降压治疗与心血管病预防课件

BPreductionandCVprevention

降压治疗与心血管病预防

–关注降压质量，丰富高血压专业内涵–王继光上海交通大学医学院附属瑞金医院上海市高血压研究所BPreductionandCVprevention1RelativeriskreductionsbyantihypertensivetreatmentinearlytrialsProgressiontosevereHTCHFStrokeCHDTotalmortalityCVmortality-94％*-53%*-40%*-16%*-13%-21%**P<0.05CollinsR,etal.BrMedBull1994;50:272-298.Relativeriskreductionsbyan2BPLTTC.Lancet2003;362:1527-45.0-5-10-15-20-25-30StrokeCHDCHFTotalmortality-23%-15%-16%-14%－4/3mmHgN＝20888MajorCVevents-15%RelativeriskreductionsbyantihypertensivetreatmentinrecenttrialsBPLTTC.Lancet2003;362:1527-43Do5classesofantihypertensivedrugsdifferinthepreventionofCVcomplications?5大类降压药物改善结局的作用有差别吗?Do5classesofantihypertensi41.PreventionofstrokeCCBsaremoreprotectiveagainststroke.预防卒中:CCBs>利尿剂/阻滞剂>ACEIs

1.Preventionofstroke5CCBsvs.

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/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBswithoutCONVINCE p=0.68CONVINCE所有CCBs p=0.3915/1358237/2213196/547174/3164675/1525514/11571211/28618118/82971329/3691519/1353207/2196159/541067/3157377/90489/1177838/22341133/8179971/30520–10.2%(4.8)2p=0.02–7.6%(4.4)2p=0.07StaessenJA,etal.Lancet2001;37:1305-15.StaessenJAetal.JHypertens2003;21:1055-76.CCBsvs.利尿剂/阻滞剂:利尿剂/阻滞剂CCB60ACEIs较好123UKPDSSTOP2/ACEIsCAPPPALLHAT/LisinoprilANBP2所有ACEIs p=0.1617/358237/2213148/5493675/15255107/30391184/2635821/400215/2205189/5492457/9054112/3044994/2019510.2%(4.6)2p=0.03ACEIsvs.

利尿剂/阻滞剂:致死性与非致死性脑卒中利尿剂/阻滞剂试验事件数/研究对象人数异质性检验危险比(95%可信区间)差别(SD)CCBs利尿剂/阻滞剂较好StaessenJA,etal.Lancet2001;37:1305-15.StaessenJAetal.JHypertens2003;21:1055-76.0ACEIs较好123UKPDS17/35821/400107降压治疗与心血管病预防课件8

相对危险度(95%CI)赖诺普利较好氨氯地平较好+1%(–9%to+11%)CHD+5%(–3%to+13%)总死亡率+4%(–3%to+12%)联合CHD脑卒中联合CVD需要住院的GI出血心衰心绞痛冠脉血运重建外周动脉疾病0.51.02.0+23%(+8%to+41%)+6%(0to+12%)+20%(+6%to+37%)-13%(–22%to–4%)+9%(0to+19%)0(–9%to+11%)+19%(+1%to+40%)P=0.055P=0.047P=0.003P=0.007P=0.004P=0.036

终点事件

差别(95%CI)LeenenFHH,etal.Hypertension2006;48:374-384.ALLHAT：赖诺普利vs.氨氯地平相对危险度赖诺普利较好氨氯地平较好+1%(–9%to9

相对危险度(95%CI)培多普利较好安慰剂较好9%(0%to17%)Combinedmacro+micro14%(2%to25%)Alldeaths18%(2%to32%)CVdeathsNonCVdeathsTotalcoronaryTotalcerebrovascularStrokeHeartfailureTotalrenaleventsTotaleyeevents0.51.02.08%(-12%to24%)14%(2to24%)6%(-10%to20%)2%(-18%to19%)21%(15%to27%)5%(-1%to10%)P=0.42

终点事件

差别(95%CI)PatelAetal.Lancet2007;370:829-40.ADVANCE：培多普利vs.安慰剂2%(-20%to19%)P=0.86相对危险度培多普利较好安慰剂较好9%(0%to1710165/1280102/6108218/5571157/128198/6110215/5569PROGRESS/perindoprilonlyEUROPAADVANCE

0.511.52.0培多普利

vs.

