降压治疗策略与目标的回顾及进展培训课件

1、降压治疗策略与目标的回顾及进展降压治疗策略与目标的回顾及进展降压治疗策略研究的重点 血压水平与心血管危险 降压治疗与心血管危险控制 治疗益处及来源(why) 治疗对象(who) 治疗目标水平(what) 治疗方案(which)2降压治疗策略与目标的回顾及进展降压治疗策略研究的重点 血压水平与心血管危险2降压治疗策略与Lancet 2002,360:1903血压、年龄与脑卒中死亡率(100万人群资料分析)Stroke mortality(floating absolute risk and 95%CI)2561286432168421120140160180Usual sysytolic blo

2、odPressure (mmHg)Usual diastolic bloodPressure (mmHg)2561286432168421708010011090Stroke mortality(floating absolute risk and 95%CI)A: Systolic blood pressureB: Diastolic blood pressureAge at rist:80-89Years70-79Yaes60-69years50-59YearsAge at rist:80-89Years70-79Yaes60-69years50-59Years3降压治疗策略与目标的回顾及

3、进展Lancet 2002,360:1903血压、年龄与脑卒中死IHD mortality(floating absolute risk and 95%CI)2561286432168421120140160180Usual sysytolic bloodPressure (mmHg)Usual diastolic bloodPressure (mmHg)2561286432168421708010011090IHD mortality(floating absolute risk and 95%CI)A: Systolic blood pressureB: Diastolic blood p

4、ressureAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsAge at rist:80-89Years70-79Yaes60-69years50-59Years40-49yearsLancet 2002,360:1903血压、年龄与冠心病死亡率(100万人群资料分析)4降压治疗策略与目标的回顾及进展IHD mortality25612864321684211CauseAge atNumber ofOf deathrisk(years)deathsStroke40-494140.36 (0.32-0.40)50-591

5、3720.38 (0.35-0.40)60-6929390.43 (0.41-0.45)70-7943270.50 (0.48-0.52)80-8926360.67 (0.63-0.71)IHD40-4913220.49 (0.45-0.53)50-5955940.50 (0.49-0.52)60-69104500.54 (0.53-0.55)70-79108520.60 (0.58-0.61)80-8956490.67 (0.64-0.70)Other40-493860.43 (0.38-0.48)vascular50-5913770.50 (0.47-0.54)60-6925490.53

6、(0.51-0.56)70-7932270.64 (0.61-0.67)80-8922510.70 (0.65-0.75)0.250.350.50.71.0A: usual systolic blood pressure (115 mmHg)Hazard ratio (95% CI) for 20 mmHgLower usual systolic blood pressureLancet 2002,360:1903收缩压 20 mmHg 差值对心血管危险影响5降压治疗策略与目标的回顾及进展CauseAge atNumber of0.250.35CauseAge atNumber ofOf de

7、athrisk(years)deathsStroke40-493480.35 (0.30-0.40)50-5912430.34 (0.32-0.37)60-6926460.40 (0.38-0.42)70-7939150.48 (0.45-0.51)80-8923400.63 (0.58-0.69)IHD40-4911140.47 (0.43-0.51)50-5949450.52 (0.50-0.55)60-6992890.56 (0.54-0.58)70-7997270.62 (0.60-0.64)80-8950680.70 (0.65-0.74)Other40-493160.43 (0.3

8、7-0.50)vascular50-5911400.48 (0.44-0.52)60-6922200.49 (0.46-0.53)70-7928530.61 (0.57-0.66)80-8919760.71 (0.64-0.79)0.250.350.50.71.0B: usual diastolic blood pressure (75 mmHg)Hazard ratio (95% CI) for 10 mmHgLower usual diastolic blood pressureLancet 2002,360:1903舒张压 10 mmHg 差值对心血管危险影响6降压治疗策略与目标的回顾及

9、进展CauseAge atNumber of0.250.35血压参数预测脑卒中和冠心病死亡率的相对能力 脑卒中 冠心病 SBP 89% 93%DBP 83% 73%PP 37% 43%MAP 100% 97%Mid BP 100% 100%Lancet 2002,360:19037降压治疗策略与目标的回顾及进展血压参数预测脑卒中和冠心病死亡率的相对能力 ESRD危险性随血压升高而增加血压分级 患者 ESRD数目 年龄校正后的 校正后的RR (n = 322554) (n = 814) 每10万人年发生率 (95%CI)理想 61089 51 5.3 1.0正常 81621 86 6.6 1.2

