糖尿病患者的优化血压管理策略

Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,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,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,2010,糖尿病降压管理新动向,高传玉,河南省人民医院心血管内科,联系,13937165590,G,会议精粹,拜新同 降压达标 挽救生命,高血压的认知,:,历史和过程,药物治疗高血压现状,:,汇翠分析,糖尿病高血压管理目标,:,指南要求,2010,糖尿病合并高血压研究,:,新动向,ACC,2010,糖尿病降压管理,精萃,拜新同 降压达标 挽救生命,高血压领域的探索历程,“,Hypertension may be an important compensatory mechanism which should not be tampered with,even were it certain that we could control it.”,高血压是一项重要的代偿性机制，不需要处理（即使我们能够对此进行控制）,Paul Dudley White,1931 Textbook of Cardiology.,认识高血压,更多心脑获益的降压策略,血压与卒中,MacMahon S,Rodgers A.,J Hypertens.,1994;12(suppl 10):S5-S14.,75%,脑卒中发生在血压未明显升高患者,Results from 7 prospective observational studies,405,000 individuals,843 strokes,Approximately three quarters of all strokes,occurred among the 95%of participants classified as normotensives,Baseline DBP category,109,0,50,000,100,000,150,000,200,000,0,100,150,200,250,50,Average usual DBP,73,78,84,91,98,105 DBP(mm Hg),Normotensives,(DBP95 mmHg),Number of individuals,Number of strokes,降压治疗临床试验残余的心血管危险,SHEP,MRC,Syst-Eur,PROGRESS,SHEP Cooperative Research Group.,JAMA.,1991;265:3255-3264.,MRC Working Party.,BMJ.,1992;304:405-412.,原发事件的风险,(%),Staessen,JA et al.,Lancet,.1997;350:757-764.,PROGRESS Collaborative Group.,Lancet.,2001;358:1033-1041.,Risk shown is compared with the baseline risk for a 40-year-old male nonsmoker with SBP 120 mm Hg,TC of 185 mg/,dL,(4.8,mmol,/L),no glucose intolerance,who is electrocardiographic left ventricular hypertrophy(ECG-LVH)negative,and has a probability of developing CVD of 15/1000(or 1.5%)in 8 years.Clustering of risk factors in US men aged 40 to 74 years.,Kannel,WB.In:,Genest,J et al,eds.,Hypertension:Physiopathology and Treatment,.888-910.,BP,(SBP 150 mm Hg),x1.5,Lipids,(TC 260 mg/,dL,6.7,mmol,/L),x2.3,x3.5,Smoking,x1.7,x3.9,X5.9,x2.7,SBP,、吸烟和,TC,协同显著增加心血管危险,高血压病人危险因素综合管理,Paolo,Verdecchia,et,al.Hypertension 2005;46;386-392,CCB,与,ACEI,对脑卒中的影响,随机组间收缩压的差值（,mmHg,）,PROGRESSCom,SYST-EUR,NORDIL,-5,CAPPP,PEACE,PROGRESS,CAMELOT,EUROPA,HOPE,ANBP2,STOP2/ACE-I,ALLHAT/ACE-I,.2,.4,.4,.8,1,1.2,1.4,2.0,1.8,-5,0,5,10,15,卒中事件,OR,ACEI,PART-2,LIKPDS39,SCAT,IDNT2,CAMELOT,Syst,-China,STONE,PREVENT,CONVINCE,MIDAS,INSIGHT,STOP2/CCB,ALLHAT/CCB,INVEST,NORDIL,SHELL,0,5,10,15,ELISA,CCB,NICOLE,ACTION,NICS,VHAS,LIKPDS39,PEACE,PROGRESS,PROGRESSCom,CAMELOT,EUROPA,HOPE,ANBP2,STOP2/ACE-I,CAPPP,ALLHAT/ACE-I,IDNT2,CAMELOT,Syst,-China,SYST-EUR,STONE,PREVENT,ACTION,NICOLE,INSIGHT,NORDIL,STOP2/CCB,ALLHAT/CCB,VHAS,CONVINCE,INVEST,.2,.4,.4,.8,1,1.2,1.4,2.0,1.8,-5,0,5,10,15,-5,0,5,10,15,ELISA,冠心病事件,OR,随机组间收缩压的差值（,mmHg,）,ACEI,CCB,SHELL,NICS,CCB,与,ACEI,对冠心病事件的影响,Paolo,Verdecchia,et,al.Hypertension 2005;46;386-392,糖尿病患者降压治疗目标明确,130/80,mmHg,思考：降压达标的涵义,降压达标仅仅是,130/80mmHg,吗？