安慰剂:致死性与非致死性脑卒中培多普利较好安慰剂较好安慰剂试验事件数/研究对象人数危险比(95%可信区间)血压差别(mmHg)培多普利5/25/25.6/2.2PROGRESSManagementCommittee.Lancet200;358:1033-41;FoxKetal.Lancet2003;362:782-8;PatelAetal.Lancet2007;370:829-40.165/1280157/1281PROGRESS/p112.PreventionofMIAmlodipineprovidessimilarprotectionagainstMIasACEIs.心肌梗死预防:氨氯地平

≈

利尿剂/阻滞剂≈

ACEIs

2.PreventionofMI1216/1358154/2213157/547161/31641362/1525517/11571767/28618166/82971933/3691516/1353179/2196183/541077/3157798/904818/11771271/22341133/81791404/305204.5%(3.9)2p=0.261.9%(3.7)2p=0.61MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBswithoutCONVINCE p=0.38CONVINCEAllCCBs p=0.140123CCBsvs.

利尿剂/阻滞剂:致死性与非致死性心肌梗死CCBs较好利尿剂/阻滞剂较好利尿剂/阻滞剂试验事件数/研究对象人数异质性检验危险比(95%可信区间)差别(SD)CCBsStaessenJA,etal.Lancet2001;37:1305-15.StaessenJAetal.JHypertens2003;21:1055-76.16/135816/13534.5%(3.9)2p=130.200.150.100.050.0001234567基线CHD随访时间（年）赖/氨1.06(0.99-1.32)0.69RR(95%Cl)P值0.200.150.100.050.0001234567基线无CHD氨氯地平赖诺普利赖/氨0.98(0.88-1.13)0.78RR(95%Cl)P值ALLHAT:致死/非致死性CHD发生率随访时间（年）LeenenFHH,etal.Hypertension2006;48:374-384.CHD累计发生率0.200114AHA/ACC高血压合并冠心病降压治疗建议：

各类降压药物的异质性RosendorffCetal.Circulation2007;115:2761-88.…Thereisalsocontinuingdebateoverwhetherthereare“classeffects”forantihypertensivedrugsorwhethereachdrugmustbeconsideredindividually.Itisreasonabletoassumethatthereareclasseffectsforthiazide-typediuretics,ACEinhibitors,andARBs,whichhaveahighdegreeofhomogeneityintheirmechanismsofactionandsideeffects.Itisequallyclearthattherearemajordifferencesbetweendrugswithinmoreheterogeneousclassesofagents,suchas-blockersorCCBs.AHA/ACC高血压合并冠心病降压治疗建议：

各类降压药物的153.PrventionofstrokeandMIAmlodipinevs.ARBs脑卒中与心肌梗死预防:氨氯地平

vs.ARBs

3.PrventionofstrokeandMI16PreventionofstrokeandMIbyamlodipineandARBs氨氯地平与ARBs预防卒中与心肌梗死Ameta-analysisofRCTs随机对照临床试验综合分析WangJGetal.Hypertension2007;50:333-339.PreventionofstrokeandMIby17氨氯地平vs.ARBs*:

脑卒中氨氯地平较好ARBs较好IDNTVALUECASE-J所有试验p=0.4630/579322/764960/2354412/10,58218/567281/759647/2349346/10,512–15.9%(6.2)2p=0.020.51.01.52.0*厄贝沙坦、缬沙坦、坎地沙坦ARBs氨氯地平试验事件数/研究对象人数异质性检验危险比(95%可信区间)差别(SD)WangJGetal.Hypertension2007;50:333-339.氨氯地平vs.ARBs*:脑卒中氨氯地平较好ARBs较18IDNTVALUECASE-JAlltrialsp=0.4051/579369/764917/2354437/10,58233/567281/759618/2349332/10,512–16.7%(6.1)2p=0.010.51.01.52.0氨氯地平vs.ARBs*:MIARBs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)氨氯地平氨氯地平较好ARBs较好*厄贝沙坦、缬沙坦、坎地沙坦WangJGetal.Hypertension2007;50:333-339.IDNT51/57933/567–16.7%(6.1)19Whydiffer,beyondBPcontrol,orbecauseofbetterBPcontrol?为什么有差别，是“降压外作用”，还是“高质量的降压才是硬道理”？Whydiffer,beyondBPcontrol,201.LowersystemicBPCentralvs.peripheralBP降低整个动脉系统的血压:中心动脉压

