降压治疗与心血管病预防课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,BP reduction and CV prevention,降压治疗与心血管病预防,关注降压质量，丰富高血压专业内涵,王继光,上海交通大学医学院附属瑞金医院,上海市高血压研究所,BP reduction and CV prevention,1,Relative risk reductions by antihypertensive treatment in early trials,Progression,to severe HT,CHF,Stroke,CHD,Total,mortality,CV,mortality,-94*,-53%*,-40%*,-16%*,-13%,-21%*,*,P,利尿剂,/,阻滞剂,ACEIs,1.Prevention of stroke,5,CCBs,vs,.,利尿剂,/,阻滞剂,:,致死性与非致死性脑卒中,利尿剂,/,阻滞剂,CCBs,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,),0,CCBs,较好,1,2,3,利尿剂,/,阻滞剂较好,MIDAS/NICS/VHAS,STOP2/CCBs,NORDIL,INSIGHT,ALLHAT/Amlodipine,ELSA,CCBs without CONVINCEp=0.68,CONVINCE,所有,CCBsp=0.39,15/1358,237/2213,196/5471,74/3164,675/15255,14/1157,1211/28618,118/8297,1329/36915,19/1353,207/2196,159/5410,67/3157,377/9048,9/1177,838/22341,133/8179,971/30520,10.2%(4.8)2p=0.02,7.6%(4.4)2p=0.07,Staessen JA,et al.Lancet 2001;37:1305-15.Staessen JA et al.J Hypertens 2003;21:1055-76.,CCBs vs.利尿剂/阻滞剂:利尿剂/阻滞剂CCB,6,0,ACEIs,较好,1,2,3,UKPDS,STOP2/ACEIs,CAPPP,ALLHAT/Lisinopril,ANBP2,所有,ACEIsp=0.16,17/358,237/2213,148/5493,675/15255,107/3039,1184/26358,21/400,215/2205,189/5492,457/9054,112/3044,994/20195,10.2%(4.6)2p=0.03,ACEI,s,vs,.,利尿剂,/,阻滞剂,:,致死性与非致死性脑卒中,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,利尿剂,/,阻滞剂较好,Staessen JA,et al.Lancet 2001;37:1305-15.Staessen JA et al.J Hypertens 2003;21:1055-76.,0ACEIs较好123UKPDS17/35821/40010,7,降压治疗与心血管病预防课件,8,相对危险度,(95%CI),赖诺普利较好,氨氯地平较好,+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.Hypertension 2006;48:374-384.,ALLHAT：赖诺普利,vs.,氨氯地平,相对危险度赖诺普利较好氨氯地平较好+1%(9%to,9,相对危险度,(95%CI),培多普利较好,安慰剂较好,9%(,0,%to 17%),Combined macro+micro,14%(2%to 25%),All deaths,18%(2%to 32%),CV deaths,Non CV deaths,Total coronary,Total cerebrovascular,Stroke,Heart failure,Total renal events,Total eye events,0.5,1.0,2.0,8%(-12%to 24%),14%(2 to 24%),6%(-10%to 20%),2%(-18%to 19%),21%(15%to 27%),5%(-1%to 10%),P,=,0.42,终点事件,差别,(95%CI),Patel A et al.Lancet 2007;370:829-40.,ADVANCE：培多普利,vs.,安慰剂,2%(-20%to 19%),P=0.86,相对危险度培多普利较好安慰剂较好 9%(0%to 17,10,165/1280,102/6108,218/5571,157/1281,98/6110,215/5569,PROGRESS/perindopril only,EUROPA,ADVANCE,0.5,1,1.5,2.0,培多普利,vs,.,安慰剂,:,致死性与非致死性脑卒中,培多普利较好,安慰,剂较好,安慰剂,试验,事件数,/,研究对象人数,危险比,(,95%,可信区间,),血压差别,(mm Hg),培多普利,5/2,5/2,5.6/2.2,PROGRESS Management Committee.Lancet 200;358:1033-41;,Fox K et al.Lancet 