高血压与降压治疗策略-中国高血压防治指南解读课件

1、高血压与降压治疗策略中国高血压防治指南解读中国高血压防治指南(2005)血压水平分类和定义 分类 收缩压(mmHg) 舒张压(mmHg)正常血压 120 和 80正常高值 120-139 或 80-89高血压 140 或 90 1级 140-159 或 90-99 2级 160-179 或 100-109 3级 180 或 110单纯收缩期高血压 140 和 90男性女性合计604530150构成比例 (%)正常血压正常高值高血压I级高血压II级高血压III级36.148.443.038.634.030.415.612.32.4中国大陆成年人群血压水平分类

2、(2002)卫生部心血管病防治研究中心，中国心血管病报告 2007中国大陆人群血压正常高值检出率(%)1991(29.0%) 2002(34.0%)18-24 25.4 28.525-34 26.0 30.935-44 30.2 36.745-54 32.9 38.055-64 32.7 34.965-74 31.2 30.375 28.7 28.1年龄组 1991年 2002年卫生部心血管病防治研究中心，中国心血管病报告 2007Prospective Studies Collaboration. Lancet. 2002;360:1903-1913.StrokeCHD25612864321

3、68421120140160180Usual SBP (mmHg)Stroke mortality(floating absolute risk and 95% CI)Age at risk(y):80-8970-7960-6950-5980-8970-7960-6950-59Age at risk(y):2561286432168421120140160180Usual SBP (mmHg)40-49Stroke and CHD Mortality Rate in Each Decade of Age versus Usual Systolic Blood Pressure at the S

4、tart of That Decade100%80%60%40%20%0%4040-4950-5960-6970-7980+17%16%16%20%20%11%Age (y)Frequency of hypertensionsubtypes in all untreatedsubjects (%)Frequency distribution of untreated hypertensive individuals by age and hypertension subtype. Numbers at the tops of bars represent the overall percent

5、age distribution of untreated hypertension in that age group. , ISH (SBP140 mm Hg and DBP90 mm Hg); , SDH (SBP140 mm Hg and DBP90 mm Hg); , IDH (SBP140 mm Hg and DBP90 mm Hg).IDH, SDH and ISH Subtypes in American Patients Franklin SS. Hypertension 2001;37:869Huang J, et al. J Hypertens 2004;17:955-9

6、62IDH, SDH and ISH Subtypes in Chinese Patients HOT：心血管危险分层与CVD事件BMJ 2002, 324:71RR：1.58 1.38 1.60 1.79 1.51Cl:1.45-1.72 1.18-1.61 1.41-1.82 1.56-2.05 1.38-1.66P:0.0001 0.0001 0.0001 0.0001 0.0001MajorcardiovasculareventsAll myocardialinfarctionAll strokeCardiovascularmortalityTotalmortalityRisk:Med

7、iumHighVery High20151050Events per 1000 patient years中国高血压防治疗指南(2010)心血管高危患者建议收缩压180mmHg 和/或 舒张压110mmHg糖尿病3 个心血管危险因素伴1个或多个亚临床器官损害:心电图(尤其是心肌劳损)或超声心动图(尤其是向心性)左心室肥厚超声检查显示颈动脉壁增厚或斑块动脉硬度增加血清肌酐轻度升高估测的肾小球滤过率或肌酐清除率下降微量白蛋白尿或蛋白尿 临床心、脑血管病或慢性肾脏疾病 中国高血压防治指南(2005)降压治疗的实施过程对高血压患者临床评价后，进行心血管危险水平分层(低危、中危、高危、很高危)所有患者都

8、应采用非药物治疗措施制定降压治疗计划，确定血压控制目标值很高危、高危患者：立即开始药物治疗中危：随访观测数周，然后决定是否开始药物治疗低危：随访观测数月，然后决定是否开始药物治疗治疗随访，调整治疗方案14121086420010203040506070Absolute risk of stroke(per 1000 patients of follow-up)Strokes saved(per 1000patient-years of treatment)STOP-1PATSPROGESSHSCSGSTONECoope & WarrenderSyst-EURSyst-ChinaSHEPEWPH

9、EMRC-EMRC-1HDFP心血管危险程度与降压治疗绝对获益STROKE0.51.02.0Relative 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 (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

10、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 Collaboration. Lancet. 2003;362:1527-1535.BP-Lowering Treatment TrialistsComparisons of Diff

11、erent Active TreatmentsBPLTT: STROKEComparisons of different active treatments2003 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. CA2/01/01/10.50.711.42Specified Dr