vs.肱动脉血压

1.LowersystemicBP21不同部位的血压水平有所不同不同部位的血压水平有所不同22降压治疗与心血管病预防课件2301.02.03.04.05.06.0140135130125120115CAFE研究：外周与中心血压外周SBP:mean=0.7(-0.4to1.7)mmHg中心SBP:mean=4.3(3.3to5.4)mmHg133.9133.2125.5121.2SBP(mmHg)Timesincerandomisation(years)WilliamsB,etal.Circulation2006;113:1213-1225.阿替洛尔氨氯地平01.02.03.04.05.06.014013513012242.Lower24-hourBPTheroleofmorningsurge降低24小时血压:晨峰血压

2.Lower24-hourBP25Pedersenetal.JHypertens2007;25:707-712.Pedersenetal.JHypertens2026MeanSBPdifference(Amlodipine-valsartan,mmHg)16111621-4-3-1012给药后时间（小时）-2ABPMinVALUE:给药后24小时内收缩压的差别(氨氯地平vs缬沙坦，n=659)-2.7mmHgP=0.039Pedersenetal.JHypertens2007;25:707-712.MeanSBPdifference(Amlodipin27EarlymorningBPsurge清晨高血压的风险6:000:0012:0018:00Mulleretal.NEnglJMed1985;313:1315–1322;Marleretal.Stroke1989;20:473–476.020406080100120140160180卒中(per2h)05101520253035404550心肌梗死(perh)Stroke(n=1,167)Myocardialinfarction(n=2,999)TimeofthedayEarlymorningBPsurge清晨高血压的风险283.Nottoolow,nottoofastTreatpatientsindividually不宜太低，不应太快:应遵循个体化原则3.Nottoolow,nottoofast29MI或卒中发病率(%)MIStroke60>60to70>70to80>80to90>90to100>100to110>11005101520253035随访期间的平均舒张压

(mmHg)MIandstrokebyaveragefollow-upDBPinINVESTMesserliFH

etal.AnnInternMed2006;144:884–93.MI或卒中发病率(%)MIStroke60>630高血压合并冠心病患者降压治疗130/80缺血性心脏病心衰130/80STEMI不稳定性心绞痛或NSTEMI130/80or120/80稳定性心绞痛not<60mmHgslowly130/80合并冠心病危险因素特别注意降压速度降压治疗目标血压(mmHg)冠心病不同阶段RosendorffCetal.Circulation2007;115:2761-88.not<60mmHgnot<60mmHgnot<60mmHgnot<60mmHgslowlyslowlyslowlyslowly130/80or120/80高血压合并冠心病患者降压治疗130/80缺血性心脏病心衰1331高血压一旦确诊，应及早开始降压治疗。降低血压是抗高血压治疗获益的关键。与利尿剂、阻滞剂、ACEIs以及ARBs相比，CCBs具有较强的脑卒中预防作用。卒中是我国高血压患者最常见的并发症，因此，CCBs应作为我国高血压患者的基础性用药。各种DHP-CCBs之间预防心肌梗死的作用可能存在很大差异。氨氯地平是唯一有证据显示与利尿剂、阻滞剂、ACEIs具有相似的预防心肌梗死作用的DHP-CCB。降压药物之间的差异很可能仅仅是其降压质量的差异。与其强调降压之外的作用，不如强化降压、降脂、降糖等多重危险因素干预。高血压一旦确诊，应及早开始降压治疗。降低血压是抗高血压治疗获32Thankyouverymuch！Thankyouverymuch！33BPreductionandCVprevention

降压治疗与心血管病预防

–关注降压质量，丰富高血压专业内涵–王继光上海交通大学医学院附属瑞金医院上海市高血压研究所BPreductionandCVprevention34RelativeriskreductionsbyantihypertensivetreatmentinearlytrialsProgressiontosevereHTCHFStrokeCHDTotalmortalityCVmortality-94％*-53%*-40%*-16%*-13%-21%**P<0.05CollinsR,etal.BrMedBull1994;50:272-298.Relativeriskreductionsbyan35BPLTTC.Lancet2003;362:1527-45.0-5-10-15-20-25-30StrokeCHDCHFTotalmortality-23%-15%-16%-14%－4/3mmHgN＝20888MajorCVevents-15%RelativeriskreductionsbyantihypertensivetreatmentinrecenttrialsBPLTTC.Lancet2003;362:1527-436Do5classesofantihypertensivedrugsdifferinthepreventionofCVcomplications?5大类降压药物改善结局的作用有差别吗?Do5classesofantihypertensi371.PreventionofstrokeCCBsaremoreprotectiveagainststroke.预防卒中:CCBs>利尿剂/阻滞剂>ACEIs

1.Preventionofstroke38CCBsvs.

