從高血壓到心力衰竭挑戰(zhàn)與對策幻燈

1、從高血壓到心力衰竭挑戰(zhàn)與對策挑戰(zhàn)與對策1. McKee et al. N Engl J Med. 1971;285:1441-1446.2. Levy D. JAMA 1996;275:1557-1562.高血壓: 心力衰竭的主要危險因素Framingham Heart Study Framingham 隨訪研究的資料顯示，高血壓 是心力衰竭發(fā)生的主要危險因素。 約90%90%的心力衰竭患者，在發(fā)生心力衰竭前 曾有高血壓史。160/100BP (mm Hg)Lloyd-Jones et al. Circulation 2002;106: 3068-3072.3343 men and 4199

2、women followed for 25 years no HF at baseline血壓水平與心力衰竭危險AgeMaleFemaleMaleFemaleMaleFemale051015202530Lifetime risk (%)40 years80 years60 yearsYears Normal LV Subclinical Clinical heartLV structure remodeling LV dysfunction failure& function Heart failureObesityDiabetesHTNSmokingDyslipidemiaDiabetesM

3、ILVHDiastolicdysfunctionYears/months SystolicdysfunctionDeathVasan RS et al. Arch Intern Med. 1996;156:1789-1796.HTN = HypertensionMI = Myocardial InfarctionLVH = Left ventricle hypertrophy高血壓如何進展到心力衰竭因心力衰竭首次住院患者左心室射血分數(shù)ALLHATHF BY EF LEVELN=1399EF50%心力衰竭預后：人群研究隨訪( (年) ) 死亡率(%)(%) HF-REF HF-PEFOlmste

4、d(1998) 5.0 65 65Framingham(1999) 6.2 75 46Helsinki(1997) 4.0 54 43心力衰竭預后：臨床研究薈萃分析(Somaratne, 2008) 17 17項研究，2450124501例，平均治療隨訪4747個月 38%38%患者死亡，RF-REF 40%RF-REF 40%，HF-PEF 32%HF-PEF 32%降壓治療有效降低心、腦血管病事件17 17項臨床試驗薈萃分析項臨床試驗薈萃分析-50-40-30-20-100Heart failure1Fatal/Nonfatalstroke1Fatal/NonfatalCHD1Risk r

5、eduction (%)1. Moser and Herbert. J Am Coll Cardiol. 1996; 2. Collins R et al. Lancet 1990.Vascular deaths-52%-38%-16%-21%HYVET: Heart Failureplaceboactive- Placebo_ ActiveA = CA vs placebo; B = ACE inhibitor vs placebo; C = more intensive vs less intensive blood- pressure-lowering; D = ARB vs contr

6、ol; E = ACE inihibitor vs CA; F = CA vs diuretic or -blocker; G = ACE inhibitor vs diuretic and -blocker.Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.BP-Lowering Treatment TrialistsA = CA vs placebo; B = ACE inhibitor vs placebo; C = more intensive vs less in

7、tensive blood- pressure-lowering; D = ARB vs control; E = ACE inihibitor vs CA; F = CA vs diuretic or -blocker; G = ACE inhibitor vs diuretic and -blocker.Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.BP-Lowering Treatment TrialistsACEI vs. placeboCA vs. place

8、boMore vs. lessARB vs. controlACEI vs. D/BBCA vs. D/BBACEI vs. CA219/8233104/338254/7494302/5935547/12498732/23425502/10357269/824688/327472/13394359/5919809/18652850/29734609/10345-5/-2-8/-4-4/-3-2/-1+2/0+1/0+1/+10.82 (0.69-0.98)1.21 (0.93-1.58)0.84 (0.59-1.18)0.84 (0.72-0.97)1.07 (0.96-1.19)1.33 (

9、1.21-1.47)0.82 (0.73-0.92)0.51.02.0Heart FailureEvents/participants1st Listed2nd ListedDifference in BP(Mean, mmHg)Relative risk(95% CI)Relative RiskFavours 1st listedFavours 2nd listed1. Table adapted from Blood Pressure Lowering Trialists Collaboration. Lancet. 2003;362:1527-1535.2. Gottdiener JS

