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1、高血压并糖尿病患者需要更严格地控制血压,王 文 中国高血压联盟 卫生部心血管病防治研究中心 中国医学科学院阜外心血管病医院,中国35-64岁人群队列人群31728人（1992-2002） 基线血压(mmHg)与10年总心血管事件 发病的相对危险(RR),SBP 120 1960s- Severe Hypertension 180/110 1970s- Moderate Hypertension 160/100 1980s- Mild Hypertension 140/90 1990s- Older Systolic Hypertension 140/130 / 85 2005- DM，CHD，
2、STK 130 / 80,血压水平定义,血压 (mmHg) SBP DBP 正常血压 120 80 正常高值 120139 8089 高血压 140 和/或 90 2005: CHL 标准;,PROGRESS国际结果,治疗组 对照组 危险下降% 脑卒中事件: 高血压(n=2916) 163 235 32 非高血压(n=3187) 144 185 27 重要血管事件: 高血压(n=2916) 240 331 29 非高血压(n=3187) 218 273 24,糖尿病平均收缩压(mmHg)与脑卒中发生率(%),UKPDS: 4801例糖尿病 (50-54岁) 随访10年,SBP,14.4,20.
3、3,22.2,23.8,29.1,36.2,0,5,10,15,20,25,30,35,40,总死亡(%),UKPDS: 糖尿病m SBP水平与死亡率关系 （随访10年）,UKPDS-38: 强化降压与糖尿病大血管及微血管事件,（R Turner, UK BMJ 1998;317:703) 对象 (入选间期19771991年) 1148例高血压伴2DM,758例强化降压, 390例非强化降压治疗, 随访8.4年。 治疗： 强化降压400例ACEI，358例阻滞剂； 非强化390例，避免ACEI/阻滞剂,UKPDS-38：基线特征,强化降压（n758） 非强化（n390） 平均年龄（岁） 56.
4、4 56.5 男 （） 54 56 BMI（kg/m2） 29.8 29.3 SBP（mmHg） 15920 16018 DBP (mmHg) 9410 949 吸烟（） 23 22 降压治疗史（） 66 67,UKPDS-36： 2DM随访10年SBP与事件（1/1000人年）,SBP DM并发症 死于DM 总死亡 心梗 卒中 微血管病 外周血管病 心衰 (mmHg) 120 22.9 4.3 6.9 9.4 5.7 120-129 28.5 5.7 12.8 10.3 1.8 7.2 0.6 1.3 130-139 37.7 10.0 15.9 13.8 3.6 9.3 1.5 3.0 1
5、40-149 45.4 10.8 19.2 16.2 6.0 11.1 1.4 3.5 150-159 53.3 15.5 24.5 19.3 8.3 11.6 1.8 5.1 160 58.3 19.9 29.4 21.6 11.0 14.6 2.8 6.4 (5054岁，4801人)（BMJ，2000，321：412）,UKPDS-36: SBP与10年事件,UKPDS-38：血压差别12/5mmHg (144/82 vs 156/87 mmHg),UKPDS-38：终点事件（强化 VS 非强化）,UKPDS-38：有关糖尿病临床终点,UKPDS-38：血管性死亡 （心梗、猝死、卒中、周围
6、血管病、肾衰）,UKPDS-38：微血管终点(眼底激光)、 心梗/猝死、卒中事件,ADVANCE: a factorial randomised trial of blood pressure lowering and intensive glucose control in 11,140 patients with type 2 diabetes,Effects of a fixed combination of the ACE inhibitor, perindopril, and the diuretic, indapamide on major vascular events,ADVA
7、NCE：Baseline characteristics,Blood pressure reduction, 2.2 mmHg (95% CI 2.0-2.4); p0.001, 5.6 mmHg (95% CI 5.2-6.0); p0.1,2.0,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Hazard ratio,0.5,1.0,Age (years),= 65,536,592,11% (0 to
8、21),Sex,Male,546,594,10% (-1 to 20),Female,315,344,8% (-7 to 21),SBP (mmHg), 7.5,451,481,11% (-1 to 22),All participants,861,938,9% (0 to 17),Coronary events,*2P=0.02,Non-fatal MI or death from coronary heart disease Unstable angina requiring hospitalisation, coronary revascularisation or silent MI,
9、Major coronary heart disease,265,294,11% (-6 to 24),All coronary heart disease,468,535,14% (2 to 24),Other coronary heart disease,283,324,14% (-1 to 27),*,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Hazard ratio,0.5,1.0,2.0,Ce
10、rebrovascular events,Major cerebrovascular disease,215,218,2% (-18 to 19),All cerebrovascular disease,286,303,6% (-10 to 20),Other cerebrovascular disease,79,99,21% (-6 to 41),2.0,*,*2P=0.40,Non-fatal stroke or death from cerebrovascular disease Transient ischaemic attack or subarachnoid haemorrhage
11、,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Hazard ratio,0.5,1.0,Renal events,2.0,Hazard ratio,0.5,1.0,New or worsening nephropathy,181,216,18% (-1 to 32),New microalbuminuria,1094,1317,21% (14 to 27),Total renal events,1243,
12、1500,21% (15 to 27)*,*2P=0.01,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,Eye events,2.0,Hazard ratio,0.5,1.0,*2P=0.09,New or worsening eye disease,289,286,-1% (-18 to 15),Visual deterioration,2446,2514,5% (-1 to 10),Total eye
13、 events,2531,2611,5% (-1 to 10)*,Number of events,Per-Ind,Placebo,(n=5,569),(n=5,571),Relative risk,reduction (95% CI),Favours,Per-Ind,Favours,Placebo,ADVANCE Summary,Routine treatment of type 2 diabetic patients with perindopril-indapamide resulted in: 14% reduction in total mortality 18% reduction
14、 in cardiovascular death 9% reduction in major vascular events 14% reduction in total coronary events 21% reduction in total renal events,Benefits appeared to be similar in all major subgroups. Treatment was very well tolerated, with few side effects and adherence similar to that with placebo.,*most
15、ly new onset microalbuminuria,Absolute benefits of routine treatment with perindopril and indapamide,脑卒中: ABCD HOT UKPDS,严格降压,常规降压,Relative Risk ( 95% CI ),0.98 (0.402.43),0.80 (0.411.56),0.56 (0.370.90),严格降压与常规降压对糖尿病患者脑卒中事件的影响,心血管总事件： ABCD HOT UKPDS,严格降压,常规降压,Relative Risk ( 95% CI ),0.91 (0.601.37),0.67 (0.451.00),0.69 (0.550.86),严格降压与常规降压对糖尿病患者心血管事件的影响,卒中,DM 终点,DM 死亡,微血管病,UKPDS: 严格降糖与严格降压治疗终点减少(%)的比较
