降压治疗研究新动向

降压治疗研究新动向,强化、优化和简化,扩展降压治疗能获益的人群,，当前主要聚焦,在80岁以上高龄高血压患者和血压水平140/90的心血管高危患者(心、脑血管病与糖尿病)。,新动向(一),The results of this trial should provide reliable evidence,about the effects of blood-pressure-lowering therapy in this very high-risk population.,抚慰剂,纳催离缓释片 雅施达,抚慰剂,HYVET:,总死亡率,总死亡率降低,21%,随访时间年,百分率%,纳催离缓释片,雅施达,1912,1933,1492,1565,814,877,379,420,202,231,从HYVET到临床实践,适用于收缩压160mmHg以上，一般状况尚好，生活能自理，认知功能无明显减退的高龄高血压患者。,降压速度应该相对较平缓，防止体位性低血压。血压控制目标值150/80mmHg。,RAS阻滞剂治疗心血管高危患者,循证证据,HOPE(Ramipril,2000),PROGRESS(Perindopril,2001),EUROPA(Perindopril,2003),ADVANCE(Perin/Indap,2007),ONTARGET(Telmisartan,2021),HOPE 139/79 3/3,PROGRESS 147/86 9/4,EUROPA 137/82 5/2,ADVANCE 145/81 5/3,ONTARGET 142/82 6/4,基线血压 血压,RAS阻滞剂治疗心血管高危患者,基线血压与血压下降幅度,mmHg,HT,NT,S,D,159.0,159.0,94.0,91.0,136.0,127.2,79.0,74.8,Blood Pressure values in PROGRESS,在心血管高危患者,强化,血压控制。血压控制目标值,130/80mmHg,正在不断获得循证证据,。,新动向(二),SBP,From UKPDS to ADVANCE,UKPDS,ADV,ACCORD Study,Action to Control Cardiovascular risk in Diabetes,Prisant LM.J Clin Pharmacol 2004;44(4):423-430,HbA1c:,6.0%vs 7.0-7.9%,(,因强化治疗总死亡率增加,08年2月7日,宣布提前中止),SBP:,120 mmHg vs,140 mmHg,100,120,140,160,180,Systolic blood pressure(mmHg),1,2,4,8,Annual rate(%),Ischaemic stroke,100,120,140,160,180,Systolic blood pressure(mmHg),0.01,0.02,0.04,0.08,0.16,0.32,Haemorrhagic stroke,Arima H,et al.J Hypertens.2006;24:1201-1208,PROGRESS:,Adjusted relative of,doubling of serum creatinine,or ESRD(,95%CI,),Usual systolic BP(mm Hg)during follow-up,Proteinuria,1g/day,Proteinuria,1g/day,1,0,6,12,160,4.80,5.40,8.40,1.70,1.2,0.70,2.22,4.81,1.60,Reference,1.2,100,80,60,40,20,0,120,120-139,140-159,60,100,80,60,40,20,0,70,70-79,80-89,90,Achieved systolic blood pressure levels,(mmHg),Achieved systolic blood pressure levels,(mmHg),Age-and sex-adjusted incidence rate,CKD:,P,trend=0.004,Non-CKD:,P,trend0.0001,CKD:,P,trend=0.001,Non-CKD:,P,trend0.0001,CKD,Non-CKD,Incidence rate(1000 person-years),PROGRESS CKD Substudy:SBP and CVD,0,20,40,60,80,100,110,100,120,130,140,150,160,170,180,190,200,210,220,Nadir,129.5 mm Hg,Systolic Blood,pressure,mm hg,Relative Hazard,370,0,20,40,60,80,100,50,60,70,80,90,100,110,120,Nadir,73.8 mm Hg,Diastolic Blood,pressure,mm hg,Relative Hazard,2200,Messerli FH,et al.Ann Intern Med.2006;144:884-893,冠心病患者血压控制水平与心血管危险,Rosendorff C,et al.Circulation 2007;115:,Treatment of Hypertension in IHD,A Scientific Statement from AHA,2007.4,冠心病患者需要积极控制血压，合理的血压控,制目标值130/80mmHg。a,B,应该相对缓慢降低血压，防止DBP60mmHg。,优化降压治疗方案，比较不同降压治疗药物和治疗方案在长期治疗过程中对血压控制、靶器官、不良反响、代谢以及终点事件等影响的差异。