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1、The Relationship of Systolic and Diastolic Blood Pressure to Cardiovascular Disease Risk:Observational Data,Prevalence of Hypertension in the US,Percent hypertensive,18-29,Based on NHANES III(phase 1 and 2)Hypertension defined as blood pressure 140/90 mmHg or treatment,30-39,40-49,50-59,60-69,70-79,
2、80+,Age,3%,9%,18%,38%,51%,66%,72%,JNC-VI.Arch Intern Med.1997;157:2413-2446.,Risk of hypertension(%),Residual lifetime risk of developing hypertension among people with blood pressure 140/90 mmHg,Years,Lifetime Risk of Developing Hypertension Beginning at Age 65,Men,Women,Vasan RS,et al.JAMA.2002;28
3、7:1003-1010.Copyright 2002,American Medical Association.,Mortality According to Blood Pressure in Men Age 50 to 69,Society of Actuaries.Blood Pressure Study,1939.,Ratio(%)of actual to expected mortality,Systolic blood pressure(mmHg),Diastolic blood pressure(mmHg),Age-adjusted annualincidence of CHD
4、per 1000,Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease(CHD)at baseline,Systolic blood pressure(mmHg),Blood Pressure and Risk for Coronary Heart Disease in Men,Diastolic blood pressure(mmHg),Age 65-94,Age 35-64,Age 65-94,Age 35-64,Framingham Heart Study,
5、30-year Follow-up.NHLBI,1987.,Relative risk of CHD mortality,He J,et at.Am Heart J.1999;138:211-219.Copyright 1999,Mosby Inc.,11271,Risk of CHD Death According to SBP and DBP in MRFIT,Decile,112-71-,118-76-,121-79-,125-81-,129-84-,132-86-,137-89-,142-92-,15198,(lowest 10%),(highest 10%),SBP(mmHg),DB
6、P(mmHg),Systolic blood pressure(SBP)Diastolic blood pressure(DBP),CHD=coronary heart disease,Relative risk of stroke death,11271,Risk of Stroke Death According to SBP and DBP in MRFIT,Decile,112-71-,118-76-,121-79-,125-81-,129-84-,132-86-,137-89-,142-92-,15198,(lowest 10%),(highest 10%),SBP(mmHg),DB
7、P(mmHg),Systolic blood pressure(SBP)Diastolic blood pressure(DBP),He J,et at.Am Heart J.1999;138:211-219.Copyright 1999,Mosby Inc.,Age-adjusted annual CVD event rate per 1000,Wilking SV et al.JAMA.1988;260:3451-3455.,Men,Women,Isolated Systolic Hypertension and CVD Risk in Framingham,ISH BP 160/95 m
8、mHgBP 140/95 mmHg,82,43,33,2.4,18,2.5,CVD=cardiovascular disease ISH=isolated systolic hypertensionP0.001 for difference between both men and women with ISH and blood pressure(BP)140/95 mmHg,The Relationship of Hypertension Treatment to CVD Risk Reduction:Introduction,Incidence of cardiovascular dis
9、ease,120,Hypertension Treatment Effect Mirrors Observational Data,140,160,180,200,220,Observational Data,Treatment Effect,Systolic blood pressure(mmHg),Landmark Clinical TrialsHypertension Treatment and Cardiovascular Disease Outcomes,1967 VA Cooperative Study on DBP 115-1291970 VA Cooperative Study
10、 on DBP 90-1141979 HDFP1980 Australian Trial,Oslo Trial1985 MRC I,EWPHE1991 SHEP,STOP-Hypertension 1992 MRC II in the elderly1997 Syst-Eur 2002 LIFE2002 ALLHAT,Relative Risk for Coronary Heart Disease,Odds ratios and95%confidence intervals,0,0.5,1,1.5,2,0.79(0.69 to 0.90),He J,et al.Am Heart J.1999;
11、138:211-219.Copyright 1999,Mosby,Inc.,Active treatment better than placebo,Active treatment worse than placebo,Relative Risk for Stroke,0,0.5,1,1.5,2,0.63(0.55 to 0.72),Odds ratios and95%confidence intervals,Active treatment better than placebo,Active treatment worse than placebo,He J,et al.Am Heart
12、 J.1999;138:211-219.Copyright 1999,Mosby,Inc.,The Veterans Administration Cooperative Study on Antihypertensive Agents,The VA Cooperative Study,1967,VA Cooperative Study Group.JAMA.1967;202:1028-1034.,HCTZ=hydrochlorothiazide,-12,12,The VA Cooperative Study,1967:Change in Systolic and Diastolic Bloo
13、d Pressure,Change in Systolic BP(mmHg),Percent of patients,Percent of patients,Change in Diastolic BP(mmHg),-76,-60,-44,-28,0,28,Decrease(-),(+)Increase,Active drugs,Placebo,Active drugs,Placebo,VA Cooperative Study Group.JAMA.1967;202:1028-1034.Copyright 1967,American Medical Association.,-12,12,-7