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/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBswithoutCONVINCE p=0.68CONVINCE所有CCBs p=0.3915/1358237/2213196/547174/3164675/1525514/11571211/28618118/82971329/3691519/1353207/2196159/541067/3157377/90489/1177838/22341133/8179971/30520–10.2%(4.8)2p=0.02–7.6%(4.4)2p=0.07StaessenJA,etal.Lancet2001;37:1305-15.StaessenJAetal.JHypertens2003;21:1055-76.CCBsvs.利尿剂/阻滞剂:利尿剂/阻滞剂CCB390ACEIs较好123UKPDSSTOP2/ACEIsCAPPPALLHAT/LisinoprilANBP2所有ACEIs p=0.1617/358237/2213148/5493675/15255107/30391184/2635821/400215/2205189/5492457/9054112/3044994/2019510.2%(4.6)2p=0.03ACEIsvs.

利尿剂/阻滞剂:致死性与非致死性脑卒中利尿剂/阻滞剂试验事件数/研究对象人数异质性检验危险比(95%可信区间)差别(SD)CCBs利尿剂/阻滞剂较好StaessenJA,etal.Lancet2001;37:1305-15.StaessenJAetal.JHypertens2003;21:1055-76.0ACEIs较好123UKPDS17/35821/4001040降压治疗与心血管病预防课件41

相对危险度(95%CI)赖诺普利较好氨氯地平较好+1%(–9%to+11%)CHD+5%(–3%to+13%)总死亡率+4%(–3%to+12%)联合CHD脑卒中联合CVD需要住院的GI出血心衰心绞痛冠脉血运重建外周动脉疾病0.51.02.0+23%(+8%to+41%)+6%(0to+12%)+20%(+6%to+37%)-13%(–22%to–4%)+9%(0to+19%)0(–9%to+11%)+19%(+1%to+40%)P=0.055P=0.047P=0.003P=0.007P=0.004P=0.036

终点事件

差别(95%CI)LeenenFHH,etal.Hypertension2006;48:374-384.ALLHAT：赖诺普利vs.氨氯地平相对危险度赖诺普利较好氨氯地平较好+1%(–9%to42

相对危险度(95%CI)培多普利较好安慰剂较好9%(0%to17%)Combinedmacro+micro14%(2%to25%)Alldeaths18%(2%to32%)CVdeathsNonCVdeathsTotalcoronaryTotalcerebrovascularStrokeHeartfailureTotalrenaleventsTotaleyeevents0.51.02.08%(-12%to24%)14%(2to24%)6%(-10%to20%)2%(-18%to19%)21%(15%to27%)5%(-1%to10%)P=0.42

终点事件

差别(95%CI)PatelAetal.Lancet2007;370:829-40.ADVANCE：培多普利vs.安慰剂2%(-20%to19%)P=0.86相对危险度培多普利较好安慰剂较好9%(0%to1743165/1280102/6108218/5571157/128198/6110215/5569PROGRESS/perindoprilonlyEUROPAADVANCE

0.511.52.0培多普利

vs.

安慰剂:致死性与非致死性脑卒中培多普利较好安慰剂较好安慰剂试验事件数/研究对象人数危险比(95%可信区间)血压差别(mmHg)培多普利5/25/25.6/2.2PROGRESSManagementCommittee.Lancet200;358:1033-41;FoxKetal.Lancet2003;362:782-8;PatelAetal.Lancet2007;370:829-40.165/1280157/1281PROGRESS/p442.PreventionofMIAmlodipineprovidessimilarprotectionagainstMIasACEIs.心肌梗死预防:氨氯地平

≈

利尿剂/阻滞剂≈

ACEIs

2.PreventionofMI4516/1358154/2213157/547161/31641362/1525517/11571767/28618166/82971933/3691516/1353179/2196183/541077/3157798/904818/11771271/22341133/81791404/305204.5%(3.9)2p=0.261.9%(3.7)2p=0.61MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBswithoutCONVINCE p=0.38CONVINCEAllCCBs p=0.140123CCBsvs.

