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1、BP reduction and CV prevention 降压治疗与心血管病预防 关注降压质量，丰富高血压专业内涵,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 trials,Progression to severe HT,CHF,Stroke,CHD,Total mortality,CV mortality,-94*,-53%*,-40%*,-16%*,-13%,-21%*,*P 利尿剂/阻滞剂 ACEIs,CCBs vs. 利尿剂/阻滞剂: 致
2、死性与非致死性脑卒中,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,1,2,3,利尿剂/阻滞剂较好,MIDAS/NICS/VHAS STOP2/CCBs NORDIL INSIGHT ALLHAT/Amlodipine ELSA CCBs without CONVINCE p = 0.68 CONVINCE 所有CCBs p = 0.39,15/1358 237/2213 196/5471 74/3164 675/15255 14/1157 1211/28618 118/8297 1329/36915,19/
3、1353 207/2196 159/5410 67/3157 377/9048 9/1177 838/22341 133/8179 971/30520,10.2% (4.8) 2p = 0.02,7.6% (4.4) 2p = 0.07,Staessen JA, et al. Lancet 2001;37:1305-15. Staessen JA et al. J Hypertens 2003;21:1055-76.,0,ACEIs较好,1,2,3,UKPDS STOP2/ACEIs CAPPP ALLHAT/Lisinopril ANBP2 所有ACEIs p = 0.16,17/358 2
4、37/2213 148/5493 675/15255 107/3039 1184/26358,21/400 215/2205 189/5492 457/9054 112/3044 994/20195,10.2% (4.6) 2p = 0.03,ACEIs vs. 利尿剂/阻滞剂: 致死性与非致死性脑卒中,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;
5、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%),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,0.5,1.0,2.0,+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=0.055,P=0.047,P
6、=0.003,P=0.007,P=0.004,P= 0.036,终点事件,差别(95% CI),Leenen FHH, et al. Hypertension 2006;48:374-384.,ALLHAT：赖诺普利 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+micro,14% (2% to 25%),All deaths,18% (2% to 32%),CV deaths,Non CV deaths,Total coronary,Total cerebrovascular,Stroke,Heart f
7、ailure,Total renal events,Total eye events,0.5,1.0,2.0,8% (-12% to 24%),14% (2 to 24%),6% (-10% to 20%),2% (-18% to 19%),21% (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=0.86,165/1280 102/6108 218/5571,157/1281 98
8、/6110 215/5569,PROGRESS/perindopril only EUROPA ADVANCE,0.5,1,1.5,2.0,培多普利 vs. 安慰剂: 致死性与非致死性脑卒中,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 (mm Hg),培多普利,5/2 5/2 5.6/2.2,PROGRESS Management Committee. Lancet 200;358:1033-41; Fox K et al. Lancet 2003;362:782-8; Patel A et al. Lancet 2007; 370:
9、829-40.,2. Prevention of MI Amlodipine provides similar protection against MI as ACEIs. 心肌梗死预防: 氨氯地平 利尿剂/阻滞剂 ACEIs,16/1358 154/2213 157/5471 61/3164 1362/15255 17/1157 1767/28618 166/8297 1933/36915,16/1353 179/2196 183/5410 77/3157 798/9048 18/1177 1271/22341 133/8179 1404/30520,4.5% (3.9) 2p = 0.2
10、6,1.9% (3.7) 2p = 0.61,MIDAS/NICS/VHAS STOP2/CCBs NORDIL INSIGHT ALLHAT/Amlodipine ELSA CCBs without CONVINCE p = 0.38 CONVINCE All CCBs p = 0.14,0,1,2,3,CCBs vs. 利尿剂/阻滞剂: 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),CCBs,Staessen JA, et al. Lancet 2001;37:1305-1
11、5. 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) 0.69,RR(95%Cl) P 值,0.200.150.100.050.00,0 1 2 3 4 5 6 7,基线无CHD,氨氯地平 赖诺普利,赖/氨 0.98(0.88-1.13) 0.78,RR(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
12、;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 antihypertensive drugs or whether each drug must be considered individually. It is reasonable to assume that there are
13、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 major differences between drugs within more heterogeneous classes of agents, such as -blockers or CCBs.,3. Prvention of stroke and MI Amlodipine vs. ARBs 脑卒中与心肌梗死预防: 氨氯地平 vs. ARBs,Prevention of stroke and MI by amlodipine and ARBs 氨氯地平与ARBs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,