10、 (0.8-1.7)正常高值 73798 134 11.1 1.9 (1.4-2.7)高血压 1级（轻度） 85684 275 21.0 3.1 (2.3-4.3) 2级（中度） 23459 158 43.6 6.0 (4.3-8.4) 3级（重度） 5464 73 96.1 11.2 (7.7-16.2) 4级（极重度）1429 37 187.1 22.1 (14.2-34.3)Klag MJ, Whelton PK, Randali BL et al, New Eng J Med. 1996;334:14-18.8降压治疗策略与目标的回顾及进展ESRD危险性随血压升高而增加血压分级 血压水

11、平的分类和定义(JNC-7) 分类 收缩压(mmHg) 舒张压(mmHg)正常血压 120 和 80高血压前期 120 - 139 或 80 - 89高血压1级 140 - 159 或 90 - 99高血压2级 160 或 100 9降压治疗策略与目标的回顾及进展血压水平的分类和定义(JNC-7) 分类 血压水平的分类和定义(ESH/ESC 2003)分类收缩压(mmHg)舒张压(mmHg)理想血压 120 80正常血压 120 - 129 80 - 84正常高值 130 - 139 85 - 891级高血压(轻度) 140 - 159 90 - 992级高血压(中度) 160 - 179 1

12、00 - 1093级高血压(重度) 160 110单纯收缩期高血压 140 9010降压治疗策略与目标的回顾及进展血压水平的分类和定义(ESH/ESC 2003)分类收缩110110119120129130139140149150159160+SBP, mm Hg% of men302520151050Adjusted relative risk5432107070747579808485899094100+DBP, mm Hg% of men302520151050Adjusted relative risk32.521.510.509599MRFIT: Arch Intern Med 19

13、93; 153:59811降压治疗策略与目标的回顾及进展1101101191201291301391401正常血压者临界血压者正常血压者临界血压者90%10%47%53%临界高血压转归(Tecumsch Study, 3年随访)12降压治疗策略与目标的回顾及进展正常血压者临界血压者正常血压者临界血压者90%10%47%5降压治疗临床试验荟萃分析结果T = treatmentC = controlNon-fatal eventsFatal eventsTCTCTCTCNumbers individuals020040060080010001200% reductionin oddsStroke3

14、9%CHD16%Vascular deaths21%All other deaths2%13降压治疗策略与目标的回顾及进展降压治疗临床试验荟萃分析结果T = treatmentC =0.080.060.040.020012345Years after randomizationIschemic StrokeHemorrhagic StrokePlacebo TreatmentActive TreatmentCumulative Stroke RateSHEP study: JAMA 2000; 284:26514降压治疗策略与目标的回顾及进展0.080.060.040.020012345Yea

15、rs aAnti-hypertensive therapy & incidence of HFn 840 1,627 4,736 4,695 1,148F.U. (mths) 56 25 53 24 101 Reduction 17% 51% 54% 29% 56%p ns 0.01 0.001 ns 0.0043% per year15降压治疗策略与目标的回顾及进展Anti-hypertensive therapy & inTrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSY

16、ST-CHINAALLHeterogeneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82All cardiovascular end points199:289137:18674:94410:56932%SD 52P=0.001Fatal and non-fatal stroke103:15944:7745:59195:29537%SD 62P=0.00125%SD 82P=0.004SHEPSYST-EURSYST-CH

17、INAALLHeterogeneity:P=0.96Fatal and non-fatal MI(including sudden death)90:11259:7733:44182:233Eur Heart J 1999:1(suppl):p316降压治疗策略与目标的回顾及进展TrialNumber of end pointsOdds Eur Heart J 1999:1(suppl):p3TrialNumber of end pointsTreat:ControlOdds rations andconfidence limitsSHEPSYST-EURSYST-CHINAALLHetero

18、geneity:P=0.38Reduction andSDTreatment betterTreatment worse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82Total mortality213:242133:13761:82397:46117%SD 62P=0.008Cardiovascular mortality90:11259:7733:44182:23325%SD 82P=0.00517降压治疗策略与目标的回顾及进展Eur Heart J 1999:1(suppl):p3TrPROGRESS: 预防脑卒中再发随访时间

