老年高血壓降壓指南課件

1、從HYVET到2008年中國老年高血壓治療指南Treatment betterControl better00.20.40.60.81.01.21.41.61.82.02.2Total mortalityDouble-blind trials (meta-analysis) (RR = 1.14, P = 0.05)All trials (meta-analysis) (RR = 1.06, P = 0.30)HYVET-Pilot (diuretic) (RR = 1.307, P = 0.34)HYVET-Pilot (ACE) (RR = 1.143, P = 0.65)HYVET-Pi

2、lot (all active) (RR = 1.227, P = 0.42)Cardiovascular deathDouble-blind trials (meta-analysis) (RR = 1.11, P = 0.42)All trials (meta-analysis) (RR = 1.01, P = 0.93)HYVET-Pilot (diuretic) (RR = 1.166, P = 0.62)HYVET-Pilot (ACE) (RR = 1.087, P = 0.79)HYVET-Pilot (all active) (RR = 1.127, P = 0.66)Stro

3、ke eventsDouble-blind trials (meta-analysis) (RR = 0.64, P = 0.01)All trials (meta-analysis) (RR = 0.67, P = 0.01)HYVET-Pilot (diuretic) (RR = 0.313, P = 0.01)HYVET-Pilot (ACE) (RR = 0.629, P = 0.21)HYVET-Pilot (all active) (RR = 0.471, P = 0.02)J Hypertens 2003;21:2408-2416Western Europe(86) Easter

4、 Europe(2144) China(1526)Astrania(19) Tunisia(70)Placebo1,912Active1,9333,845Entered into placebo Run-in Inclusion criteria: exclusion criteria: Aged 80 or more， standing SBP 140mmHg systolic pressure：160 -199mmHg Stroke in last 6 months diastolic pressure110 mmHg， dementia informed consent required

5、 ongoing nursing care primary outcome： Stroke events (Fatal and non fatal)Target blood pressure 150/80 mmHgHYVET:MethodsPlacebo(n= 1912)Active(n= 1933)Age (years)83.5 83.6 Female n (%)1,152 (60.3%)1,174 (60.7%)Blood Pressure:Sitting SBP (mmHg)173.0 173.0 Sitting DBP (mmHg)90.8 90.8 Orthostatic Hypot

6、ension n (%) 169 (8.8%)152 (7.9%)Isolated Systolic Hypertension n (%)623 (32.6%)625 (32.3%)HYVET: Baseline data Fall in SBP 20mmHg and/or fall in DBP 10mmHg Placebo(n= 1912)Active(n= 1933)Current smoker6.6%6.4%Diabetes(Known DM/DM treatment/glucose1.11mmol/l)6.9%6.8%Total cholesterol(mg/dl)206.7206.

7、7HDL cholesterol(mg/dl)52.6552.65Serum creatinine(umol/l)89.288.6Uric acid(umol/l)279280Body Mass index(kg/m*m)24.724.7HYVET: Baseline dataCardiovascular risk factorP=0.046HYVET: Fatal StrokeFatal stroke 39 % treatment placebo treatment placeboTime of Follow-up（year）Rate %191219331492156581487737942

8、0202231P80歲)?老年高血壓合并腦卒中急性腦梗死72小時內(nèi)降壓治療應慎重，現(xiàn)有指南建議血壓過高(SBP200mmHg)時或病情穩(wěn)定后再進行降壓治療，SBP如需降至180mmHg以內(nèi)，24小時的降壓幅度應( ? )。急性腦出血 SBP180mmHg時應給予降壓治療，目標血壓為(?)老年高血壓伴有雙側頸動脈70%狹窄時降壓治療應慎重,收縮壓一般不應低于(?）。什么是體位性低血壓?回 答不一定 建議對經(jīng)過選擇的80歲以上,認知功能良好,無嚴重腦血管病變的患者進行降壓治療.10mmHg伴有頭暈或暈厥。在老年收縮期高血壓者伴有糖尿病、低血容量，應用利尿劑、擴血管藥或精神類藥物者容易發(fā)生體位低血壓

9、。 謝 謝Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial:The Telmisartan trial in cardiovascular protectionONTARGET Study Designadapted from Unger T., Am J Cardiol 2003;91 (suppl):28G34GBecause of an extraordinary effort by investigators in 40 countries, it was possible

10、to complete recruitment for the ONTARGET study in May 2003, seven months ahead of the scheduled timeline. The ONTARGET trial currently recruited 25,621 patients.Possible results for the end of the Trial for ONTARGET Non-Inferiority ComparisonONTARGETONTARGET: Key Baseline CharacteristicsRamiprilTelm

11、isartanCombinationN857685428502Age66.466.466.5% females27.226.326.5% CAD74.474.574.7% Stroke/TIA21.020.620.9% Diabetes36.738.037.9BP 141.8/82.1141.7/82.1141.9/82.1Statins61.062.061.8Antiplatelet80.581.181.1-blocker56.556.957.4ONTARGET: Change in BP (mmHg)RamiprilTelmisartanCombinationSystolic-6.0-6.

