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1、策略 循证 证据 高血压、冠心病最新循证医学结果及临床意义 从ALLHAT到ASCOT,中国医师协会循证医学专业委员会主任委员 胡大一,长效钙拮抗剂治疗冠心病伴高血压安全有效，证据充分,策略,循证,证据,降低心血管风险，及早控制血压达标是主导作用,长效钙拮抗剂临床应用的地位,以往大量临床研究表明，降压治疗的益处主要来自血压降低本身,临床试验证实长期有效降压治疗能减少30%-50% 心脑血管病发生率。 益处大小受患者心血管危险程度、血压控制目标 水平、治疗方案降压以外有利作用或不利作用的 影响。,IHDIschemic Heart Disease,Prospective Studies Coll
2、aboration. Lancet. 2002;360:1903-1913.,收缩压,舒张压,IHD Mortality (Floating Absolute Risk and 95% CI),Usual Systolic BP (mm Hg),50-59 years,60-69 years,70-79 years,80-89 years,Age at risk:,40-49 years,血压、年龄与冠心病死亡率(100万人群资料分析),ALLHAT：平均收缩压,ALLHAT Collaborative Research Group. JAMA. 2002;288:2981-2997.,0,2
3、0,16,8,4,1,2,3,4,5,6,事件发生时间（年）,氯噻酮,氨氯地平,赖诺谱利,ALLHAT：各治疗组主要终点（致死性冠心病和非致死性心肌梗死）无显著差异,7,12,氯噻酮,氨氯地平,赖诺谱利,有风险病人数,15 255 9048 9054,14 477 8576 8535,13 820 8218 8123,13 102 7843 7711,11 362 6824 6662,6340 3870 3832,2956 1878 1770,209 215 195,累积事件率（%）,氨氯地平vs 氯噻酮: RR 0.98, P=0.65 赖诺普利vs 氯噻酮: RR 0.99, P=0.81
4、,ALLHAT表明 降压是抗高血压药物减少心血管事件的主要作用,Blood Pressure Lowering Treatment Trialists Collaboration BPLTC协作研究 Second cycle of overview analyses（2003）,Institute for International Health,BPLTC协作研究: 29项随机对照试验,AASK ABCD (H) ABCD (N) ALLHAT ANBP2 CAPPP CONVINCE ELSA HOPE HOT,IDNT INSIGHT JMIC-B LIFE NICOLE NICS-EH
5、 NORDIL PART-2 PREVENT PROGRESS,QUIET RENAAL SCAT SCOPE SHELL STOP-2 SYST-EUR UKPDS-HDS VHAS,广泛的病人群和代表性,纳入162341病人 平均年龄65岁，52男性 平均随访28年 共随访超过700000病人年,BPLTC协作研究:,前瞻性 荟萃分析,CORONARY HEART DISEASE Comparisons of different active treatments,RR (95% CI),Favours first listed,Favours second listed,BP diffe
6、rence (mm Hg),0.5,1.0,2.0,Relative Risk,0.96 (0.88,1.05),1.01 (0.94,1.08),0.98 (0.91,1.05),ACE vs. CA,CA vs. D/BB,ACE vs. D/BB,2/0,1/0,1/1,STROKE Comparisons of different active treatments,RR (95% CI),Favours first listed,Favours second listed,0.5,1.0,2.0,Relative Risk,BP difference (mm Hg),1.09 (1.
