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1、BP reduction and CV prevention 降压治疗与心血管病预防关注降压质压质 量，丰富高血压专业压专业 内涵王继光 上海交通大学医学院附属瑞金医院 上海市高血压研究所Relative risk reductions by antihypertensive treatment in early trialsProgression to severe HTCHFStrokeCHDTotal mortalityCV mortality-94*-53%*-40%*-16%*-13% -21%*P 利尿剂/阻滞剂 ACEIs CCBs vs. 利尿剂剂/阻滞剂剂: 致死性与非致死性
2、脑脑卒中利尿剂/阻滞剂CCBs试验事件数 / 研究对象人数异质性检 验 危险比 (95%可信区间)差别 (SD)0 CCBs较好123 利尿剂/阻滞剂较好MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBs without CONVINCE p = 0.68CONVINCE所有CCBsp = 0.3915/1358237/2213196/547174/3164675/1525514/11571211/28618118/82971329/3691519/1353207/2196159/541067/3157377/9048
3、9/1177838/22341133/8179971/3052010.2% (4.8) 2p = 0.027.6% (4.4) 2p = 0.07Staessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 0ACEIs较好123UKPDSSTOP2/ACEIsCAPPPALLHAT/LisinoprilANBP2所有ACEIsp = 0.1617/358237/2213148/5493675/15255107/30391184/2635821/400215/2205189
4、/5492457/9054112/3044994/2019510.2% (4.6) 2p = 0.03ACEIs vs. 利尿剂剂/阻滞剂剂: 致死性与非致死性脑脑卒中利尿剂/阻滞剂试验事件数 / 研究对象人数异质性检 验 危险比 (95%可信区间)差别 (SD)CCBs利尿剂/阻滞剂较好Staessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 相对危险度 (95% CI)赖诺普利 较好氨氯地平 较好+1% (9% to +11%)CHD+5% (3% to +13%)
5、 总死亡率+4% (3% to +12%) 联合CHD脑卒中联合CVD需要住院的GI出血心衰心绞痛冠脉血运重建外周动脉疾病0.51.02.0+23% (+8% to +41%)+6% ( 0 to +12%)+20% (+6% to +37%)-13% (22% to 4%)+9% ( 0 to +19%)0 (9% to +11%)+19% (+1% to +40%)P=0.055P=0.047P=0.003P=0.007P=0.004P= 0.036终点事件差别(95% CI)Leenen FHH, et al. Hypertension 2006;48:374-384.ALLHAT：赖诺
6、普利 vs. 氨氯地平相对危险度 (95% CI)培多普利 较好安慰剂 较好9% (0% to 17%)Combined macro+micro14% (2% to 25%) All deaths18% (2% to 32%) CV deathsNon CV deaths Total coronary Total cerebrovascularStroke Heart failureTotal renal eventsTotal eye events0.51.02.08% (-12% to 24%)14% (2 to 24%)6% (-10% to 20%)2% (-18% to 19%)21
7、% (15% to 27%)5% (-1% to 10%)P=0.42终点事件差别(95% CI)Patel A et al. Lancet 2007; 370:829-40.ADVANCE：培多普利 vs. 安慰剂2% (-20% to 19%) P=0.86165/1280102/6108218/5571157/128198/6110215/5569PROGRESS/perindopril onlyEUROPAADVANCE0.511.52.0培多普利 vs. 安慰剂剂: 致死性与非致死性脑脑卒中培多普利较好安慰剂较好安慰剂试验事件数 / 研究对象人数危险比 (95%可信区间)血压差别 (
8、mm Hg)培多普利5/25/25.6/2.2PROGRESS Management Committee. Lancet 200;358:1033-41; Fox K et al. Lancet 2003;362:782-8; Patel A et al. Lancet 2007; 370:829-40.2. Prevention of MI2. Prevention of MIAmlodipine provides similar protection against MI as ACEIs.心肌梗死预防: 氨氯地平 利尿剂/阻滞剂 ACEIs16/1358154/2213157/54716
9、1/31641362/1525517/11571767/28618166/82971933/3691516/1353179/2196183/541077/3157798/904818/11771271/22341133/81791404/305204.5% (3.9) 2p = 0.261.9% (3.7) 2p = 0.61MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBs without CONVINCE p = 0.38CONVINCEAll CCBsp = 0.140123CCBs vs. 利尿剂剂/阻滞剂剂:
10、 致死性与非致死性心肌梗死CCBs较好利尿剂/阻滞剂较好利尿剂/阻滞剂试验事件数 / 研究对象人数异质性检 验 危险比 (95%可信区间)差别 (SD)CCBsStaessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76. 0.200.150.100.050.00 0 1 2 3 4 5 6 7基线CHD随访时间（年）赖/氨 1.06(0.99-1.32) 0.69RR(95%Cl) P 值0.200.150.100.050.00 0 1 2 3 4 5 6 7基线无CHD氨
11、氯地平 赖诺普利赖/氨 0.98(0.88-1.13) 0.78RR(95%Cl) P 值ALLHAT: 致死/非致死性CHD发生率随访时间（年）Leenen FHH, et al. Hypertension 2006;48:374-384.CHD累计发生率AHA/ACC高血压合并冠心病降压治疗建议： 各类降压药物的异质性Rosendorff C et al. Circulation 2007;115:2761-88.There is also continuing debate over whether there are “class effects” for antihypertensi
12、ve drugs or whether each drug must be considered individually. It is reasonable to assume that there are class effects for thiazide-type diuretics, ACE inhibitors, and ARBs, which have a high degree of homogeneity in their mechanisms of action and side effects. It is equally clear that there are maj
13、or differences between drugs within more heterogeneous classes of agents, such as -blockers or CCBs. 3. Prvention of stroke and MI3. Prvention of stroke and MIAmlodipine vs. ARBs脑卒中与心肌梗死预防: 氨氯地平 vs. ARBsPrevention of stroke and MI by Prevention of stroke and MI by amlodipine and ARBs amlodipine and
14、ARBs 氨氯地平与氨氯地平与ARBsARBs预防卒中与心肌梗死预防卒中与心肌梗死A meta-analysis of RCTs 随机对照临床试验综合分析Wang JG et al. Hypertension 2007; 50: 333-339. 氨氯氯地平 vs. ARBs*: 脑脑卒中氨氯地平较好ARBs较好IDNT VALUECASE-J所有试验 p = 0.4630/579322/764960/2354412/10,58218/567281/759647/2349346/10,51215.9% (6.2) 2p = 0.020.51.01.52.0* 厄贝沙坦、缬沙坦、坎地沙坦ARBs
15、氨氯地平试验事件数 / 研究对象人数异质性检验 危险比 (95%可信区间)差别 (SD)Wang JG et al. Hypertension 2007; 50:333-339. IDNT VALUECASE-JAll trials p = 0.4051/579369/764917/2354437/10,58233/567281/759618/2349332/10,51216.7% (6.1) 2p = 0.010.51.01.52.0氨氯氯地平 vs. ARBs*: MIARBs试验事件数 / 研究对象人数异质性检验 危险比 (95%可信区间)差别 (SD)氨氯地平氨氯地平较好ARBs较好* 厄贝沙坦、缬沙坦、坎地沙坦Wang JG et al. Hypertension 2007; 50:333-339. Why differ, beyond BP control, or because of better BP control ? 为什么有差别，是“降压外作用”，
