穩(wěn)定性冠心病的血壓管理研究證據(jù)和臨床意義-課件

高血壓與冠心病血壓的升高促使動(dòng)脈粥樣硬化的發(fā)生與發(fā)展；冠心病的心血管事件、死亡與升高的收縮壓/舒張壓水平正相關(guān)；高血壓患者冠心病的患病率是血壓正常的3-4倍；全球60%-70%冠心病患者有高血壓；49％的心肌梗塞病例都是由高血壓引起EffectofSystolicBPandDiastolicBP

onCHDMortality:MRFITScreenees(N=316,099)**Menaged35to57yearsfollowedupforameanof12years.Deathrate

per10,000

person-yearsDiastolicBP(mmHg)SystolicBP(mmHg)Adaptedfrom:Neatonetal.ArchInternMed.1992;152:56-64.穩(wěn)定型冠心病臨床試驗(yàn)基線血壓水平SBP(mmHg)HOPEEUROPAQUIETPEACECAMELOTACTION139/79137/82123/74134/78129/78137/80糖尿病、心臟病、腎臟病，有腦卒中史和血管病者<130/80mmHg

根據(jù)：

PROGRESS(127/75ratherthan136/76mmHg)EUROPA（128/78ratherthan133/80mmHg）

CAMELOT（124/76ratherthan130/77mmHg)

上述冠心病和腦卒中后患者的受益，主要來(lái)自血壓降低。是二級(jí)預(yù)防研究，還是降壓試驗(yàn)?zāi)?？ESH/ESC2019年高血壓指南INVEST:InternationalVerapamil

SR-TrandolaprilStudy:

aprospective,randomized,open,blinded-endpoint(so-calledPROBE)trial

22,576patientsaged>/=50yearswithhypertensionandcoexistingCAD.

PatientswererandomizedtoaregimencontainingeitherverapamilSRoratenolol.

ameanfollow-upof2.7years

primaryoutcome:firstoccurrenceofallcausedeath,nonfatalMI,ornonfatalstroke.

INVEST研究：舒張壓與事件

事件發(fā)生率%02468101214161820<6060-7070-8080-9090-100100-110>110MI卒中DBP（mmHg）

INVEST冠心病患者是一類更加特殊的群體

冠脈血流受血壓的影響較大低血壓時(shí)冠脈血流量降低，而高血壓時(shí)心肌耗氧量增加總體來(lái)講,冠脈血流與舒張壓呈正相關(guān)，當(dāng)舒張壓低于60mmHg時(shí)，冠脈血流明顯降低因此，冠心病患者在抗高血壓治療的同時(shí)必須警惕降壓過低的風(fēng)險(xiǎn)高血壓合并冠心病患者的降壓靶標(biāo)冠心病合并心衰患者的降壓靶標(biāo)卡維地洛前瞻性隨機(jī)累積存活(COPERNICUS:TheCarvedilolProspectiveRandomizedCumulativeSurvival)試驗(yàn)提示較低的血壓(SP<120mmHg)對(duì)有些患者是合乎需要的聲明建議對(duì)于合并心衰患者，血壓應(yīng)<130/80mmHg,但尚應(yīng)考慮血壓甚至進(jìn)一步降至低于120/80mmHgRosendorffCetal.Circulation.2019;115:2761-88冠心病合并高血壓治療三個(gè)核心原則對(duì)于高血壓合并冠心病的患者,降壓治療應(yīng)緩慢進(jìn)行;舒張壓(DBP)不應(yīng)降得太低,不宜低于60mmHg;降壓治療的起始與目標(biāo)血壓在大多數(shù)這類患者為130/80mmHg

但AHA聲明還指出：在未控制的嚴(yán)重高血壓患者，服用抗血小扳藥或抗凝藥時(shí)，血壓應(yīng)即刻降低。這些原則說明了高血壓合并冠心病患者降壓治療的復(fù)雜性,也決定了采用個(gè)體化的治療原則RosendorffCetal.Circulation.2019;115:2761-88

對(duì)于脈壓大的老年患者：降低收縮壓往往容易引起舒張壓過低(<60mmHg).醫(yī)生應(yīng)該仔細(xì)觀察病人是否出現(xiàn)不利的癥狀