7、00,1.18),ACE vs. D/BB,0.93 (0.86,1.01),CA vs. D/BB,1.12 (1.01,1.25),ACE vs. CA,2/0,1/0,1/1,2004年高血压领域重要研究再次表明降压本身的重要性,ACTION CCB vs P PEACE ACEI vs P CAMELOT CCB vs P vs ACEI,HTNCAD,CHD/CAD,HTNCHD,INVEST CCB+ACEI vs BB+D VALUE CCB vs ARB ASCOT CCB+ACEI vs BB+D,HTN,* CCB=苯磺酸氨氯地平,*,*,*,VALUE: 设计 选择性加量
8、至目标 BP (140/90 mmHg),Month 0.5 0 1 2 3 4 6 * 72,A 10 mg + HCTZ 25 mg,A 5 mg,A 10 mg + HCTZ 12.5 mg,A 10 mg,V 80 mg,V 160 mg,V 160 mg + HCTZ 12.5 mg,V 160 mg + HCTZ 25 mg,氨氯地平组,V 160 mg + HCTZ 25 mg + Free add-on,A 10 mg + HCTZ 25 mg + Free add-on,缬沙坦组,筛选,随机,End of treatment adjustment period,Rollove
9、r from previous therapy (92%),*Patient visits every 6 months for months 672.,Julius S et al. Lancet. June 2004;363.,Julius S et al. Lancet. June 2004;363.,缬沙坦 (N= 7649),氨氯地平 (N = 7596),135,140,145,150,155,mmHg,月,(或终末随访),治疗组随时间变化的坐位收缩压,Baseline,1,24,48,2,3,4,6,12,18,30,36,42,54,60,66,0,1.0,2.0,3.0,4.
10、0,1,24,48,mmHg,2,3,4,6,12,18,30,36,42,54,60,66,月,5.0,缬沙坦与氨氯地平SBP的差异,1.0,(或终末随访),VALUE: 氨氯地平降SBP疗效优于新型ARB,VALUE:试验结束时血压控制情况,56%,DBP (90 mmHg),88%,58%,SBP (140 mmHg),% 研究期间血压达标的患者比例,缬沙坦组,氨氯地平组,Both SBP (140 mmHg) and DBP (90 mmHg),62%,92%,64%,Julius S et al. Lancet. June 2004;363.,VALUE:主要终点(心脏病事件),14
11、 12 10 8 6 4 2 0,Time (months),0 6 12 18 24 30 36 42 48 54 60 66,Proportion of Patients With First Event (%),缬沙坦组,氨氯地平组,HR = 1.03; 95% CI = 0.941.14; P = 0.49,Julius S et al. Lancet. June 2004;363.,Number at risk,Valsartan,Amlodipine,7596,7649,7469,7459,7424,7407,7267,7250,7117,7085,6772,6732,6955,6
12、906,6576,6536,5959,5911,3725,3765,1474,1474,6391,6349,VALUE: 致死性和非致死性脑卒中,Julius S et al. Lancet. June 2004;363.,Number at risk,Valsartan,Amlodipine,7596,7649,7499,7494,7455,7448,7334,7312,7195,7170,6918,6877,7055,7022,6744,6692,6163,6093,3846,3859,1532,1516,6587,6515,6 5 4 3 2 1 0,Time (months),0 6
13、12 18 24 30 36 42 48 54 60 66,Proportion of Patients With First Event (%),缬沙坦组,氨氯地平组,HR = 1.15; 95% CI = 0.981.35; P = 0.08,Time (months),Number at risk,Valsartan,Amlodipine,7596,7649,7497,7499,7458,7458,7332,7319,7205,7177,6905,6853,7065,7016,6727,6680,6141,6078,3840,3864,1532,1520,6562,6504,Propor
14、tion of Patients With First Event (%),7 6 5 4 3 2 1 0,VALUE: 致死及非致死心肌梗死,0 6 12 18 24 30 36 42 48 54 60 66,缬沙坦组,氨氯地平组,HR = 1.19; 95% CI = 1.02-1.38; P = 0.02,Julius S et al. Lancet. June 2004;363.,19,VALUE: 根据1个月内降压效应的结果分析,致死/非致死性心脏事件,致死/非致死性脑卒中,全因死亡,心肌梗死,心衰住院,0.4,0.6,0.8,1.0,1.2,1.4,早期降压有效患者* (n = 9336),非早期降压有效患者 (n = 5663),Odds Ratio 95% CI,*Those not on previous tx: SBP 10 mmHg at one month; those on previous tx: SBP baseline at one month. *P 0.05; P 0.01.,Pooled Treatment Groups,*,*,
