颅内动脉狭窄血压干预

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,*,*,*,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,*,*,*,徐安定,附属第一医院 神经内科,-,血压控制部分解读,Hyperlipidaemia,27%,Smoking,27%,Obesity,18%,Inactivity,27%,Carotid stenosis,4%,Hypertension,35%,Relative risk,Percentages indicate prevalence,2%,Atrial fibrillation,Alberts,.,Curr,Med Res,Opin,2003;19:438441,1,前言：高血压是最重要的卒中危险因素,0 1 2 3 4 5 6 7 8 9 10,Framingham Study:,DBP,5mmHg,Stroke Risk,4,6%,Stroke and usual BP among 2435 individuals with a history of TIA or minor stroke.,Rodgers A,MacMahon S,et al.BMJ.1996:313:147,4.00,2.00,1.00,0.50,0.25,75,80,85,90,95,Usual Diastolic BP(mmHg),RR of,secondary,stroke,4.00,2.00,1.00,0.50,0.25,Usual Systolic BP(mmHg),120,130,140,150,160,170,RR of,secondary,stroke,There is a Continuous Epidemiological Relationship Between Blood Pressure Levels and Recurrent Stroke Risk,BMJ 2009;338:b1665,Anti-Hypertension reduce the stroke recurrence,1,、前 言,中国：,sICAS,存在于,33%-50%,缺血性卒中患者,50%TIA,患者,其他亚洲国家：泰国、韩国、新加坡,47%28-60%48%,美国：,10%,，但在其非洲裔、亚裔、西班牙裔依然高发。,前述二级预防研究中包含有相当部分的,sICAS,患者，所以,sICAS,患者的血压管理服从大局！,2,sICAS,血压目标值,卒中二级预防中血压,目标值？,Guideline type Organization Pub year Goal Bp,JNC7(USA)2003,1),140/90mmHg,Hypertension ESH(EU)2007,2),130/80mmHg,CHL(China)2009,3),130/80mmHg,CHINA 2010*,140/90mmHg,ASA(USA)2006,4),uncertain,individual,Stroke ESO(EU)2008,5),uncertain,individual,Guideline China 2010,6),Generally,140/90,ideal,130/80 mmHg,ASA-IS 2011,7),uncertain,individual,1)Hypertension 2003;42:12061252,2)J Hypertension.2007,25:1105-1187,3)Chin Hypertension Guideline,2009,7)Stroke,online 2011,Jan,4)Stroke 2006;37;577-617,5),Cerebrovasc,Dis,2008;25:457507,6)Chin,Neurol,J,2010,43:1-7,*,中国高血压指南,2010,？,PROGRESS,后分析,未显示以往认为的血压水平和卒中之间的“,J”,型关系，给积极降压提供有力证据。,ESH 2007,卒中降压目标,130/80mmHg,的主要依据,J,Hypertens,2006,，,24:12011208,J Hypertension 2009,27:21212158,二级预防研究太少！,Rothwell,PM,et al.Stroke,2003 Nov;34(11),2583-2590.,双侧颈动脉狭窄,70%,SBP,160mmHg,62,人,相对风险,RR,0.68,1.05,1.25,双侧颈动脉狭窄,70%,160 mmHg,62,人,0.50,脑卒中患者颈动脉狭窄与血压水平,Total:8328 cases from 3 trials,心血管事件,(%),0,10,20,30,40,50,60,110,110,-120,120,-130,130,-140,140,-150,150,-160,INVEST,(,冠心病 患者,),心脏事件,(%),治疗,SBP(mmHg,),0,10,20,30,120,-130,130,-140,140,-150,150,-160,170,-180,180,VALUE,(,高危患者,),治疗,SBP(mmHg,),160,ONTAGET,0,10,20,30,112,121,126,130,133,149,160,(,高危患者 主要伴冠心病,),3,2,1,心血管事件,(%),调整后,HR,136,140,144,0,10,20,30,心血管事件,(%),35,治疗,DBP(mmHg,),TNT,61-70,71-80,91-100,100,(,冠心病患者,),3,2,1,调整后,HR,81-90,4,5,60,治疗,SBP(mmHg,),0,高血压治疗的,J-,形曲线问题,ESH2009,R,eappraisal,J Hypertension 2009,27:21212158,针对冠心病和卒中的高血压目标值调整,J,型现象一般不太容易发生，但是在严重动脉粥样硬化疾病的患者可能存在,对所有高血压患者，谨慎推荐达标值在,130-139/80-85mmHg,，而且可能靠近其低值,一次相对完美的回归真实世界,How about the blood pressure goal in patients with,sICAS,?140/90 mmHg?,ASA/AHA 2011:,大前提：绝对目标血压水平和降低程度,不确定,，应,个体化,(a B),小背景：对颅内大动脉狭窄,50%-99%,导致的卒中或,TIA,患者，长期维持,BP,140/90 mmHg may be reasonable,(b B),。