從高血壓到心力衰竭挑戰(zhàn)與對策-課件幻燈

1、從高血壓到心力衰竭挑戰(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%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 women fo

2、llowed 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 failureObesityDiabetesHTNSmokingDyslipidemiaDiabetesMILVHDias

3、tolicdysfunctionYears/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(jìn)展到心力衰竭因心力衰竭首次住院患者左心室射血分?jǐn)?shù)ALLHATHF BY EF LEVELN=1399EF50%心力衰竭預(yù)后：人群研究隨訪(年) 死亡率(%) HF-REF HF-PEFOlmsted(1998) 5.0 65

4、65Framingham(1999) 6.2 75 46Helsinki(1997) 4.0 54 43心力衰竭預(yù)后：臨床研究薈萃分析(Somaratne, 2008) 17項研究，24501例，平均治療隨訪47個月 38%患者死亡，RF-REF 40%，HF-PEF 32%降壓治療有效降低心、腦血管病事件17項臨床試驗薈萃分析-50-40-30-20-100Heart failure1Fatal/Nonfatalstroke1Fatal/NonfatalCHD1Risk reduction (%)1. Moser and Herbert. J Am Coll Cardiol. 1996; 2

5、. Collins R et al. Lancet 1990.Vascular deaths-52%-38%-16%-21%HYVET: Heart Failureplaceboactive- Placebo_ ActiveStrokeSystolic BP Difference Between Randomized Groups (mm Hg)0.250.500.751.001.251.50-10-8-6-4-2024Systolic BP Difference Between Randomized Groups (mm Hg)0.250.500.751.001.251.50-10-8-6-

6、4-2024CHDA = CA vs placebo; B = ACE inhibitor vs placebo; C = more intensive vs less intensive 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.

7、 Lancet. 2003;362:1527-1535.RR of Outcome EventRR of Outcome EventABCDEFGABCDEFGBP-Lowering Treatment TrialistsHeart FailureSystolic BP Difference BetweenRandomized Groups (mm Hg)RR of Outcome Event-10-8-6-4-20240.250.500.751.001.251.50ABCDEFGA = CA vs placebo; B = ACE inhibitor vs placebo; C = more

8、 intensive vs less intensive 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

9、. placeboCA vs. placeboMore 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

10、.07 (0.96-1.19)1.33 (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;362:1527-1

11、535.2. Gottdiener JS 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.

12、at RiskChlorthalidone 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 RiskChlor

13、thalidone 152551456313980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years 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 1525514563139801

14、33251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years 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.Proportion With Death From Any Cause (%)Follow-up (months)

15、0.0061218243036424854AmlodipinePlaceboIrbesartanIDNT: No Significant Difference in Death From Any Cause061218243036424854Follow-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

16、-regression analysis: Relation between odds ratios for CHF and differences in achieved SBP between randomized groups 5.03.01.41.00.2-5-2.52.557.51000-5-2.52.557.52.55107.52.55Systolic blood pressure difference between randomized groups (mmHg)Odds ratio for congestive heart failure

17、ACE inhibitors orangiotensin-receptor blockersCalcium channel blockersMIDASDREAMVHASINSIGHTALLHAT/CCB-DCONVINCEIDNT/CCB-PLBSHELLINVESTSYST-EURACTIONASCOTSTOP2/CCB-BBFEVERCamelot/CCB-PLBSYST-ChinaSTONEPREVENTNICSTRANSCENDALLHAT/ACE-DUKPDS39LIFESTOP2/ACE-BBRENAACIDNT/ARB-PLBCamelot/CCB-PLBEUROPA1.2CAP

18、PPANBP2DIABHYCARPEACEPART-2HOPENORDILVerdecchia P, et al. Eur Heart J. 2009;30:679-688. 病程早期阻止病情進(jìn)展和逆轉(zhuǎn)靶器官結(jié)構(gòu)與功能損害 病程中晚期 預(yù)防心、腦血管病和腎臟病終點事件降壓治療目標(biāo)的演進(jìn)與轉(zhuǎn)移:不同病程階段的目標(biāo)Devereux R, et al. JAMA. 2004;292:2350-2356Hazard Ratio: 0.58 (0.38-0.86) p .008LIFE-ECHO substudyImpact on LVH regression on outcomes210-1-2-3-4-5HCTZAtenololCaptoprilClonidineDiltiazemPrazosinChange in left atrial size (mm)Time