12、9-8.4Diastolic-4.6-5.2-6.0非劣勢比較(Non-Inferiority Comparison)Tel vs. RamONTARGETONTARGET Non-Inferiority ComparisonONTARGETIndirect Comparison of Telmisartan to Placebo & Percentage of Ramiprils Effects That is PreservedHOPE ResulthR/hP = 0.77 (95% CI = 0.70 0.85)ONTARGET ResulthT/hR = 1.02 (95% CI =

13、0.94 1.09)Indirect Comparison of Telmisartan to PlacebohT/hP = 0.79 (95% CI = 0.70 0.89)Percentage of Ramiprils Effect Preserved by Telmisartan93.9% (95% CI = 82.5% to 105.4%)Reasons for Permanently Stopping Study MedicationsTel vs. RamRamN=8576TelN=8542Tel vs. RamRR PHypotensive Symptoms1492291.540

14、.0001Syncope15191.270.4850Cough360930.260.0001Diarrhea12191.590.20Angioedema25100.400.0115Renal Impairment60681.140.46Any Discontinuation209919620.940.02優(yōu)勢比較(superiority Comparison)Tel + Ram vs. RamONTARGETReasons for Permanently Stopping Study MedicationsTel + Ram vs. RamRamN=8576Ram + TelN=8502Ram

15、 + Tel vs. RamRR PHypotensive Symptoms 1494062.750.0001Syncope15291.950.032Cough3603921.100.1885Diarrhea12393.280.0001Angioedema25180.730.30Renal Impairment60941.580.0050Any Discontinuation209924951.200.0001Renal Dysfunction Dialysis & Related DeathTel + Ram vs. RamRam(n=8576)%Ram + Tel (n=8502)%Ram

16、 + Tel v Ram RR (95% CI)P valueAny renal dysfunction*10.0413.351.33 (1.22-1.45)5.5 mmol/L3.325.671.71 (1.48-1.98)0.0001SAE renal failure0.280.642.27 (1.40-3.67)0.0006Need for dialysis0.550.781.42 (0.98-2.06)0.066Death after renal dysfunction1.842.211.20 (0.97-1.48)0.087*local definition臨床意義(一) ONTAR

17、GET研究驗證并豐富了在心血管高危人群通過抑制RAS能顯著減少心血管病事件，即使在當代治療背景下。這對RAS抑制劑(轉(zhuǎn)換酶抑制劑或血管緊張素受體拮抗劑)治療心血管高?；颊咛峁┝烁鼒詫嵉难C基礎。 冠心病(%) 79.5 74.5 既往心肌梗死(%) 51.9 49.3心絞痛(%) 54.9 49.8既往CABG(%) 25.7 22.5既往PTCA(%) 18.4 29.0腦卒中/TIA(%) 10.8 20.6外周血管病(%) 42.3 13.6ECG-LVH(%) 8.2 13.1高血壓(%) 47.6 68.6糖尿病(%) 38.9 38.0MAU(%) 20.5 13.2HOPE與ON

18、TARGET入選人群比較HOPE(Ram) ONTARGET(Tel) HOPE與ONTARGET治療背景比較 HOPE(2000) ONTARGET(2008)Asprin 75% 81%阻滯劑 39% 57%他汀類 28% 62% HOPE與ONTARGET主要終點事件發(fā)生率比較(心肌梗死、腦卒中、心血管死亡 / % / 4年) HOPE(2000) ONTARGET(2008) 安慰劑 Ramipril Ramipril Telmisartan17.8 14 14.11 13.93臨床意義(二) 雖然ARB替米沙坦可以替代ACEI治療，增加了治療藥物的有效選擇，但是并不是取代。ACEI(Ramipril和Peridopril)依然是治療心血管高?；颊叩慕饦藴省?雅施達在心血管高?；颊哐C證據(jù)PROGRESS (腦卒中史, 2001年)EUROPA (穩(wěn)定性冠心病, 2003年)ADVANCE (2型糖尿病, 2007年)臨床意義(三) 臨床實踐中一般應按照循證原則選擇治療方案、藥物品種和劑量。在心血管高?；颊?，目前不推薦ACEI+A