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1、降压治疗中的J-Curve现象,上海交通大学医学院附属瑞金医院上海市高血压研究所王继光,CV events,BP,血压与心血管风险的J 形曲线关系,Observational studiesRandomized controlled trialsThe strategy to avoid J-curve,PSC:Stroke mortality and usual BP,80-89 y,70-79 y,60-69 y,50-59 y,Age at risk:,Stroke mortality(floating absolute risk and 95%CI),256,128,64,32,16,
2、8,4,2,1,120,140,160,180,Usual SBP(mm Hg),80-89 y,70-79 y,60-69 y,50-59 y,Age at risk:,70,80,90,100,110,2,1,4,8,16,32,64,128,256,Systolic blood pressure,Diastolic blood pressure,Usual DBP(mm Hg),Prospective Studies Collaboration.Lancet 2002;360:190313.,80-89 years,70-79 years,60-69 years,50-59 years,
3、40-49 years,256,128,64,32,8,4,2,1,!,!,!,!,!,!,70,80,90,100,110,!,!,!,!,Diastolic blood pressure,Age at risk:,16,256,128,64,32,8,4,2,1,120,140,160,180,!,!,!,!,!,!,!,!,16,PSC:IHD mortality and usual BP,IHD mortality(floating absolute risk and 95%CI),Usual SBP(mm Hg),Usual DBP(mm Hg),Prospective Studie
4、s Collaboration.Lancet 2002;360:190313.,APCSC:stroke and usual BP,64.0,32.0,16.0,8.0,4.0,2.0,1.0,0.5,0.25,110,120,130,140,150,160,170,Usual systolic blood pressure(mmHg),l,l,l,l,l,l,l,Age at risk 70 years60-69 years60 years,Hazard ratio and 95%CI,Asia Pacific Cohort Studies Collaboration.J Hypertens
5、 2003;21:707716.,P for heterogeneity=0.002,澳洲,亚洲,Hazard ratio,+10 mmHg:1.22(1.18-1.26),+10 mmHg:1.31(1.26-1.35),Mean usual SBP(mmHgl),APCSC:收缩压与冠心病事件,Asia Pacific Cohort Studies Collaboration.J Hypertens 2003;21:707716.,MI或卒中发病率(%),MI Stroke,60,60 to 70,70 to 80,80 to 90,90 to 100,100 to 110,110,0,5
6、,10,15,20,25,30,35,随访期间的平均舒张压(mm Hg),MI and stroke by average follow-up DBP in INVEST,Messerli FH et al.Ann Intern Med 2006;144:88493.,高血压合并冠心病患者降压治疗,130/80,缺血性心脏病心衰,130/80,STEMI,不稳定性心绞痛或NSTEMI,130/80 or 120/80,稳定性心绞痛,not 60 mm Hg,slowly,130/80,合并冠心病危险因素,特别注意,降压速度,降压治疗目标血压(mm Hg),冠心病不同阶段,Rosendorff
7、C et al.Circulation 2007.,not 60 mm Hg,not 60 mm Hg,not 60 mm Hg,not 60 mm Hg,slowly,slowly,slowly,slowly,130/80 or 120/80,Observational studiesRandomized controlled trialsThe strategy to avoid J-curve,血压与心血管风险,7,6,5,4,3,2,1,0,100,110,120,130,140,150,160,170,180,190,200,SBP(mm Hg),Relative Benefit,1
8、.00,0.85,0.70,0.55,0.40,0.25,0.10,0.3,VALISH:血压,Ogihara T,et al.Hypertension.2010;56:196-202.,VALISH:心血管事件,Ogihara T,et al.Hypertension.2010;56:196-202.,NAVIGATOR:Mean Sitting BP,McMurray JJ et al.N Engl J Med 2010.,NAVIGATOR:Primary&secondary outcomes,McMurray JJ et al.N Engl J Med 2010.,ACCORD:Sys
9、tolic pressures(mean+95%CI),Average:133.5 Standard vs.119.3 Intensive,Delta=14.2,Mean#Meds Intensive:3.2 3.4 3.5 3.4 Standard:1.9 2.1 2.2 2.3,N Engl J Med 2010;362:1575-85.,ACCORD:Primary&secondary outcomes,N Engl J Med 2010;362:1575-85.,Systole,Diastole,2nd shoulder,1st shoulder,增强压力Augmentation Pr
10、essure(AP),脉压(PP),射血期,(msec),舒张期,Incisura,Start of the Wave,中心动脉压力波形,P1,AIx=AP/PP,0,80,85,90,95,100,105,0,3,6,12,24,36,Final,HOT:Diastolic BP(%patients reaching target),Target 80 mm Hg,Target 85 mm Hg,Target 90 mm Hg,DBP(mm Hg),74%,80%,43%,85%,52%,57%,67%,75%,56%,71%,83%,86%,57%,86%,73%,55%,Follow-u
11、p(months),74%,80%,43%,85%,52%,57%,67%,75%,56%,71%,83%,86%,57%,86%,73%,55%,74%,80%,43%,85%,52%,60%,57%,67%,75%,56%,71%,83%,86%,75%,57%,86%,73%,55%,Hansson L,et al.Lancet 1998;351:175562.,0,5,10,15,20,25,Major CV events/1000 patient years,Target DBP mm Hg,p=0.005 for trend,90,85,80,HOT:Major CV events
12、 in patients with diabetes at randomisation,Hansson L,et al.Lancet 1998;351:175562.,Observational studiesRandomized controlled trialsThe strategy to avoid J-curve,24-h 动态血压(1),180,160,140,120,100,80,60,40,SD24=15.5 mmHg,day SD=9.2 mmHg,night SD=8.9 mmHg,(9.2 x 14)+(8.9 x 6)SDdn=9.1 mmHg14+6,12,14,16
13、,18,20,22,0,2,4,6,8,10,Hours,Bilo G et al.J Hypertens 2007;25:2058-66.,(SDd x Hrd)+(SDn x hrn)SDdn=hrd+hrn,长期血压监测,泡沫细胞,脂纹,中层病变,粥瘤,纤维斑块,复合病变/破裂,动脉粥样硬化,35-45岁 45-55 岁 55-65岁 65岁,StiffnessVisual explanation,Quality Carotid Stiffness,正常凋亡率：3%,维持内皮层稳定,过度凋亡,发生粥样硬化,对抗动脉硬化,内皮细胞凋亡和动脉硬化,形成斑块、斑块破裂,内皮的连续性,The“Quality First”approach,选择有效药物，实现降压达标选择长效降压药物，控制24小时血压选择能够长期坚持使用的药物，长期、平稳控制血压选择作用于血管的降压药物,在观察研究中，将不同血压水平者进行对比，血压较高者心血管风险也较高。在降压治疗临床试验中，在将血压降低到140/90 mm Hg以下后进一步降低血压时，对特定的患者、特定并发症或特定的降压方式，都可能出现所谓J-curve现象，导致心血管风险升高。为了充分发挥降压治疗预防心脑血管并发症的有益作用，避免J-curve现象，应密切监测血压、检测血管、选择平稳控制血压的药物。,Thank you very much！,