10、et al. Ann Intern Med. 2002;137:631-639.ACEI = ACE inhibitorCA = calcium antagonistARB = angiotensin receptor blockerD/BB = diuretic or beta blockerEffects of antihypertensive treatment on the development of HF in hypertensive patients0.060.060.030.000123456Cumulative HF RateNo. at RiskChlorthalidon

11、e 152551456313980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HF0.050.040.020.01ALLHAT: 住院心力衰竭發(fā)生率Davis BR, et al. Circulation 2008;118:ChlorthalidoneLisinoprilAmlodipine0.020.010.000123456Cumulative HF RateNo. at RiskChlorthalidone 1525514563

12、13980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HFALLHAT: 住院HF-REF發(fā)生率Davis BR, et al. Circulation 2008;118:ChlorthalidoneAmlodipineLisinopril0.020.010.000123456Cumulative HF RateNo. at RiskChlorthalidone 152551456313980133251162465863212Aml

13、odipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HFALLHAT-HF: 住院HF-PEF發(fā)生率Davis BR, et al. Circulation 2008;118:ChlorthalidoneAmlodipineLisinoprilLewis et al. N Engl J Med. 2001;345:851-860.IDNT: No Significant Difference in Death From Any Cause061218243036424854Follo

14、w-up (mo)603001020IrbesartanAmlodipineControlRRR 37%p 0.001RRR 23%p = 0.15Subjects (%)Lewis EJ et al. N Engl J Med 2001;345(12):851-60.IDNT: Time to CHFMeta-regression analysis: Relation between odds ratios for CHF and differences in achieved SBP between randomized groups 5.03.02.221.81.61.41.00.80.

15、60.40.2-5-2.52.557.51000-5-2.52.557.52.55107.52.55Systolic blood pressure difference between randomized groups (mmHg)Odds ratio for congestive heart failureACE inhibitors orangiotensin-receptor blockersCalcium channel blockersPREVENTNICS1.2CAPPPVerdecchia P, et al. Eur Heart J. 2009;30:679-688. 病程早期

16、阻止病情進展和逆轉(zhuǎn)靶器官結(jié)構(gòu)與功能損害 病程中晚期 預防心、腦血管病和腎臟病終點事件降壓治療目標的演進與轉(zhuǎn)移:不同病程階段的目標不同病程階段的目標Devereux R, et al. JAMA. 2004;292:2350-2356Hazard Ratio: 0.58 (0.38-0.86) p .008LIFE-ECHO substudyImpact on LVH regression on outcomes210-1-2-3-4-5HCTZAtenololCaptoprilClonidine DiltiazemPrazosinChange in left atrial size (mm)T

17、ime since randomisation8 weeks1 year2 yearsLong-term antihypertensive treatment with hydrochlorothiazide reduces left atrial sizeCirculation 1998;98:40從高血壓到心力衰竭心力衰竭的預防策略心力衰竭的預防策略 高血壓是心力衰竭最常見的重要危險因素。大多數(shù)患者心力衰竭的發(fā)生與發(fā)展歸因于血壓和神經(jīng)內(nèi)分泌激素未獲得有效控制。 早期積極控制血壓水平能顯著降低心力衰竭的發(fā)生率與死亡率，以RAS阻滯劑和利尿劑為基礎(chǔ)的降壓治療可能是預防心力衰竭發(fā)生的優(yōu)化治療方案

18、。Years Normal LV Subclinical Clinical heartLV structure remodeling LV dysfunction failure& function Heart failureObesityDiabetesHTNSmokingDyslipidemiaDiabetesMILVHDiastolicdysfunctionYears/months SystolicdysfunctionDeathVasan RS et al. Arch Intern Med. 1996;156:1789-1796.HTN = HypertensionMI = Myoca

19、rdial InfarctionLVH = Left ventricle hypertrophy高血壓如何進展到心力衰竭0.020.010.000123456Cumulative HF RateNo. at RiskChlorthalidone 152551456313980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HFALLHAT: 住院HF-REF發(fā)生率Davis BR, et al. Circulation 2008;118:ChlorthalidoneAmlodipineLisinoprilLewis et al. N Engl J Med. 2