各地城市會(huì)問得最多的問題之一：老年患者BP170/60mmHg,是否應(yīng)該降壓？VALUE:AnalysisofResultsBasedon

BPControlat6MonthsFatal/Non-fatalcardiaceventsFatal/Non-fatalstrokeAll-causedeathMyocardialinfarctionHeartfailurehospitalisations*SBP<140mmHgat6months.**P<0.01.PatientsTreatedWithValsartanPatientsTreatedWithAmlodipineHazardRatio95%CI0.40.60.81.01.2Controlledpatients*(n=5253)Non-controlledpatients(n=2396)********0.40.60.81.01.2Controlledpatients*(n=5502)Non-controlledpatients(n=2094)HazardRatio95%CI********0.76

(0.66–0.88)0.60

(0.48–0.74)0.79

(0.69–0.91)0.83

(0.66–1.03)0.62

(0.50–0.77)OddsRatio0.73

(0.63–0.85)0.50

(0.39–0.64)0.79

(0.69–0.92)0.91

(0.71–1.17)0.64

(0.52–0.79)OddsRatioWeberMAetal.Lancet.2019;363:2047–49.VALUE:AnalysisofResultsBasedon

ImmediateResponse*Fatal/Non-fatalcardiaceventsFatal/Non-fatalstrokeAll-causedeathMyocardialinfarctionHeartfailurehospitalisations0.40.60.81.01.21.4Immediateresponders*(n=9336)Non-immediateresponders(n=5663)OddsRatio95%CI*Thosenotonprevioustx:SBP≥10mmHgatonemonth;thoseonprevioustx:SBP≤baselineatonemonth.**P<0.05;?P<0.01.**?**0.88(0.79–0.97)0.83(0.71–0.98)0.90(0.81–0.99)0.89(0.76–1.04)0.87(0.75–1.01)OddsRatioWeberMAetal.Lancet.2019;363:2047–49.atonemonth動(dòng)脈壓力感受器興奮降壓過快心率增加心血管中樞心迷走神經(jīng)心交感神經(jīng)抑制降壓過快危害一：導(dǎo)致心率增加心率過快是心血管死亡的獨(dú)立危險(xiǎn)因素和預(yù)測(cè)因素

姚泰主編，《生理學(xué)》，人民衛(wèi)生出版社，2019降壓過快危害二：引起冠脈血供不足冠心病及高血壓患者降壓過快心率過快舒張壓降低冠脈粥樣硬化冠脈自我調(diào)節(jié)力降低冠脈血供不足回心血量減少冠心病高血壓“大多數(shù)慢性高血壓病人應(yīng)該在幾周內(nèi)逐漸降低血壓至目標(biāo)水平，這樣對(duì)遠(yuǎn)期事件的減低有益?！?019中國(guó)高血壓防治指南2019ACC/AHA冠心病降壓治療建議“inpatientswithanelevatedDBPandocclusiveCADwithevidenceofmyocardialischemia,theBPshouldbelowered

slowly”指南、建議對(duì)降壓速度的描述那么冠心病患者呢？日本高血壓指南對(duì)降壓速度的建議老年人肝臟、腎臟功能減退，藥物代謝緩慢。起始應(yīng)采用半量，四周后加量，使血壓在2-3個(gè)月或更長(zhǎng)時(shí)間內(nèi)達(dá)標(biāo)ToshioOGIHARA,etal.HypertensRes2019;26:1–36高血壓合并冠心病的5個(gè)階段

高血壓合并高冠心病風(fēng)險(xiǎn);高血壓合并慢性穩(wěn)定性心絞痛;高血壓合并急性冠脈綜合征或NSTEMI高血壓合并STEMI;高血壓合并缺血性心臟病所導(dǎo)致的心力衰竭AHA/ACC關(guān)于缺血性心臟病降壓治療的聲明

藥物的選擇，需分類而行RosendorffCetal.Circulation.2019;115:2761-880.40.60.81.01.21.40.21.82.015105-5OddsratioforCHDACEI’sALLHATACEIUKPDS39EUROPAPROGRESSPROGRESSComCAMELOTHOPEPEACECAPPPSTOP-2ACEIANBP-2SystolicBPdifferencebetweengroups(mmHg)Verdecchiaetal20190NICSALLHATCCBPREVENTIDNT-2CONVINCEVHASSyst-ChinaSYSTEURCAMELOTSTONENICOLEACTIONNORDILINVESTSTOP-2CCBINSIGHT151050-5CCB’sELSARelationshipBetweenOddsRatio

forCHDandAchievedBPDifferencesPreventionofCVDACEIs?HOPE√

、ONTARGET√ARBs?ONTARGET√andTRANSCEND?

