《高血压治疗的坚持与改变.ppt》由会员分享，可在线阅读，更多相关《高血压治疗的坚持与改变.ppt（27页珍藏版）》请在三一办公上搜索。
1、高血压治疗的坚持与改变,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,“Quality first”From ambiguous to clear recommendations,The“Quality First”approach,降低整个动脉系统的血压（中心动脉压vs肱动脉血压）降低24小时血压（晨峰血压）不宜太低，不宜太快（应遵循个体化原则）多重危险因素干预（降脂、降糖、戒烟）,Systolic pressures(mean+95%CI),Average:133.5 Standard vs.119.3 Intensive,Delta=14.2,Mean#Meds Intensi
2、ve:3.2 3.4 3.5 3.4 Standard:1.9 2.1 2.2 2.3,Diastolic Pressures(mean+95%CI),Mean#Meds Intensive:3.2 3.4 3.5 3.4 Standard:1.9 2.1 2.2 2.3,Primary&secondary outcomes,Also examined fatal/Nonfatal HF(HR=0.94,p=0.67),a composite of fatal coronary events,nonfatal MI and unstable angina(HR=0.94,p=0.50)and
3、a composite of the primary outcome,revascularization and unstable angina(HR=0.95,p=0.40),Primary outcome Nonfatal MI,Nonfatal Stroke or CVD Death,Total stroke,HR=0.8995%CI(0.73-1.07),HR=0.5995%CI(0.39-0.89)NNT for 5 years=89,Mean Sitting BP,McMurray JJ et al.N Engl J Med 2010.,Extended and core CV o
4、utcomes,Placebo693 events(14.8%)Valsartan672 events(14.5%),Placebo377 events(8.1%)Valsartan375 events(8.1%),McMurray JJ et al.N Engl J Med 2010.,Exploratory outcomes:CV&total mortality,Placebo327 events(7.0%)Valsartan295 events(6.4%),Placebo116 events(2.5%)Valsartan128 events(2.8%),McMurray JJ et al
5、.N Engl J Med 2010.,McMurray JJ et al.N Engl J Med 2010.,Adverse events of interest,*MedDRA preferred terms include:hypotension,dizziness(including dizziness exertional,dizziness postural),syncope,presyncope and shock(not otherwise specified),IDACO:晨峰血压的预测价值,Li Y,et al.Hypertension 2010;in press.,Th
6、e“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,“Quality first”From ambiguous to clear recommendations,Possible combinations of antihypertensive drugs,J Hypertens 2007;25:1105-87.,Thiazide diuretics,ACEIs,ARBs,CCBs,-blockers,-blockers,JNC指南推荐的降压治疗起始药物,NICE/
7、BHS(2006)：降压药物推荐,A:ACEI or ARB B:-阻滞剂 C:CCB D:利尿剂(噻嗪类),*与其它联合治疗方案相比，阻滞剂与利尿剂联合治疗方案会增加新发糖尿病风险,National Collaborating Centre for Chronic Conditions.Hypertension:management of hypertensionin adults in primary care:partial update.London:Royal College of Physicians,2006.,ACCOMPLISH:主要终点及组成,复合CV发病率/死亡率心血管死
8、亡率心梗中风不稳定心绞痛住院冠状动脉成形术猝死复苏成功,危险比(95%),Aml/Ben较好,0.80(0.720.90)0.80(0.62-1.03)0.78(0.62-0.99)0.84(0.65-1.08)0.75(0.50-1.10)0.86(0.74-1.00)1.75(0.73-4.17),Ben/HCTZ较好,Jamerson K et al.N Engl J Med 2008;359:2417-28.,ASCOT-BPLA：一、二级终点,0.50,0.70,1.00,1.45,主要终点 非致死性MI(包括症状MI)+致死性冠心病 次要终点非致死性MI(除外无症状MI)+致死性冠