,新动向(三),0,-2,-4,-6,-8,-10,-12,-14,-16,-18,0,-2,-4,-6,-8,-10,-12,-14,Placebo,Placebo,Losartan,Losartan,Valsartan,Valsartan,Irbesartan,Irbesartan,Candesarten,Candesarten,Telmisartan,Eprosatan,Eprosatan,Telmisartan,Olmesartan,Olmesartan,Systolic BP,Diastolic BP,ARB动态血压监测研究系统综述,24h平均下降值,Fabia MJ,et al.J Hypertens.2007;25:1327-1336,0,-2,-4,-6,-8,-10,-12,-14,-16,-18,0,-2,-4,-6,-8,-10,-12,-14,Placebo,Placebo,Losartan,Losartan,Valsartan,Valsartan,Irbesartan,Irbesartan,Candesarten,Candesarten,Telmisartan,Eprosatan,Eprosatan,Telmisartan,Olmesartan,Olmesartan,Systolic BP,Diastolic BP,ARB动态血压监测研究系统综述,治疗后18-24h平均下降值,Fabia MJ,et al.J Hypertens.2007;25:1327-1336,100,90,80,70,60,50,40,30,20,10,0,Patients(%),Treatment Groups,N,1156,=,781,96,907,355,646,335,320/CTZ,320,160/HCTZ,160,80,80/12.5,Placebo,7.0,13.1,24.2,4.8,16.7,32.6,3.1,33.3,51.4,17.9,32.8,48.4,25.8,56.4,74.6,22.5,35.7,54.2,45.2,67.1,84.8,2 wk,4 wk,8 wk,Weir MR,et al.Am J Hypertens 2007;20:807,缬沙坦剂量对降压疗效的影响,达标率和达标时间,60,70,80,90,100,50,40,30,20,10,0,0,7,14,21,28,35,42,49,56,Duration of Treatment(days),Patients Achieving Goal(%),Valsartan 320/HCTZ,Valsartan 160/HCTZ,Valsartan 320,Valsartan/HCTZ 80/125,Valsartan 160,Valsartan 80,Placebo,Weir MR,et al.Am J Hypertens 2007;20:807,缬沙坦不同剂量对降压疗效的影响,Reduction of proteinuria after one year of treatment,:,29%with Micardis 80,vs.,20%with losartan 100,p0.05,Comparative Long term Efficacy of Two AT1 Receptor Blockers(,Telmisartan vs.Losartan,)on Proteinuria in Patients with Type-2 Diabetes and Overt Nephropathy and Hypertension,Bakris G,et al.22th ASH Meeting,May 21,2007,CHICAGO,J hypertens.,2005;23:445-453.,NICE Combi Study,(,Nifedipine and Candesartan Combination,),Controlled-release nifedipine and candesartan low-dose combination therapy in patients with essential hypertension,Combination,Uptitration,NICE Combi Study,Nifedipine CR&Candesartan versus High Dose Candesartan,0,0.02,-0.02,-0.04,-0.06,-0.08,-0.10,-0.12,两组间,P,0.002,JMICB:长效硝苯地平与ACEI,延缓冠状动脉粥硬化进展的比较,长效硝苯地平,ACEI,治疗持续3年,治疗后冠脉管腔最小直径变化,mm,0.02,0.27 mm,P,0.543,0.12,0.27 mm,P,0.001,Shinoda E,et al.,Hypertension.2005 Jun;45(6):1153-8.,Ram,(n=8576),%,Ram+Tel(n=8502),%,Ram+Tel v Ram,RR(95%CI),P value,Any renal dysfunction*,10.04,13.35,1.33(1.22-1.45),5.5 mmol/L,3.32,5.67,1.71(1.48-1.98),0.0001,SAE renal failure,0.28,0.64,2.27(1.40-3.67),0.0006,Need for dialysis,0.55,0.78,1.42(0.98-2.06),0.066,Death after renal dysfunction,1.84,2.21,1.20(0.97-1.48),0.087,*local definition,ONTARGET:,Renal Dysfunction Dialysis,&Related Death,Tel+Ram vs.Ram