12、ug better0.50.711.42PlacebobetterSpecified Drug betterPlacebobetterCoronary heart disease eventsStrokeNo ofNo ofRelative riskrelative riskNo of No ofRelative riskRelative risktrialsevents(95% CI)(95% CI)trialsevents(95% CI)(95% CI)Thiazides1117100.86 (0.75 to 0.98)1013700.62 (0.53 to 0.72) blockers6

13、8510.89 (0.78 to 1.02)76900.83 (0.70 to 0.99)Anglotensin converting enzyme inhibitors2140830.83 (0.78 to 0.89)1312200.78 (0.66 to 0.92)Angiotensin receptor blockers43780.86 (0.53 to 1.40)00Calcium channel blockers2220090.85 (0.78 to 0.92)99760.66 (0.58 to 0.75)Drug choice open58710.89 (0.78 to 1.01)

14、47630.96 (0.75 to 1.23)All classes of drug6494170.85 (0.81 to 0.89)3847120.73 (0.66 to 0.80)Relative risk estimates of CHD events and stroke according to class of drugLaw MR, et al. Online from BMJ.com on 24 May, 2009Excluding CHD events in trials of blockers in people with a history of CHD中国高血压防治指南

15、(2005)血压控制目标值中青年高血压患者 140/90 mmHg老年高血压患者 150/90 mmHg 糖尿病或肾病患者130/80 mmHgINVEST血压控制达标与终点事件发生的关系15.05.72.4161412108642025% 25%至50% 50%至75% 75% 随诊时血压达标百分比（140/90 mmHg）患者总数（n） 3838 3757 6664 8316一级终点心肌梗死（致死非致死性）脑卒中（致死非致死性）发生临床终点事件百分比P 值均小于0.001VALUE：BP Control and OutcomesCli

16、nical outcomes by proportion of time with BP Control(covariate adjusted)proportion of time with BP HR(95% CI)Reduced RiskIncreased RiskControl ( 140; 90mmHg)Primary Endpoint 25%1.79(1.357-2.363) 25% to 50%1.30(1.035-1.625) 50% to 75%1.06(0.875-1.277) 75%1.00CV morbidity or Mortality 25%1.76(1.382-2.

17、243) 25% to 50%1.24(1.009-1.513) 50% to 75%1.14(0.893-1.250) 75%1.00MI (Fatal and non fatal) 25%1.64(1.073-2.509) 25% to 50%1.24(0.079-1.757) 50% to 75%1.14(0.859-1.512) 75%1.00Stroke (Fatal and non fatal) 25%2.04(1.270-3.265) 25% to 50%1.14(0.761-1.697) 50% to 75%1.11(0.822-1.535) 75%1.00Hospitaliz

18、ation for CHF 25%1.74(1.157-2.630) 25% to 50%1.16(0.831-1.630) 50% to 75%0.99(0.746-1.314) 75%1.0003.5321HR (95% CL)Exponential time-to-event model adjusted for covariates age. BMI history of CHD. Stroke. LVH. Type 2 diabetes. Smoking.High total cholesterol and proteinuria. Additional adjus

19、tment for 5th order polynomials of msDBP and msSBP. Major cardiovascular events (per 100 patients-years) in all treated hypertensive and in hypertensive patients with diabetes in relation to target blood pressures of 90. 85, and 80 mm Hg. 302520151050 80 85 90 90 85 80P=0.50 for trendP=0.005 for tre

20、ndAll hypertensive patients(n=18790)Hypertensive with diabetes(n=1501)Target blood pressure groupsMajor cardiovascular events/1000 patients-yearsHOT: 糖尿病患者血压控制与CV事件发生率10987654100110120130140150160170Achieved systolic blood pressure (mmHg)Annual patient event rate (%)Median systolic bloodPressure (mm

21、Hg)106116125135144154168No. of person-Years14314266897411983913849423470ADVANCE: Achieved BP levels and all renal eventsDe Galan BE, et al. J Am Soc Nephrol. 2009; Feb.18, onlineSBPs achieved by treatment in placebo-controlled trials in elderly hypertensivesEWPHE 840 72 182 150 172 Coope and Warrend

22、er 884 68 196 162 180 SHEP 4376 72 170 143 155 STOP-1 1627 76 195 167 186 MRC elderly 4396 70 185 156 165 Syst-Eur 4695 70 174 151 161 Syst-China 2394 67 171 151 160SCOPE 4964 76 166 145 148 HYVET 3845 83 173 144 159JATOS 4418 74 171 138 147Zanchetti A, et al. J Hypertens. 2009;27: N Age(years) Base