9、心病总的冠心病终点事件总的心血管病事件和操作总死亡率 心血管病死亡率 致死性和非致死性脑卒中致死性和非致死性心力衰竭,2.00,Unadjusted Hazard ratio(95%CI)0.90(0.79-1.02)0.87(0.76-1.00)0.87(0.79-0.96)0.84(0.78-0.90)0.89(0.81-0.99)0.76(0.65-0.90)0.77(0.66-0.89)0.84(0.66-1.05),Dahlf B et al.Lancet 2005:366;895-906.,氨氯地平培哚普利较好,阿替洛尔苄氟噻嗪较好,相对危险度(95%CI),赖诺普利较好,氨氯地平
10、较好,+1%(9%to+11%),CHD,+5%(3%to+13%),总死亡率,+4%(3%to+12%),联合CHD,脑卒中,联合CVD,需要住院的GI出血,心衰,心绞痛,冠脉血运重建,外周动脉疾病,0.5,1.0,2.0,+23%(+8%to+41%),+6%(0 to+12%),+20%(+6%to+37%),-13%(22%to 4%),+9%(0 to+19%),0(9%to+11%),+19%(+1%to+40%),P=0.055,P=0.047,P=0.003,P=0.007,P=0.004,P=0.036,终点事件,差别(95%CI),Leenen FHH,et al.Hype
11、rtension 2006;48:374-384.,ALLHAT：赖诺普利 vs.氨氯地平,Months,Number at risk,Valsartan,Amlodipine,7596,7649,7497,7499,7458,7458,7332,7319,7205,7177,6905,6853,7065,7016,6727,6680,6141,6078,3840,3864,1532,1520,6562,6504,%of patients with 1st event,76543210,VALUE:致死及非致死心肌梗死,0612182430364248546066,缬沙坦组,氨氯地平,HR=1
12、.19;95%CI=1.02-1.38;P=0.02,Julius S et al.Lancet.June 2004;363.,19,CCBs vs.利尿剂/阻滞剂:致死性与非致死性脑卒中,0,1,2,3,MIDAS/NICS/VHASSTOP2/CCBsNORDIL/Diltiazem INSIGHT/Nifedipine GITSALLHAT/AmlodipineELSA/Lacidipine CCBs without CONVINCEp=0.68CONVINCE/Verapamil SR All CCBsp=0.39,15/1358237/2213196/547174/3164675/1
13、525514/11571211/28618118/82971329/36915,19/1353207/2196159/541067/3157377/90489/1177838/22341133/8179971/30520,10.2%(4.8)2p=0.02,7.6%(4.4)2p=0.07,CCBs较好,利尿剂/阻滞剂较好,利尿剂/阻滞剂,试验,事件数/研究对象人数,异质性检验,危险比(95%可信区间),差别(SD),CCBs,Staessen JA,et al.Lancet 2001;37:1305-15.Staessen JA et al.J Hypertens 2003;21:1055-
14、76.,80,40,0,+40%,Syst-China:Fatal and non-fatal endpoints,Liu LS et al.J Hypertens 1998;16:1823-1829.,Placebo(n=1141),Total mortalityCV mortalityStroke mortalityAll CV eventsFatal and non-fatal stroke,Active treatment(n=1253),Placebo better,8244209459,6133107445,Active treatment better,-39,-39,-58,-
15、37,-38,8244209459,6133107445,FEVER：主要终点事件,Liu LS et al.J Hypertens 2005;23:2157-2172.,0,2,4,6,8,10,0,6,12,18,24,30,36,42,48,54,60,26.8%,HCTZ非洛地平+HCTZ,随访时间（月）,主要终点（%）,Chinese Hypertension Intervention Efficacy(CHIEF)：General design,Hypertensive patients at high CV risk(n=12,000),Amlodipine 2.5 mg/d+t
16、elmisartan 40 mg/d,Amlodipine 2.5 mg/d+amiloride 1.25/HCTZ 12.5 mg/d,Primary endpoint:CV death,stroke and MI,2y,4y,3y,1y,0y,Clear recommendations,If no compelling indications or contraindications,simply start with CLASSIC(Amlodipine),with the possible replacement of or combination with FASHION(ARB/ACEI).The A+A partnership.,Thank you very much！,
