降壓治療研究新動態(tài)回顧與展望課件

1、降壓治療研究新動態(tài)降壓治療研究新動態(tài) 回顧與展望回顧與展望 80歲以上高齡高血壓歲以上高齡高血壓 (HYVET) 高血壓前期高血壓前期 (TROPH, PHARAO) 心房顫動心房顫動 (ADVANCE post hoc)新動態(tài)新動態(tài)( (一一): ): 擴(kuò)展降壓治療獲益人群擴(kuò)展降壓治療獲益人群1.00.90.80.70.60.50.40.30100200300400500600700800900100011001200DaysControlRamiprilSurvival functionPHARAO Study: Primary EndpointDevelopment of Hyperte

2、nsionHazard ratio0.656(0.533-0.807)Luders S, et al. J Hypertens. 2008;26:1487-1496* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *604020090100 120 130140160170180190200220230240PrehypertensionUncertainty Range 55 75% of the general pop

3、ulation% of screened populationNormotensionPrehypertensionMasked HypertensionSustainedHypertensionMixed population with WhiteCoat Hypertension and SustainedHypertension (FPs & TPs)Masked Hypertension (office BP 140/90 mmHg) (FNs)ADVANCE-AF ADVANCE-AF 研究研究 11140例例2 2型糖尿病，心房顫動占型糖尿病，心房顫動占7.6%。 peri

4、ndopril / indapamide 降壓治療降壓治療4.3 年，年， 治療組治療組血壓比對照組降低血壓比對照組降低 5.3 / 2.3 mmHg。 心房顫動患者降壓治療后總死亡率與心心房顫動患者降壓治療后總死亡率與心 血管死亡率分別降低血管死亡率分別降低14%與與18%，NTT 42。Eur Heart J. 2009; March 12. online publication.The ACTIVE Steering Committee. Am Heart J. 2006; 151:1187-93Atrial fibrillation Clopidogrel Trial with Irb

5、esartan for prevention of Vascular Events 腦卒中史腦卒中史 (PROGRESS再分析再分析, WASID) 糖尿病糖尿病 (ADVANCE)新動態(tài)新動態(tài)(二二): 心血管高?；颊邚?qiáng)化血壓控制心血管高?；颊邚?qiáng)化血壓控制100806040200120120-139 140-159 601008060402007070-7980-89 90Achieved systolic blood pressure levels(mmHg)Achieved diastolic blood pressure levels(mmHg)Age-and sex-adjusted

6、 incidence rate CKD: P trend=0.004Non-CKD: P trend0.0001 CKD: P trend=0.001Non-CKD: P trend0.0001CKDNon-CKDIncidence rate (1000 person-years)PROGRESS - CKD Substudy: SBP and CVDWASID Trial(Warfarin-Aspirin Symtomatic Intracranial Disease)Relationship Between Blood Pressure and Strke Recurrence in Pa

7、tients With Intracranial Arterial StenosisTuran TN, et al.Circulation.2007;115:2969-297510.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)P0.000110.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)Probability of Ischemic StrokeP0.000110.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)Probability of Isc

8、hemic Stroke in Territory10.90.80.70.60.50.40.30.20.10012345Follow-up (yrs)P0.0065Probability of Ischemic Stroke in TerritoryP0.0001Probability of Ischemic Stroke=160SBP=160SBPDBP=90DBP=90Turan NT, et al. Circulation. 2007;115:2969-2975WASIDHazard Ratios for Ischemic Stroke According to SBP and DBP

9、No. of events/patientsMedianFavorsFavorsHazard ratio P forPer-IndPlaceboBlood pressurePer-Indplacebo(95% CI) trendAll renal eventsAll participants1243/5569 1500/55710.79 (0.73 to 0.85)Baseline systolic blood pressure (mmHg)120134/615167/560113 mmHg0.70 (0.56 to 0.88)0.75120-139367/1736431/1793131 mm

10、Hg0.85 (0.74 to 0.97)140-159439/1945563/2003149 mmHg0.75 (0.66 to 0.85)160303/1273339/1215172 mmHg0.81 (0.70 to 0.95)Baseline diastolic blood pressure (mmHg)70208/846240/88166 mmHg0.84 (0.70 to 1.02)0.8570-79387/1748481/175875 mmHg0.77 (0.67 to 0.88)80-89386/1862479/183484 mmHg0.76 (0.66 to 0.87)902