（新建议）,？,Circulation,2007;115;2969-2975;originally published online May 21,2007,WASID Bp post-hoc Analysis 2007,：,lower Bp,lower incidence of evens,Trial,S,tenting,and,A,ggressive,M,edical,M,anagement for,P,reventing,R,ecurrent stroke in,I,ntracranial,S,tenosis,支架（,Wingspan)+,积极药物治疗,积极药物治疗,SAMMPRIS,研究设计,Patients with 70-99%,stenosis,and TIA or stroke within 30 days prior to enrollment,积极药物治疗,积极药物治疗,+,支架置入术,R,两组的药物治疗相同，包括：,Aspirin 325 mg/day for entire follow-up,Clopidogrel 75mg per day for 90 days,Aggressive,protocol driven risk factor management primarily targeting blood pressure 140/90 mm Hg(130/80 diabetics)and low density cholesterol 70 mg/dl,Chimowitz,MI,et al.Journal of Stroke and,Cerebrovascular,Diseases 2011;20(4):357-368,预期随访,1-3,年（平均,2,年）,积极药物治疗,阿司匹林每天,325mg,，整个随访期,氯吡格雷每日,75mg,，,90,天,积极的方案驱动的危险因素控制，目标值血压,140/90 mm Hg(,糖尿病,130/80),以及,LDL70%,狭窄的第,1,年卒中,22%SAMMPRIS,：强化药物干预组,12%,Kasner,SE,et al.Circulation 2006;113:555-563,对,WASID,研究进行分析，在校正了年龄性别和种族后，颅内动脉狭窄严重程度是狭窄动脉区域复发缺血性卒中的独立预测因素。,70%,vs,70%,：,HR=2.08,P=0.0019,2,sICAS,血压,目标值？,Anding,Xu,Controlling Hypertension and Stroke Prevention:From Guideline to,Clinical Practice.Asia-Pacific Cardiology,March,2011,in press,卒中二级预防人群的大型,RCT,少，从中得到的血压目标值不十分明确,对,sICAS,人群尚缺乏前瞻性研究证据，现有的证据支持一般应,140/90mmHg,。但证据不强。,建议：积极降压，同时保证其安全性,低血流动力学梗死：不宜过强降压,其他脑梗死：,CCB(,nitrendipine,),卒中二级预防降压研究：缺乏针对,sICAS,的研究,THZ Vs others,BB Vs others,ACEI Vs others,ARB Vs others,CCB Vs others,不同降压药额外的卒中预防效果？,BMJ 2009;338:b1665,doi:10.1136/bmj.b1665,Stroke.2012;43:00-00.,2012,年最新荟萃分析，纳入,8,项随机对照研究,29 667,例,卒中二级预防患者,不同降压药额外的卒中预防效果？,LIEF,研究的亚组研究中证实,ARB,可延缓内颈动脉中膜增厚,ARB,治疗组与阿替洛尔相比，在第,3,年的治疗中,2,组的血压降低是一致的，,氯沙坦较阿替洛尔显著延缓颈动脉内中膜横断面积的进展,；,氯沙坦,n=23,，阿替洛尔,n=22,-7.9%,-1.7%,Blood Pressure.2005;14:177183,-100 -50 0 50 100,试验名称,n,基线,IMT(,m),变化值,/y,(,m),ACEIs:CCBs,ACEIs:CCBs,ACEIs:CCBs,Koshlyama,11:11,22:-104,Topouchlan,18:21,680:720,-80:-40,Pontremoll,16:15,820:840,-65:-110,Stanton,34:35,792:763,-17:-48,ELVERA,63:63,1057:1019,0:-17,All trails,142:145,Heterogeneity:x,2,=4.5,P,=0.34,CCBs,更优,ACEIs,更优,-23(-42 to-4),P=0.02,CCBs Vs,ACEIs,：颈动脉,IMT,变化,Stroke,2006;37;1933-1940,AHA/ASA 2011,关于血压干预的推荐,推荐意见,推荐,/,证据级别,能获得推荐的最佳降压