19、（年）发生事件患者的比例安慰剂组 治疗组危险下降28% (95%的可信限 17-38%)P0.0001Lancet 2001; 358: 1033-410.200.150.100.050.00123418降压治疗策略与目标的回顾及进展PROGRESS: 预防脑卒中再发随访时间（年）发生事件患降压治疗的益处 平均下降 脑卒中 3540% 心肌梗死 2025% 心力衰竭 50% 19降压治疗策略与目标的回顾及进展降压治疗的益处 TrialsNumber ofOdds ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS15

20、/135815/1353STOP2/CCBs369/2213362/2196NORDIL228/5471153/3157INSIGHT152/3164153/3157ALLHAT/Aml 2203/152551256/9048ELSA 17/115713/1177CCBs without CONVINCE2984/286182030/22341-3.1% (3.2) 2P=0.31Heterogeneity P=0.95CONVINCE319/8297337/8179All CCBs3303/369152367/30520-2.3% (2.9) 2P=0.42 Heterogeneity P=

21、0.95UKPDS59/35875/400STOP2/ACEIs369/2213380/2205CAPPP190/5493184/5492ALLHA/Lis2203/152551314/3044ANBP2210/3039195/3044HYVET/AD30/42627/431All ACEIs3061/267842175/20626-0.4% (3.1) 2P=0.89Heterogeneity P=0.90LIFE 431/4588383/4605SCOPE266/2460259/2477All ARBs697/7048642/7082-9.2% (5.9) 2P=0.09Heterogen

22、eity P=0.42ALLHAT/Dox851/15268514/9067All trias 4489/532795698/67295-1.8% (2.1) 2P=0.38Heterogeneity P=0.96 降压治疗临床试验汇萃分析：总死亡率（CCB、ACEI、ARB vs 利尿剂/b阻滞剂）New drugs betterOld drugs better0123Total mortalityStaessen JA. J Hypertens 2003,21:105520降压治疗策略与目标的回顾及进展TrialsNumber ofOdds ratiosTrialsNumber ofOdd

23、s ratios Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS7/135810/1353STOP2/CCBs221/2213212/2196NORDIL115/5471131/5410INSIGHT52/316460/3157ALLHAT/Aml 992/15255592/9048ELSA 8/11574/1177CCBs without CONVINCE1438/309471039/246852.0% (4.4) 2P=0.64Heterogeneity P=0.59CONVINCE143/8297152/8179All

24、CCBs1581/392441191/328642.7% (4.1) 2P=0.51 Heterogeneity P=0.68UKPDS32/35848/400STOP2/ACEIs221/2213226/2205CAPPP95/549376/5492ALLHA/Lis992/15255609/9054ANBP282/303984/3044HYVET/AD23/42622/431All ACEIs1539/231461365/191262.2% (4.3) 2P=0.61Heterogeneity P=0.50LIFE 234/4588204/4605SCOPE152/2460145/2477

25、All ARBs386/7048349/7082-10.6% (8.1) 2P=0.15Heterogeneity P=0.59All trias 2104/501152349/560230.5% (3.1) 2P=0.87Heterogeneity P=0.53 降压治疗临床试验汇萃分析：心血管病死亡率（CCB、ACEI、ARB vs 利尿剂/b阻滞剂）New drugs betterOld drugs better0123Total mortality21降压治疗策略与目标的回顾及进展TrialsNumber ofOdds ratiosTrialsNumber ofOdds ratios

26、Diferecevents/paitients(95% Cls)(SD)OldNewMIDAS/NICS/VHAS37/135839/1353STOP2/CCBs637/2213636/2196NORDIL453/5471466/5410INSIGHT397/3164383/3157ALLHAT/Aml 3941/152552432/9048ELSA 33/115727/1177CCBs without CONVINCE5498/286183983/223413.6% (2.4) 2P=0.14Heterogeneity P=0.78CONVINCE365/8297364/8179All CC

27、Bs5863/369154347/305203.4% (2.3) 2P=0.15 Heterogeneity P=0.86UKPDS78/358107/400STOP2/ACEIs637/2213586/2205CAPPP401/5493438/5492ALLHA/Lis3941/152552514/9054ANBP2429/3039394/3044All ACEIs*5486/263584039/201952.6% (3.6) 2P=0.59Heterogeneity P=0.006LIFE 588/4588508/4605SCOPE268/2460242/2477All ARBs856/7

28、048750/7082-14.3% (5.5) 2P=0.004Heterogeneity P=0.69ALLHAT/Dox2245/152681592/9067All trias*7627/5285310728/66864-1.4% (4.8) 2P=0.69Heterogeneity P0.0001 降压治疗临床试验汇萃分析：CVD发生率（CCB、ACEI、ARB vs 利尿剂/b阻滞剂）New drugs betterOld drugs better0123Total mortalityStaessen JA. J Hypertens 2003,21:105522降压治疗策略与目标的回顾