利尿剂/阻滞剂:致死性与非致死性心肌梗死CCBs较好利尿剂/阻滞剂较好利尿剂/阻滞剂试验事件数/研究对象人数异质性检验危险比(95%可信区间)差别(SD)CCBsStaessenJA,etal.Lancet2001;37:1305-15.StaessenJAetal.JHypertens2003;21:1055-76.16/135816/13534.5%(3.9)2p=460.200.150.100.050.0001234567基线CHD随访时间（年）赖/氨1.06(0.99-1.32)0.69RR(95%Cl)P值0.200.150.100.050.0001234567基线无CHD氨氯地平赖诺普利赖/氨0.98(0.88-1.13)0.78RR(95%Cl)P值ALLHAT:致死/非致死性CHD发生率随访时间（年）LeenenFHH,etal.Hypertension2006;48:374-384.CHD累计发生率0.200147AHA/ACC高血压合并冠心病降压治疗建议：

各类降压药物的异质性RosendorffCetal.Circulation2007;115:2761-88.…Thereisalsocontinuingdebateoverwhetherthereare“classeffects”forantihypertensivedrugsorwhethereachdrugmustbeconsideredindividually.Itisreasonabletoassumethatthereareclasseffectsforthiazide-typediuretics,ACEinhibitors,andARBs,whichhaveahighdegreeofhomogeneityintheirmechanismsofactionandsideeffects.Itisequallyclearthattherearemajordifferencesbetweendrugswithinmoreheterogeneousclassesofagents,suchas-blockersorCCBs.AHA/ACC高血压合并冠心病降压治疗建议：

各类降压药物的483.PrventionofstrokeandMIAmlodipinevs.ARBs脑卒中与心肌梗死预防:氨氯地平

vs.ARBs

3.PrventionofstrokeandMI49PreventionofstrokeandMIbyamlodipineandARBs氨氯地平与ARBs预防卒中与心肌梗死Ameta-analysisofRCTs随机对照临床试验综合分析WangJGetal.Hypertension2007;50:333-339.PreventionofstrokeandMIby50氨氯地平vs.ARBs*:

脑卒中氨氯地平较好ARBs较好IDNTVALUECASE-J所有试验p=0.4630/579322/764960/2354412/10,58218/567281/759647/2349346/10,512–15.9%(6.2)2p=0.020.51.01.52.0*厄贝沙坦、缬沙坦、坎地沙坦ARBs氨氯地平试验事件数/研究对象人数异质性检验危险比(95%可信区间)差别(SD)WangJGetal.Hypertension2007;50:333-339.氨氯地平vs.ARBs*:脑卒中氨氯地平较好ARBs较51IDNTVALUECASE-JAlltrialsp=0.4051/579369/764917/2354437/10,58233/567281/759618/2349332/10,512–16.7%(6.1)2p=0.010.51.01.52.0氨氯地平vs.ARBs*:MIARBs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)氨氯地平氨氯地平较好ARBs较好*厄贝沙坦、缬沙坦、坎地沙坦WangJGetal.Hypertension2007;50:333-339.IDNT51/57933/567–16.7%(6.1)52Whydiffer,beyondBPcontrol,orbecauseofbetterBPcontrol?为什么有差别，是“降压外作用”，还是“高质量的降压才是硬道理”？Whydiffer,beyondBPcontrol,531.LowersystemicBPCentralvs.peripheralBP降低整个动脉系统的血压:中心动脉压

vs.肱动脉血压

1.LowersystemicBP54不同部位的血压水平有所不同不同部位的血压水平有所不同55降压治疗与心血管病预防课件5601.02.03.04.05.06.0140135130125120115CAFE研究：外周与中心血压外周SBP:mean=0.7(-0.4to1.7)mmHg中心SBP:mean=4.3(3.3to5.4)mmHg133.9133.2125.5121.2SBP(mmHg)Timesincerandomisation(years)WilliamsB,etal.Circulation2006;113:1213-1225.阿替洛尔氨氯地平01.02.03.04.05.06.014013513012572.Lower24-hourBPTheroleofmorningsurge降低24小时血压:晨峰血压

2.Lower24