CombinationofACEIsandARBs?ONTARGETxACEIoutcometrialsinchronicstableCADpatients

withoutHF:TotalityoftrialevidenceMIStrokeAll-causedeathEventrate(%)FavorsACEIACEIRevascularizationFavorsplaceboPlacebo7.56.42.115.58.97.72.716.30.860.860.770.930.00040.00040.00040.0250.50.751.251OddsratioPPepineCJ,ProbstfieldJL.VascBioClinPract.

CMEMonograph;UFCollegeofMedicine.2019;6(3).HOPE,EUROPA,PEACE,QUIET

亞組：在β阻滯劑、他汀和抗血小板的基礎(chǔ)上應(yīng)用ACEI治療穩(wěn)定性冠心病患者ACERTIL

8mg高血壓合并冠心病的降壓治療不論血壓是否增高，

EUROPA、PROGRESS、ADVANCE研究結(jié)果高度一致總?cè)巳焊哐獕喝巳悍歉哐獕喝巳篜ROGRESSCollaborativeGroup.Lancet2019;358:1033-41.EUROPAInvestigators.Lancet2019;362:782-88.ADVANCECollaborativeGroup.Lancet2019;370:829-40.卒中后患者卒中再發(fā)-20-100-30RRR(%)-32%-27%-28%心血管死亡、心肌梗死和可復(fù)蘇的心臟驟停-15-10-50-20RRR(%)-20%-18%-20%穩(wěn)定性冠心病患者血管事件-50-10RRR(%)-9%-10%-9%糖尿病患者雅施達(dá)保護(hù)心腦血管作用顯著（1）

The

consistency

ofthetreatmenteffectofan

angiotensin-converting

enzyme-inhibitor-basedtreatment

regimenin

patientswithvasculardiseaseorhighriskofvasculardisease:

acombinedanalysisofindividualdataof

ADVANCE,EUROPA,andPROGRESS

trialsin29463patientsJ.J.Brugts,T.Ninomiya,E.Boersma,W.Remme,M.Bertrand,R.Ferrari,K.Fox,S.MacMahon,J.Chalmers,andM.L.Simoons.EurHeartJ;

acceptedFeb2009:MortalityandCVeventsreductionin29463patients

receivingCoversyl-basedtherapy

(ADVANCE,EUROPA,PROGRESSanalysis,2009)11%15%18%18%All-causemortalityCardiovascularmortalityCardiovascularmortality,myocardialinfarctionCardiovascularmortality,myocardialinfarction,stroke18%Fatalandnon-fatalstroke

Non-fatalmyocardialinfarction20%Hospitaladmissionforheartfail16%(P=0.006)(P=0.004)(P<0.001)(P<0.001)(P=0.002)(P<0.001)(P=0.015)1.J.J.Brugts,T.etal..EurHeartJ;

acceptedFeb2009:RRR,%β阻滯劑治療急性心?；颊?/p>

減少死亡、再梗死和室顫的發(fā)生死亡再梗死室顫和心跳驟停26個(gè)小隨機(jī)試驗(yàn)、MIAMI、ISIS-1、COMMIT低風(fēng)險(xiǎn)亞組的薈萃分析COMMIT

collaborativegroup.Earlyintravenousthenoralmetoprololin45852patientswithacutemyocardialinfarction:randomizedplacebocontrolledtrial.Lancet2019;366:1622–32P=0.0006P=0.002P=0.0002發(fā)生率變化（%）-22%-15%-13%-25-20-15-10-50在常規(guī)治療基礎(chǔ)上β阻滯劑顯著降低心衰患者死亡率1.MERIT-HFStudyGroup.Lancet.2019;253:2019–2019.

2.CIBIS-IIInvestigators.Lancet.2019;353:9–13.

3.PackerMetal.NEnglJMed.2019;344: