老年高血压降压指南课件

1、从HYVET到2008年中国老年高血压治疗指南Treatment betterControl better00.20.40.60.81.01.21.41.61.82.02.2Total mortalityDouble-blind trials (meta-analysis) (RR = 1.14, P = 0.05)All trials (meta-analysis) (RR = 1.06, P = 0.30)HYVET-Pilot (diuretic) (RR = 1.307, P = 0.34)HYVET-Pilot (ACE) (RR = 1.143, P = 0.65)HYVET-Pi

2、lot (all active) (RR = 1.227, P = 0.42)Cardiovascular deathDouble-blind trials (meta-analysis) (RR = 1.11, P = 0.42)All trials (meta-analysis) (RR = 1.01, P = 0.93)HYVET-Pilot (diuretic) (RR = 1.166, P = 0.62)HYVET-Pilot (ACE) (RR = 1.087, P = 0.79)HYVET-Pilot (all active) (RR = 1.127, P = 0.66)Stro

3、ke eventsDouble-blind trials (meta-analysis) (RR = 0.64, P = 0.01)All trials (meta-analysis) (RR = 0.67, P = 0.01)HYVET-Pilot (diuretic) (RR = 0.313, P = 0.01)HYVET-Pilot (ACE) (RR = 0.629, P = 0.21)HYVET-Pilot (all active) (RR = 0.471, P = 0.02)J Hypertens 2003;21:2408-2416Western Europe(86) Easter

4、 Europe(2144) China(1526)Astrania(19) Tunisia(70)Placebo1,912Active1,9333,845Entered into placebo Run-in Inclusion criteria: exclusion criteria: Aged 80 or more， standing SBP 140mmHg systolic pressure：160 -199mmHg Stroke in last 6 months diastolic pressure110 mmHg， dementia informed consent required

5、 ongoing nursing care primary outcome： Stroke events (Fatal and non fatal)Target blood pressure 150/80 mmHgHYVET:MethodsPlacebo(n= 1912)Active(n= 1933)Age (years)83.5 83.6 Female n (%)1,152 (60.3%)1,174 (60.7%)Blood Pressure:Sitting SBP (mmHg)173.0 173.0 Sitting DBP (mmHg)90.8 90.8 Orthostatic Hypot

6、ension n (%) 169 (8.8%)152 (7.9%)Isolated Systolic Hypertension n (%)623 (32.6%)625 (32.3%)HYVET: Baseline data Fall in SBP 20mmHg and/or fall in DBP 10mmHg Placebo(n= 1912)Active(n= 1933)Current smoker6.6%6.4%Diabetes(Known DM/DM treatment/glucose1.11mmol/l)6.9%6.8%Total cholesterol(mg/dl)206.7206.

7、7HDL cholesterol(mg/dl)52.6552.65Serum creatinine(umol/l)89.288.6Uric acid(umol/l)279280Body Mass index(kg/m*m)24.724.7HYVET: Baseline dataCardiovascular risk factorP=0.046HYVET: Fatal StrokeFatal stroke 39 % treatment placebo treatment placeboTime of Follow-up（year）Rate %191219331492156581487737942

8、0202231P80岁)?老年高血压合并脑卒中急性脑梗死72小时内降压治疗应慎重，现有指南建议血压过高(SBP200mmHg)时或病情稳定后再进行降压治疗，SBP如需降至180mmHg以内，24小时的降压幅度应( ? )。急性脑出血 SBP180mmHg时应给予降压治疗，目标血压为(?)老年高血压伴有双侧颈动脉70%狭窄时降压治疗应慎重,收缩压一般不应低于(?）。什么是体位性低血压?回 答不一定 建议对经过选择的80岁以上,认知功能良好,无严重脑血管病变的患者进行降压治疗.10mmHg伴有头晕或晕厥。在老年收缩期高血压者伴有糖尿病、低血容量，应用利尿剂、扩血管药或精神类药物者容易发生体位低血压

9、。 谢 谢Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial:The Telmisartan trial in cardiovascular protectionONTARGET Study Designadapted from Unger T., Am J Cardiol 2003;91 (suppl):28G34GBecause of an extraordinary effort by investigators in 40 countries, it was possible

10、to complete recruitment for the ONTARGET study in May 2003, seven months ahead of the scheduled timeline. The ONTARGET trial currently recruited 25,621 patients.Possible results for the end of the Trial for ONTARGET Non-Inferiority ComparisonONTARGETONTARGET: Key Baseline CharacteristicsRamiprilTelm

11、isartanCombinationN857685428502Age66.466.466.5% females27.226.326.5% CAD74.474.574.7% Stroke/TIA21.020.620.9% Diabetes36.738.037.9BP 141.8/82.1141.7/82.1141.9/82.1Statins61.062.061.8Antiplatelet80.581.181.1-blocker56.556.957.4ONTARGET: Change in BP (mmHg)RamiprilTelmisartanCombinationSystolic-6.0-6.