,3,2,1,2,1,降压达标的内涵,“标”的意义,降压达标的要求,解读降压药物 的标准,解读,“,降压达标,”,背后的涵义,总体目标,血压目标,有效性标准,平稳性标准,依从性标准,降压的目标,总体目标,最大程度地降低长期心血管疾病的总体风险,血压目标,130/80mmHg,糖尿病患者降压达标的标准,高品质降压治疗药物的标准,有效性标准,控制血压能力（单药达标率，联合达标率）,降低心脑血管疾病患病与事件风险,减少靶器官损害（尿蛋白，,IMT,）,安全性标准,代谢指标与新发糖尿病,交感活性、心率与心梗发生率,其它不良反应,平稳性标准,降压作用,24,小时持续平稳,有效控制血压波动,ACC,2010,糖尿病降压管理动向,Topic Coordinator:Paul D.Thompson,MD,FACC,Topic Co-Coordinator:Scott D.Solomon,MD,FACC,Nurse Planner:Suzanne Hughes,MSN,RN,Topic Sponsor:Michael J.Barrett,MD,FACC,William C.Cushman,MD,FACP,FAHA,Veterans Affairs Medical Center,Memphis,TN,For The ACCORD Study Group,强化血压控制对,2,型糖尿病患者心血管事件的影响：控制糖尿病患者心血管危险行动,(ACCORD),血压试验,双重,2 x 2,析因设计,强化血糖控制,5128,标准血糖控制,5123,血脂,血压,安慰剂组,贝特,组,强化治疗组,标准治疗组,2371,2362,2753,2765,1383,1374,1391,1370,1193,1178,1184,1178,10,251,4733,*,5518,*,假定标准治疗组的事件发生率为,4%/,y,，随访,5.6,年,，则,事件发生率,下降,20%,的检验效能为,94%,第,1,年后的均值：标准组,133.5 vs.,强化组,119.3,，,Delta,值,=14.2,强化组标准组,随机分组后年份,强化治疗组,标准治疗组,血压控制情况,强化治疗组,事件,(%/yr),标准治疗组,事件,(%/yr),HR(95%CI),P,值,主要终点,208(1.87),237(2.09),0.88(0.73-1.06),0.20,总死亡,150(1.28),144(1.19),1.07(0.85-1.35),0.55,心血管死亡,60(0.52),58(0.49),1.06(0.74-1.52),0.74,非致死性,MI,126(1.13),146(1.28),0.87(0.68-1.10),0.25,非致死性卒中,34(0.30),55(0.47),0.63(0.41-0.96),0.03,所有卒中,36(0.32),62(0.53),0.59(0.39-0.89),0.01,也检测致死性,/,非致死性,HF(HR=0.94,p=0.67),、致死性冠脉事件、非致死性,MI,和不稳定型心绞痛 组成的复合终点,(HR=0.94,p=0.50),，以及主要终点、血运重建和不稳定型心绞痛组成的复合终点,(HR=0.95,p=0.40),主要和次要终点,主要终点,非致死性,MI,、非致死性卒中或,CVD,死亡,HR=0.88,95%CI(0.73-1.06),强化治疗组,标准治疗组,随机分组后年份,发生事件的患者,(%),主要终点：强化治疗组事件发生率,低于标准治疗组,P=0.20,非致死性卒中,所有卒中,HR=0.63,95%CI(0.41-0.96),HR=0.59,95%CI(0.39-0.89),发生事件的患者,(%),发生事件的患者,(%),随机分组后年份,随机分组后年份,强化治疗组卒中事件发生率,低于标准治疗组,P=0.03,P=0.01,ACCORD,血压试验评估了常规降压达标（,SBP140 mmHg,）与强化血压控制（,SBP120 mmHg,）对心血管疾病危险增加的,T2DM,患者的影响,结果并未提供明确证据说明，强化血压控制策略（,SBP120 mmHg,）能够降低此类患者的主要,CVD,事件复合终点的发生率,糖尿病患者血压仍需严格降至,140mmHg,强化降压的卒中获益明确！,启示：重新评估,T2DM,患者的血压目标值,Rhonda M.Cooper-,DeHoff,Yan Gong,Eileen M.,Handberg,Anthony A.,Bavry,Scott J.,Denardo,George L.,Bakris,and Carl J.,Pepine,on behalf of the INVEST Investigators,University of Florida,Gainesville,FL,对糖尿病合并冠心病患者降压目标的再思考,国际维拉帕米缓释剂,-,群多普利研究,(INVEST)