationship Between Odds Ratio for CHD and Achieved BP DifferencesCCBs and CV OutcomesNew Meta-Analysis (ACC, 2009)在B

8、PLTT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, VESPACCBs and CV OutcomesNew 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, B

9、B,CCB, or combination.Stage 2 Hypertension2-drug combination for most ( thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)JNC-7：降压治疗流程JNC Recommendations for an Initial Antihypertensive AgentCommittee Year RecommendationJNC 1 1977 Thiazide-type diureticJNC 2 1980 DiureticJNC 3 1984 Thiazide-typ

10、e diuretic or BBJNC 4 1988 Diuretic or BB or CCB or ACEIJNC 5 1993 Diuretic or BBJNC 6 1997 Diuretic or BBJNC 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

11、滞剂钙拮抗剂ACE抑制剂血管紧张素II受体拮抗剂降压治疗选择单药低剂量治疗两药低剂量联合治疗轻度血压升高低/中度心血管危险传统目标血压显著血压升高高/很高心血管危险更低的目标血压如果没有达到目标血压先前的药物全剂量转换低剂量的不同药物先前联合药物全剂量增加低剂量的第3个药物如果没有达到目标血压全剂量的2-3个药物联合治疗全剂量的单药治疗全剂量的2-3个药物联合治疗2007ESH/ESC指南推荐的降压治疗模式b-blockersAngiotensin receptorantagonistsThiazide diureticsCalcium antagonistsACE inhibitors-bl

12、ockers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)or BlackA: ACE Inhibitor or Angiotensin Receptor Blocker B: b-BlockerC: Calcium Channel Blocker D: Diuretic (Thiazide)Step 1A (or B*)C or DStep 3+A (or B*)CDStep 4 Resistant HTAdd: either a- blocker or spironolactone or other diureticStep 2+A (or

13、 B*)C or D* combination therapy involving B & D may induce more diabetes compared with other combination therapiesBHS IV (2001) Recommendations for Blood Pressure Lowering DrugsYounger (55yr) or Black at any AgeA: ACE Inhibitor or Angiotensin Receptor Blocker B: b-BlockerC: Calcium Channel Blocker D

14、: Diuretic (Thiazide)Step 1A C or DStep 2+AC or DStep 3+ACDStep 4 Resistant HTAdd: either a- blocker or b- blocker or spironolactone or other diureticNICE / BHS (2006)Management of Hypertension Younger (55yr) or Black at any AgeA: ACE Inhibitor or Angiotensin Receptor Blocker B: b-BlockerC: Calcium

15、Channel Blocker D: Diuretic (Thiazide)Step 1A C or DStep 2+AC or DStep 3+ACDStep 4 Resistant HTAdd: either a- blocker or b- blocker or spironolactone or other diureticIn hypertensive patients aged 55 or over, or Black patients of any age, first-choice initial therapy should be a dihydropyridine calcium channel blocker; a thiazide-type diuretic is an alternative.NICE / BHS (2006)Management of H