23、line SBPAchieved SBPActive Control中国高血压防治指南(2005)长期治疗随访实施过程继续治疗血压控制1年以上可减少剂量治疗3个月后，达到降压目标值治疗3个月后，未达到降压目标值有明显副作用增加剂量改用另一类降压药联合治疗改用另一类降压药减少剂量 降压治疗后血压下降幅度主要取决于： 血压水平和药物平均剂量 SBP= 9.1+0.1(P-154) DBP= 5.5+0.11(P-97) Law MR, et al. BMJ. 2003;326:1427-1431.降压药物联合治疗的依据(一) 150/90时，一种药物在标准剂量下，血压平均 降低仅8.7/4.7 m

24、mHg；一种、两种、三种药物 在1/2标准剂量下，血压分别平均降低6.7/3.7、 13.3/7.3、19.9/10.7 mmHg。Law MR, et al. BMJ. 2003;326:1427-1431.SBP= R+n0.078 (P-150)DBP= R+n0.088 (P-90)0.20ThiazideBeta blockerACE InhibitorCalcium channelblockerAll Classes1.04(0.88-1.20)1.00(0.76-1.24)1.16(0.93-1.39)1.01(0.90-1.12)Adding

25、 a drug from another class(on average standard doses)Doubling dose of same drug(from standard dose to twice standard)Incremental systolic blood pressure reductionRatio of observed to expected additive effects 0.89(0.69-1.09)0.19(0.08-0.30)0.23(0.12-0.34)0.2(0.14-0.28)0.37(0.29-0.45)0.22(0.19-0.25)降压

26、药物联合治疗的依据(二)Combination Therapy Versus MonotherapyMeta-analysis from 42 trialsWald DS, et al. Am J Med. 2009;122:290-300.通过不同的药理作用，中和或对抗相互的不良反应。通过降低剂量减少和减轻不良反应。降压药物联合治疗的依据(三)不良反应(A+B) 不良反应(A) + 不良反应(B)不良反应(A+B) 不良反应(2A) 或 不良反应(2B)优化降压联合治疗方案DHP-CCB + ACEI/ARB (ASCOT, ACCOMPLISH)DHP-CCB + blocker (HOT

27、, INSIGHT, ALLHAT)ACEI/ARB + Diuretics (LIFE, VALUE, ACCOMPLISH)DHP-CCB + Diuretics (VALUE, FEVER)ACEI/ARB + blocker (ALLHAT) blocker + Diuretics (LIFE, ASCOT, INSIGHT) ACEI + ARB (ONTARGET)INSIGHT：糖尿病患者终点事件患者百分数(%)0.04.08.0Co-amilozide12.0p = 0.0314.2Nifedipine GITS16.020.018.7Mancia G, et al. Hype

28、rtension 2003;41:4316.所有主要终点,非心脑血管性死亡,ESRD,心绞痛和短暂性脑缺血Co-amilozideNifedipine GITSINSIGHT serious and metabolic adverse eventsSerious adverse events0%5%10%15%20%25%30%0%2%4%6%8%10%Nifedipine GITSCo-amilozideHypokalaemiap=0.02p0.0001HyponatraemiaHyperlipidaemiaHyperglycaemiaImpaired renal functionHyper

29、uricaemiap0.0001p0.0001p=0.001p0.0001p0.0001Brown M, et al. Lancet 2000;356:36672.176 (5.6%)INSIGHT: 对新发糖尿病的影响 Nifedipine GITS020406080100120140160180Co-amilozide136 (4.3%)p=0.023Patients with newly diagnosed diabetes mellitus (n)Mancia G, et al. Hypertension 2003;41:4316.（氨氯地平+/-培哚普利 Vs. 阿替洛尔+/-苄氟噻

30、嗪）*P0.05降低百分比(%)-35-30-25-20-15-10-50*非致死心梗和冠心病死亡心血管死亡总死亡总冠脉事件致死/非致死性卒中总心血管事件和介入新发糖尿病肾损害Dahlof B, Sever P, et al. Lancet. 2005;366:895-906. ASCOT-BPLA:终点事件发生率Cumulative event rate HR (95% CI) 0.80 (0.72, 0.90)20% Risk ReductionTime to 1st CV morbidity/mortality (days)p = 0ACEI / HCTZCCB / ACEI650526.0002ACCOMPLISH: 主要终点中国高血压人群的临床特点最主要的心血管危险是脑卒中高血压发生和血压水平与摄盐量或饮食钠/钾比值较高密切有关老年人占的比例很高约定1/10男性患者有嗜酒行为脑卒中与心肌梗死的比值不同临床试验比较STONE8.0Syst-China8.7NICS-EH4.0SHEP1.2MRC II0.8STOP-H1.2Syst-Eur1.7ACTION: Events in Patients with Hypertension vs ISH Primary Endpoint EfficacyPrimary