29、及进展TrialsNumber ofOdds ratios收缩压下降与CVD危险汇萃相关分析Staessen JA. J Hypertens 2003,21:1055All cardiovascular eventsDifference (referecne minus experimental in systolic pressure (mmHg)0510152025-51.501.251.000.750.500.25Odd ratio (experimental/reference)p 0.0001STONEUKPDS L vs HPART2/SCATHOPEPATSSHEPPROGRES

30、S/ComSTOP1RCT70-80HEPEWPHEMRC2MRC1ATMHSyst-EurSyst-ChinaRENAALPROGRESS/PerSTOP2/ACEISHOT L vs HINSIGMTHOT M vs HMIDAS/NICS/VHASNORDILCAPPISTOP2/CCBsUKPDS C vs AALLHAT0510152025-51.501.251.000.750.500.25Odd ratio (experimental/reference)ALLHAT/Lis bLACKSALLHAT/Lis 65 yALLHAT/LisALLHAT/AmlCONVINCEABCD

31、/NT L vs HDIABHYCARANBP2IDNT2LIFE/ALLSCOPEPREVENTELSAAASK L vs HNICOLELIFE/DM23降压治疗策略与目标的回顾及进展收缩压下降与CVD危险汇萃相关分析Staessen JA. LIFE:收缩压差值的意义 Odds Ratio(95% CI) 观察值 预期值 pAll patients (1 mmHg) CVD死亡率 0.87(0.72-1.05) 0.90(0.78-1.05)0.75 CVD事件 0.85(0.76-0.96) 0.93(0.85-1.02)0.24 Stroke 0.74(0.63-0.88) 0.87

32、(0.79-0.95)0.11 MI 1.05(0.86-1.28) 0.93(0.85-1.02)0.28Diabetic patients (3 mmHg) CVD死亡率 0.62(0.41-0.92) 0.86(0.76-0.99)0.12 CVD事件 0.73(0.57-0.95) 0.84(0.77-0.91)0.34 Stroke 0.78(0.54-1.13) 0.78(0.71-0.85)0.99 MI 0.81(0.54-1.22) 0.85(0.78-0.93)0.82Staessen: Eur Heart J 2003;24:50424降压治疗策略与目标的回顾及进展LIF

33、E:收缩压差值的意义 ALLHAT Collaborative Research Group. JAMA. 2002;288:2981-2997.相对危险 (95% CI)氯噻酮更好氨氯地平 0.98 (0.90-1.07)0.71.3 赖诺普利 0.99 (0.91-1.08)氨氯地平更好赖诺普利更好1ALLHAT主要终点：CHD死亡和非致死性心肌梗死25降压治疗策略与目标的回顾及进展ALLHAT Collaborative Research WHO/ISHBlood Pressure LoweringTrialists Collaboration(BPLT临床试验协作研究)26降压治疗策略

34、与目标的回顾及进展WHO/ISH26降压治疗策略与目标的回顾及进展BPLT协作研究第二轮分析新入选的临床试验AASK ANBP2 ASCOT ALLHAT BENEDICT CONVINCE DIAB-HYCAR ELSA HYVET LIFE PHYLLIS PRIME PROGRESS RENAAL SCOPE SHELL27降压治疗策略与目标的回顾及进展BPLT协作研究第二轮分析新入选的临床试验AASK ABPLT协作研究第二轮分析结果(二) RR 95% CIACEI vs 利尿剂/ 阻滞剂 1.09 1.00-1.18CCB vs 利尿剂/ 阻滞剂 0.93 0.86-1.21ACE

35、I vs CCB 1.12 1.01-1.25脑卒中28降压治疗策略与目标的回顾及进展BPLT协作研究第二轮分析结果(二)脑卒中28降压治疗策r=.93,p.001SYST-EURSTOPCoopeSHEPEWPHEMRC-EMRC-I0510152025303514121086420Stroke Rate in Placebo Group (per 1000 pt-yr)Stroke Prevented (per 1000 pt-yr)Lever AF. J Hypertens 1995;13(6):57129降压治疗策略与目标的回顾及进展r=.93,p.001SYST-EURSTOPCoo