2003;362:782-8;,Patel A et al.Lancet 2007;370:829-40.,165/1280157/1281PROGRESS/p,11,2.Prevention of MI,Amlodipine provides similar protection against MI as ACEIs.,心肌梗死预防,:,氨氯地平,利尿剂,/,阻滞剂,ACEIs,2.Prevention of MI,12,16/1358,154/2213,157/5471,61/3164,1362/15255,17/1157,1767/28618,166/8297,1933/36915,16/1353,179/2196,183/5410,77/3157,798/9048,18/1177,1271/22341,133/8179,1404/30520,4.5%(3.9)2p=0.26,1.9%(3.7)2p=0.61,MIDAS/NICS/VHAS,STOP2/CCBs,NORDIL,INSIGHT,ALLHAT/Amlodipine,ELSA,CCBs without CONVINCEp=0.38,CONVINCE,All CCBsp=0.14,0,1,2,3,CCBs,vs,.,利尿剂,/,阻滞剂,:,致死性与非致死性心肌梗死,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;21:1055-76.,16/135816/13534.5%(3.9)2p=,13,0.20,0.15,0.10,0.05,0.00,0 1 2 3 4 5 6 7,基线CHD,随访时间（年）,赖/氨 1.06(0.99-1.32)0.69,RR(95%Cl),P,值,0.20,0.15,0.10,0.05,0.00,0 1 2 3 4 5 6 7,基线无CHD,氨氯地平,赖诺普利,赖/氨 0.98(0.88-1.13)0.78,RR(95%Cl),P,值,ALLHAT:,致死/非致死性CHD发生率,随访时间（年）,Leenen FHH,et al.Hypertension 2006;48:374-384.,CHD累计发生率,0.200 1,14,AHA/ACC高血压合并冠心病降压治疗建议,：各类降压药物的异质性,Rosendorff C et al.Circulation 2007;115:2761-88.,There is also continuing debate over whether there are“class effects”for antihypertensive drugs or whether each drug must be considered individually.It is reasonable to assume that there are class effects for thiazide-type diuretics,ACE inhibitors,and ARBs,which have a high degree of homogeneity in their mechanisms of action and side effects.It is equally clear that there are major differences between drugs within more heterogeneous classes of agents,such as,-blockers or CCBs.,AHA/ACC高血压合并冠心病降压治疗建议：各类降压药物的,15,3.Prvention of stroke and MI,Amlodipine vs.ARBs,脑卒中与心肌梗死预防,:,氨氯地平,vs.ARBs,3.Prvention of stroke and MI,16,Prevention of stroke and MI by,amlodipine and ARBs,氨氯地平与,ARBs,预防卒中与心肌梗死,A meta-analysis of RCTs,随机对照临床试验综合分析,Wang JG et al.Hypertension 2007;50:333-339.,Prevention of stroke and MI by,17,氨氯地平,vs.,ARBs*,:,脑卒中,氨氯地平较好,ARBs,较好,IDNT,VALUE,CASE-J,所有试验,p=0.46,30/579,322/7649,60/2354,412/10,582,18/567,281/7596,47/2349,346/10,512,15.9%(6.2)2p=0.02,0.5,1.0,1.5,2.0,*厄贝沙坦、缬沙坦、坎地沙坦,ARBs,氨氯地平,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,),Wang JG et al.Hypertension 2007;50:333-339.,氨氯地平 vs.ARBs*:脑卒中氨氯地平较好ARBs较,18,IDNT,VALUE,CASE-J,All trials p=0.40,51/579,369/7649,17/2354,437/10,582,33/567,281/7596,18/2349,332/10,512,16.7%(6.1)2p=0.01,0.5,1.0,1.5,2.0,氨氯地平,vs.,ARBs*,:,MI,ARBs,试验,事件数