高血壓合并多重危險(xiǎn)因素及靶器官損害患者的治療指南-葛世俊課件

1、高血壓合并多重危險(xiǎn)因素及靶器官損害患者的治療指南葛世俊寧波市李惠利醫(yī)院心內(nèi)科BMJ2003;326:1419A strategy to reduce cardiovascular disease by more than 80% 減少心血管疾病80%以上的策略polypill策略: 同時(shí)針對(duì)四種危險(xiǎn)因素: low density lipoprotein cholesterol blood pressure serum homocysteine platelet function) 方法:meta-analyses of randomised trials and cohort studies

2、and a meta-analysis of 15 trials of low dose (50-125 mg/day) aspirin 結(jié)果:Polypill組成:1. a statin (for example, atorvastatin (daily dose 10 mg) or simvastatin (40 mg); 2. three blood pressure lowering drugs (for example, a thiazide, a blocker, and an angiotensin converting enzyme inhibitor), each at ha

3、lf standard dose;3. folic acid (0.8 mg); 4. aspirin (75 mg). 估計(jì): Polypill減少缺血性心臟病88%(84% to 91%) .減少中風(fēng)80% (71% to 87%). 三分之一55歲或以上人群能得益.平均延長無缺血性心臟病和中風(fēng)壽命11年.降壓抗動(dòng)脈粥樣硬化：降低心血管病超過80%BMJ. 2003;326:14190%20%40%60%80%100%0%20%40%60%80%100%風(fēng)險(xiǎn)降低(%)缺血性心臟病46%降壓藥他汀阿司匹林葉酸總計(jì)卒中降壓藥他汀阿司匹林葉酸總計(jì)61%32%16%88%63%17%16%24%8

4、0%風(fēng)險(xiǎn)降低(%)該論文意義在于提出了多重危險(xiǎn)因素干預(yù)的概念(multifactorial interventions )多重危險(xiǎn)因素干預(yù)的理由主要有: 1、心血管疾病的主要敵人是動(dòng)脈粥樣硬化 2、心血管危險(xiǎn)因素有聚集性 3、干預(yù)單一危險(xiǎn)因素效果并不理想The Burden of Cardiovascular Disease in West Virginia BRFSS(1996)：69.6%高血壓患者合并其它危險(xiǎn)因素非HTN72.6%HTN27.4%只有HTN 30.4%合并危險(xiǎn)因素的HTN 患者69.6%REACH注冊(cè)研究：90.3%的高血壓患者合并超過3個(gè)危險(xiǎn)因素Vascular Hea

5、lth and Risk Management 2007;3(5):587-60344個(gè)國家、67,888名年齡45歲的患者危險(xiǎn)因素包括：接受治療的糖尿病、糖尿病腎病、無癥狀的頸動(dòng)脈狹窄70%、收縮壓150mmHg、接受治療的高膽固醇血癥、吸煙、男性55歲、女性70歲81.8% 高血壓90.3%3個(gè)危險(xiǎn)因素LDL-C BP 糖尿病吸煙肥胖多種危險(xiǎn)因素共同存在，加速動(dòng)脈粥樣硬化可干預(yù)的危險(xiǎn)因素不可干預(yù)的危險(xiǎn)因素年齡男性早發(fā)家族史氧化應(yīng)激內(nèi)皮功能受損，炎癥反應(yīng)Treating a Single Risk Factor is Not Enough: CV Risk Remains Even Afte

6、r Statin TherapyRisk of Primary Event (%)Kastelein JJP. Eur Heart J. 2005;7:F27-F33.Please see prescribing information at the end of this slide presentation.Multiple CV Risk Management Results in Dramatic Reductions in CVD10% Reductionin BP10% Reductionin TC+45% Reductionin CVD=“Attention should be

7、moved from knowing ones BP and cholesterol concentrations to knowing ones absolute CV risk and its determinants.” J. Emberson et aland Jackson et alEmberson J et al. Eur Heart J. 2004;25:484-491. Jackson R et al. Lancet. 2005;365:434-441.高血壓的主要治療目標(biāo)：最大程度降低心血管疾病總體風(fēng)險(xiǎn)主要終點(diǎn)：非致死性心梗和致死性冠心病012340.00.51.01.52

8、.02.53.03.5隨訪年數(shù)累積事件發(fā)生率（） 阿托伐他汀 10 mg安慰劑p=0.000536% 3.3年由于主要終點(diǎn)在很早就出現(xiàn)了非常顯著的差異，調(diào)脂部分比計(jì)劃提前近2年結(jié)束Sever PS, et al, Lancet. 2003;361:1149-58ASCOT-LLA：降壓基礎(chǔ)上，他汀治療獲益顯著多重危險(xiǎn)因素干預(yù)：1、治療性生活方式改變2、藥物： A 他汀 B 阿司匹林2007 Guidelines for the Management of ArterialHypertension關(guān)于他汀治療、對(duì)高血壓伴心血管疾病或糖尿病患者應(yīng)給予他汀治療。目標(biāo)：TC 4.5 mmol/l (1

9、75 mg/dl) LDL-C 2.5 mmol/l (100 mg/dl) 2007 Guidelines for the Management of ArterialHypertension、對(duì)高血壓無明顯心血管疾病但高?；颊?20% risk of events in 10 years)，即使基線TC和LDL-C水平并不增高，也應(yīng)給予他汀治療。目標(biāo)：TC 5 mmol/l (190 mg/dl) LDL-C 115 mmol/l (1.3 mg/dl) Therefore, treatments witha low-dose aspirin have favourable benefit/risk ratios only if given to patients above a certain threshold of total cardiovascular risk (1520% in 10 years).To minimize the risk of haemorrhagic stroke, antiplatelet treatment should be started after achievement of BP control.2007 Guidelines for the Manageme