12、9-8.4Diastolic-4.6-5.2-6.0非劣势比较(Non-Inferiority Comparison)Tel vs. RamONTARGETONTARGET Non-Inferiority ComparisonONTARGETIndirect Comparison of Telmisartan to Placebo & Percentage of Ramiprils Effects That is PreservedHOPE ResulthR/hP = 0.77 (95% CI = 0.70 0.85)ONTARGET ResulthT/hR = 1.02 (95% CI =

13、0.94 1.09)Indirect Comparison of Telmisartan to PlacebohT/hP = 0.79 (95% CI = 0.70 0.89)Percentage of Ramiprils Effect Preserved by Telmisartan93.9% (95% CI = 82.5% to 105.4%)Reasons for Permanently Stopping Study MedicationsTel vs. RamRamN=8576TelN=8542Tel vs. RamRR PHypotensive Symptoms1492291.540

14、.0001Syncope15191.270.4850Cough360930.260.0001Diarrhea12191.590.20Angioedema25100.400.0115Renal Impairment60681.140.46Any Discontinuation209919620.940.02优势比较(superiority Comparison)Tel + Ram vs. RamONTARGETReasons for Permanently Stopping Study MedicationsTel + Ram vs. RamRamN=8576Ram + TelN=8502Ram

15、 + Tel vs. RamRR PHypotensive Symptoms 1494062.750.0001Syncope15291.950.032Cough3603921.100.1885Diarrhea12393.280.0001Angioedema25180.730.30Renal Impairment60941.580.0050Any Discontinuation209924951.200.0001Renal Dysfunction Dialysis & Related DeathTel + Ram vs. RamRam(n=8576)%Ram + Tel (n=8502)%Ram

16、 + Tel v Ram RR (95% CI)P valueAny renal dysfunction*10.0413.351.33 (1.22-1.45)5.5 mmol/L3.325.671.71 (1.48-1.98)0.0001SAE renal failure0.280.642.27 (1.40-3.67)0.0006Need for dialysis0.550.781.42 (0.98-2.06)0.066Death after renal dysfunction1.842.211.20 (0.97-1.48)0.087*local definition临床意义(一) ONTAR

17、GET研究验证并丰富了在心血管高危人群通过抑制RAS能显著减少心血管病事件，即使在当代治疗背景下。这对RAS抑制剂(转换酶抑制剂或血管紧张素受体拮抗剂)治疗心血管高危患者提供了更坚实的循证基础。 冠心病(%) 79.5 74.5 既往心肌梗死(%) 51.9 49.3心绞痛(%) 54.9 49.8既往CABG(%) 25.7 22.5既往PTCA(%) 18.4 29.0脑卒中/TIA(%) 10.8 20.6外周血管病(%) 42.3 13.6ECG-LVH(%) 8.2 13.1高血压(%) 47.6 68.6糖尿病(%) 38.9 38.0MAU(%) 20.5 13.2HOPE与ON

18、TARGET入选人群比较HOPE(Ram) ONTARGET(Tel) HOPE与ONTARGET治疗背景比较 HOPE(2000) ONTARGET(2008)Asprin 75% 81%阻滞剂 39% 57%他汀类 28% 62% HOPE与ONTARGET主要终点事件发生率比较(心肌梗死、脑卒中、心血管死亡 / % / 4年) HOPE(2000) ONTARGET(2008) 安慰剂 Ramipril Ramipril Telmisartan17.8 14 14.11 13.93临床意义(二) 虽然ARB替米沙坦可以替代ACEI治疗，增加了治疗药物的有效选择，但是并不是取代。ACEI(Ramipril和Peridopril)依然是治疗心血管高危患者的金标准。 雅施达在心血管高危患者循证证据PROGRESS (脑卒中史, 2001年)EUROPA (稳定性冠心病, 2003年)ADVANCE (2型糖尿病, 2007年)临床意义(三) 临床实践中一般应按照循证原则选择治疗方案、药物品种和剂量。在心血管高危患者，目前不推荐ACEI+A