36、peSBPLT协作研究第一轮分析结果(二)积极降压的RR总死亡率0.97(0.85-1.11)CVD死亡率0.90(0.75-1.09)CVD事件0.85(0.76-0.96)Stroke0.80(0.65-0.98)CHD0.81(0.67-0.98)CHF0.78(0.53-1.15)30降压治疗策略与目标的回顾及进展BPLT协作研究第一轮分析结果(二)积极降压的RR30降压0510152025Major CV events/1000 patient yearsTarget DBP mm Hgp=0.005 for trend 90 85 80HOT:目标血压与CVD事件高血压合并糖尿病患

37、者31降压治疗策略与目标的回顾及进展0510152025Major CV events/Targ 降压治疗与心血管危险控制基本观点 临床试验证实长期有效降压治疗能减少30%-50% 心脑血管病发生率。 降压治疗的益处主要来自血压降低。 益处大小受患者心血管危险程度、血压控制目标 水平、治疗方案降压以外有利作用或不利作用的 影响。32降压治疗策略与目标的回顾及进展 降压治疗与心血管危险控制 临床试验证实长期有效降压治疗能血压控制目标值(JNC-7)高血压患者： 140/90 mmHg糖尿病和慢性肾脏疾病患者：130/80 mmHg33降压治疗策略与目标的回顾及进展血压控制目标值(JNC-7)高血

38、压患者：33降压治疗策略与血压控制目标值(ESH/ESC 2003)高血压患者140/90 mmHg糖尿病患者130/80 mmHg34降压治疗策略与目标的回顾及进展血压控制目标值(ESH/ESC 2003)高血压患者14JNC-7：降压治疗流程生活方式改变血压未达到控制目标值 ( 140/90), 糖尿病和慢性肾脏病 ( 180 orDBP 110No other riskfactors12 risk factors3 or more riskfactors or TODor diabetesACCV HIGH RISKV HIGH RISKV HIGH RISK V HIGH RISKHI

39、GH RISKHIGH RISKHIGH RISK MEDIUM RISK MEDIUM RISKMEDIUM RISKLOW RISKSBP 120129 orDBP 8084SBP 130139 orDBP 8589 V HIGH RISKV HIGH RISKAVERAGE RISKLOW RISK LOW RISKAVERAGE RISK心血管危险分层标准(ESH/ESC 2003)MEDIUM RISK HIGH RISK HIGH RISK 38降压治疗策略与目标的回顾及进展BLOOD PRESSURE (mm Hg)SBP 140降压治疗策略与目标的回顾及进展培训课件靶器官损害(

40、ESH/ESC 2003) 左心室肥厚 (心电图: Sokolow-Lyons 38 mm, Cornell 2440 mmmms 超声心动图: LVMI男 125, 女 110 g/m2) 超声有动脉壁增厚 (颈动脉IMT 0.9 mm)或粥样斑块证据 血肌酐轻度升高 (男115 133, 女107 124 mmol/L) 尿微量白蛋白 (30 300 mg/24h; 白蛋白/肌酐男 22, 女31mg/g)40降压治疗策略与目标的回顾及进展靶器官损害(ESH/ESC 2003) 左心室肥厚40糖尿病(ESH/ESC 2003)空腹血糖 7.0 mmol/L餐后血糖 11.0 mmol/L4

41、1降压治疗策略与目标的回顾及进展糖尿病(ESH/ESC 2003)空腹血糖 7.0 mm并存的临床情况(ESH/ESC 2003)脑血管病缺血性卒中脑出血短暂性脑缺血发作心脏疾病心肌梗死心绞痛冠状动脉血运重建充血性心力衰竭肾脏疾病糖尿病肾病肾脏损害(血肌酐男133, 女124 mol/L)蛋白尿(300 mg/24h)周围血管疾病重度视网膜病变出血或渗出视乳头水肿42降压治疗策略与目标的回顾及进展并存的临床情况(ESH/ESC 2003)脑血管病心脏疾病肾降压治疗指征(B)1级和2级高血压:Very High RiskHigh RiskMedium RiskLow Risk43降压治疗策略与目标的回顾及进展降压治疗指征(B)1级和2级高血压:Very High Ri降压治疗指征(B)Stratify riskMediumMonitor BP & otherrisk factors for at least 3 monthsSBP 140or DBP 90Begin drugtreatmentSBP 140and DBP 140or DBP 90Consider drugtreatmentSBP 140and DBP 90Continueto monitor44降压治疗策略与目标的回顾及进展降压治疗指征(B