14、6,-60,-44,-28,0,28,Decrease(-),(+)Increase,The VA Cooperative Study,1967:Assessable Morbid/Fatal Events,VA Cooperative Study Group.JAMA.1967;202:1028-1034.,*P0.001 active drug therapy vs placebo,The VA Cooperative Study,1967:Conclusions,The actively treated group experienced a reduction in multiple
15、hypertension-related endpoints21 morbid/fatal events on placebo1 morbid/fatal event on active therapy,VA Cooperative Study Group.JAMA.1967;202:1028-1034.,The VA Cooperative Study,1970,VA Cooperative Study Group.JAMA.1970;213:1143-1152.,The VA Cooperative Study,1970:Assessable Morbid/Fatal Events,VA
16、Cooperative Study Group.JAMA.1970;213:1143-1152.,*P0.001 active drug therapy vs placebo,The VA Cooperative Study,1970:Conclusions,Active treatment reduced fatal and nonfatal endpointsA subsequent analysis revealed that benefits were statistically significant only for those with baseline diastolic bl
17、ood pressure 105-114 mmHg,VA Cooperative Study Group.Circulation.1972;45(5):991-1004.VA Cooperative Study Group.JAMA.1970;213:1143-1152.,The European Working Party on High Blood Pressure in the Elderly,1985,The European Working Party on High Blood Pressure in the Elderly,1985,Amery A,et al.Lancet.19
18、85;1:1349-1354.,Survival free of event(%),Year of follow-up,EWPHE Cardiovascular Mortality On-Treatment Analysis,Active(n=416),Placebo(n=424),P=0.023,Amery A,et al.Lancet.1985;1:1349-1354.Reprinted with permission from Elsevier Science.,EWPHE=European Working Party on High Blood Pressure in the Elde
19、rly,EWPHEConclusions,Active treatment reduced cardiovascular(CV)mortality,largely due to a reduction in cardiac mortalityOlder patients(60 yrs old)with combined systolic and diastolic hypertension who received active therapy experienced 29 fewer CV events and 14 fewer CV deaths per 1,000 patient-yea
20、rs of treatment,Amery A,et al.Lancet.1985;1:1349-1354.,EWPHE=European Working Party on High Blood Pressure in the Elderly,The Hypertension Detection and Follow-up Program,1979,The Hypertension Detection and Follow-up Program,1979,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,Cumulative mortality(%
21、),0,1,3,6,Year of follow-up,HDFP Mortality RatesEntire Cohort,2,4,5,Referred Care,Stepped Care,HDFP=Hypertension Detection and Follow-up Program,*P0.01,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,(n=5,456),(n=5,485),*,0,1,3,6,2,4,5,Cumulative mortality(%),HDFP Mortality RatesDiastolic BP 90104 m
22、mHg,Referred Care,Stepped Care,HDFP=Hypertension Detection and Follow-up Program,Year of follow-up,*P0.01,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,(n=3,822),(n=3,903),*,BP=blood pressure,HDFPConclusions,Overall,stepped care(SC)compared to referred care(RC)reduced total mortality by 17%(6.4 vs
23、.7.7%;P0.01)In patients with baseline diastolic blood pressure 90104 mmHg(n=7,725),mortality was reduced by 20%with SC vs.RC(5.9%vs.7.4%;P0.01)Aggressive treatment of SC patients with the lowest baseline diastolic blood pressures(9094 and 9599 mmHg)reduced mortality,HDFP=Hypertension Detection and F
24、ollow-up Program,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,The Systolic Hypertension in the Elderly Program,1991,The Systolic Hypertension in the Elderly Program,1991,SHEP Research Group.JAMA.1991;265:3255-3264.,BP=blood pressure,Change in BP(mmHg),Years,SHEPChange in Blood Pressure,Placebo(n=
25、2,371),Active Rx(n=2,365),Years,Systolic BP,Diastolic BP,SHEP Research Group.JAMA.1991;265:3255-3264.Copyright 1991,American Medical Association.,BP=blood pressure,SHEP=Systolic Hypertension in the Elderly Program,Placebo(n=2,371),Active Rx(n=2,365),Blood pressure(mmHg),0,12,36,60,Months of follow-u
26、p,SHEPAverage Blood Pressure During Follow-up,24,48,0,SHEP=Systolic Hypertension in the Elderly Program,SHEP Research Group.JAMA.1991;265:3255-3264.Copyright 1991,American Medical Association.,Cumulative stroke rate per 100 persons,0,12,36,60,Months of follow-up,SHEPCumulative Stroke Rate,24,48,72,P