11、62/1113300/109895 mmHg0.81 (0.69 to 0.96)All renal events, macrovascular events, all-cause deathAll participants1781/55692064/5571 0.82 (0.77 to 0.88)Baseline systolic blood pressure (mmHg) 120190/615205/560113 mmHg0.82 (0.68 to 1.00) 0.35120-139527/1736590/1793131 mmHg0.89 (0.79 to 1.00)140-159615/

12、1945771/2003149 mmHg0.77 (0.69 to 0.86)160449/1273498/1215172 mmHg0.81 (0.72 to 0.93)Baseline diastolic blood pressure (mmHg)70 304/846352/88166 mmHg 0.85 (0.73 to 1.00) 0.6070-79551/1748637/175875 mmHg0.83 (0.74 to 0.93)80-89554/1852651/183484 mmHg0.81 (0.72 to 0.90)90372/1113424/109895 mmHg0.81 (0

13、.71 to 0.94)0.51.02.0Hazard ration (95% CI)ADVANCE: Baseline BP and Outcome EventsDe Galan BE, et al. J Am Soc Nephrol. 2009; Feb.18, online10987654100110120130140150160170Achieved systolic blood pressure (mmHg)Annual patient event rate (%)Median systolic bloodPressure (mmHg)106116125135144154168No.

14、 of person-Years14314266897411983913849423470ADVANCE: Achieved BP levels and all renal eventsDe Galan BE, et al. J Am Soc Nephrol. 2009; Feb.18, online 降壓治療模式的歷史演進(jìn)降壓治療模式的歷史演進(jìn) 優(yōu)化聯(lián)合治療方案優(yōu)化聯(lián)合治療方案 糾正噻嗪類利尿劑代謝缺點(diǎn)糾正噻嗪類利尿劑代謝缺點(diǎn)新動態(tài)新動態(tài)(三三): 優(yōu)化降壓治療方案優(yōu)化降壓治療方案 降壓治療模式的歷史演進(jìn)降壓治療模式的歷史演進(jìn) 序貫治療序貫治療( (Sequential Monotherap

15、y) 階梯治療階梯治療( (Stepped-care) 聯(lián)合治療聯(lián)合治療( (Combination) 處方聯(lián)合處方聯(lián)合 單片聯(lián)合單片聯(lián)合1.41.21.00.80.60.40.20ThiazideBeta 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 a drug from another class(on average standard doses)Doubling dose of same dr

16、ug(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)Combination Therapy Versus MonotherapyMeta-analysis from 42 trialsWald DS, et a

17、l. Am J Med. 2009;122:290-300.Initial Combinations of Medications for Management of Hypertension1086420 0.5 mEq/L Decrease 0.5 mEq/L DecreaseChange in Serum Potassium from BaselinePlaceboChlorthalidoneIncidence Rate(per 100 person-yrs)No. of Cases5253667No. of Participants1,5791,075179776SHEP Trial:

18、 Unadjusted incidence rate of diabetes in year 1 by change in serum potassiumShafi T, et al. Hypertension. 2008;52:1022-29.Thiazide DiureticsSympatheticNervousSystemReninAngiotensinSystemInsulinResistance K+ SupplementBlood FlowNa+/K+ATPaseK+pInsulinp Glucosep? 噻嗪類利尿劑引起血糖升高的可能機(jī)制噻嗪類利尿劑引起血糖升高的可能機(jī)制Cart

19、er BL, et al. Hypertension. 2008;52:30-36 強(qiáng)調(diào)收縮壓目標(biāo)強(qiáng)調(diào)收縮壓目標(biāo) 多效性作用的單片聯(lián)合治療多效性作用的單片聯(lián)合治療(SPC)新動態(tài)新動態(tài)( (四四): ): 簡化降壓治療目標(biāo)和模式簡化降壓治療目標(biāo)和模式簡化降壓治療的血壓目標(biāo)：收縮壓簡化降壓治療的血壓目標(biāo)：收縮壓 5050歲以上患者應(yīng)該以收縮壓水平為歲以上患者應(yīng)該以收縮壓水平為唯一的診斷依據(jù)和關(guān)鍵的治療目標(biāo)。唯一的診斷依據(jù)和關(guān)鍵的治療目標(biāo)。William B, Lindholm LH, Sever P. Lancet. Published Online June 17, 2008簡化降壓治療簡化降壓治療: STITCH研究研究(Simplified Treatment Intervention to Control Hypertension)Feldman RD, et al. Hypertension. 2