27、=0.0003,Placebo(n=2,371),Active Rx(n=2,365),SHEP=Systolic Hypertension in the Elderly Program,SHEP Research Group.JAMA.1991;265:3255-3264.Copyright 1991,American Medical Association.,Relative risk(95%CI),Stroke,CHD,Active Therapy vs.Placebo,CHF,Death,0.63,0.46,0.68,0.87,CVD,0.75,SHEPCardiovascular D
28、isease Endpoints,SHEP Research Group.JAMA.1991;265:3255-3264.,SHEP=Systolic Hypertension in the Elderly Program,CHD=coronary heart disease;CHF=congestive heart failure;CVD=cardiovascular disease,SHEPConclusions,SHEP was the first clinical trial to demonstrate that reduction of blood pressure in pati
29、ents with isolated systolic hypertension reduced cardiovascular(CV)mortalityThe relative risk of stroke was reduced by 36%with therapy compared to placebo(P=0.0003)The 5-year absolute benefits were a reduction in 30 strokes and 55 major CV disease events per 1,000 persons,SHEP Research Group.JAMA.19
30、91;265:3255-3264.,SHEP=Systolic Hypertension in the Elderly Program,The Systolic Hypertension in Europe(Syst-Eur)Trial,1997,The Systolic Hypertension in Europe Trial,1997,Staessen JA,et al.Lancet.1997;350:757-764.,Systolic BP(mmHg),Syst-Eur Mean Sitting Systolic Blood Pressure,0,Placebo(n=2,297),Act
31、ive treatment(n=2,398),1,2,3,4,Years since randomization,Staessen JA,et al.Lancet.1997;350:757-764.Reprinted with permission from Elsevier Science.,Syst-Eur=Systolic Hypertension in Europe Trial,P0.001,Syst-Eur Mean Sitting Diastolic Blood Pressure,0,1,2,3,4,Diastolic BP(mmHg),Placebo(n=2,297),Activ
32、e treatment(n=2,398),P0.001,Years since randomization,Staessen JA,et al.Lancet.1997;350:757-764.Reprinted with permission from Elsevier Science.,Syst-Eur=Systolic Hypertension in Europe Trial,Events per 100 patients,Syst-Eur Primary EndpointFatal and Nonfatal Stroke,Placebo(n=2,297),Active treatment
33、(n=2,398),P=0.003,Years since randomization,Staessen JA,et al.Lancet.1997;350:757-764.Reprinted with permission from Elsevier Science.,Syst-Eur=Systolic Hypertension in Europe Trial,Percentage relative risk reduction(95%CI),Stroke,MI,Active therapy vs.placebo,CHF,Death,42%P=0.003,29%,31%P0.001,14%,A
34、ll CVD,30%,Syst-EurCardiovascular Disease Endpoints,Staessen JA,et al.Lancet.1997;350:757-764.,MI=myocardial infarction;CHF=congestive heart failure;CVD=cardiovascular disease,Syst-Eur=Systolic Hypertension in Europe Trial,Syst-Eur Conclusions,Older men and women with isolated systolic hypertension
35、who received active treatment with a dihydropyridine calcium channel blocker experienced fewer strokes and cardiovascular disease(CVD)events than those receiving placebo.Treatment of 1,000 patients for 5 years with this type of regimen could prevent 29 strokes or 53 major CVD endpoints.,Staessen JA,
36、et al.Lancet.1997;350:757-764.,Syst-Eur=Systolic Hypertension in Europe Trial,The Australian National Blood Pressure(ANBP)Study,1980,The Australian National Blood Pressure Study,1980,The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study Mean Diastolic Blood Pressure,Diastolic
37、blood pressure(mmHg),The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study Incidence of Trial Endpoints(TEP)*,*Rates per 1,000 person-years exposure to risk.P0.05 P0.025,The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study Intention-to-Treat Trial Endpo
38、ints,The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study On-Treatment Trial Endpoints(TEP),Number of trial endpoints,Days in trial,2000,1600,1200,600,400,All TEPP0.01,All Fatal TEPP0.05,Active(n=1,721),Placebo(n=1,706),The Australian Study Committee.Lancet.1980;1:1261-1267.R
39、eprinted with permission from Elsevier Science.,The Australian Study Conclusions,The actively treated compared to placebo group experienced 30 fewer trial endpoints endpoints(P0.05)There was a significant reduction in mortality in the actively treated group,mostly due to a reduction in death from cardiovascular disease(P0.025),The Australian Study Committee.Lancet.1980;1:1261-1267.,
