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1、降压治疗策略与目标 回顾与进展,降压治疗策略研究的重点,血压水平与心血管危险 降压治疗与心血管危险控制 治疗益处及来源(why) 治疗对象(who) 治疗目标水平(what) 治疗方案(which),Lancet 2002,360:1903,血压、年龄与脑卒中死亡率(100万人群资料分析),Lancet 2002,360:1903,血压、年龄与冠心病死亡率(100万人群资料分析),Cause Age at Number of Of death risk(years) deaths Stroke 40-49 414 0.36 (0.32-0.40) 50-59 1372 0.38 (0.35-0
2、.40) 60-69 2939 0.43 (0.41-0.45) 70-79 4327 0.50 (0.48-0.52) 80-89 2636 0.67 (0.63-0.71) IHD 40-49 1322 0.49 (0.45-0.53) 50-59 5594 0.50 (0.49-0.52) 60-69 10450 0.54 (0.53-0.55) 70-79 10852 0.60 (0.58-0.61) 80-89 5649 0.67 (0.64-0.70) Other 40-49 386 0.43 (0.38-0.48) vascular 50-59 1377 0.50 (0.47-0
3、.54) 60-69 2549 0.53 (0.51-0.56) 70-79 3227 0.64 (0.61-0.67) 80-89 2251 0.70 (0.65-0.75),A: usual systolic blood pressure (115 mmHg),Hazard ratio (95% CI) for 20 mmHg Lower usual systolic blood pressure,Lancet 2002,360:1903,收缩压 20 mmHg 差值对心血管危险影响,舒张压 10 mmHg 差值对心血管危险影响,血压参数预测脑卒中和冠心病死亡率的相对能力,脑卒中 冠心病
4、SBP 89% 93% DBP 83% 73% PP 37% 43% MAP 100% 97% Mid BP 100% 100%,Lancet 2002,360:1903,ESRD危险性随血压升高而增加,血压分级 患者 ESRD数目 年龄校正后的 校正后的RR (n = 322554) (n = 814) 每10万人年发生率 (95%CI) 理想 61089 51 5.3 1.0 正常 81621 86 6.6 1.2 (0.8-1.7) 正常高值 73798 134 11.1 1.9 (1.4-2.7) 高血压 1级（轻度） 85684 275 21.0 3.1 (2.3-4.3) 2级（中
5、度） 23459 158 43.6 6.0 (4.3-8.4) 3级（重度） 5464 73 96.1 11.2 (7.7-16.2) 4级（极重度）1429 37 187.1 22.1 (14.2-34.3),Klag MJ, Whelton PK, Randali BL et al, New Eng J Med. 1996;334:14-18.,血压水平的分类和定义(JNC-7),分类 收缩压(mmHg) 舒张压(mmHg) 正常血压 120 和 80 高血压前期 120 - 139 或 80 - 89 高血压1级 140 - 159 或 90 - 99 高血压2级 160 或 100,血
6、压水平的分类和定义(ESH/ESC 2003),110,110119,120129,130139,140149,150159,160+,SBP, mm Hg,% of men,30 25 20 15 10 5 0,Adjusted relative risk,5 4 3 2 1 0,70,7074,7579,8084,8589,9094,100+,DBP, mm Hg,% of men,30 25 20 15 10 5 0,Adjusted relative risk,3 2.5 2 1.5 1 0.5 0,9599,MRFIT: Arch Intern Med 1993; 153:598,正
7、常血压者,临界血压者,正常血压者,临界血压者,90%,10%,47%,53%,临界高血压转归 (Tecumsch Study, 3年随访),降压治疗临床试验荟萃分析结果,T = treatment,C = control,Non-fatal events,Fatal events,T,C,T,C,T,C,T,C,Numbers individuals,0,200,400,600,800,1000,1200,% reduction in odds,Stroke 39%,CHD 16%,Vascular deaths 21%,All other deaths 2%,SHEP study: JAMA
8、 2000; 284:265,Anti-hypertensive therapy & incidence of HF,n 840 1,627 4,736 4,695 1,148 F.U. (mths) 56 25 53 24 101 Reduction 17% 51% 54% 29% 56% p ns 0.01 0.001 ns 0.0043,% per year,Eur Heart J 1999:1(suppl):p3,PROGRESS: 预防脑卒中再发,随访时间（年）,发生事件患者的比例,安慰剂组,治疗组,危险下降28% (95%的可信限 17-38%) P0.0001,Lancet 20
9、01; 358: 1033-41,0.20 0.15 0.10 0.05 0.00,1,2,3,4,降压治疗的益处,平均下降 脑卒中 3540% 心肌梗死 2025% 心力衰竭 50%,Trials Number of Odds ratios Diferece vents/paitients (95% Cls) (SD) Old New MIDAS/NICS/VHAS 15/1358 15/1353 STOP2/CCBs 369/2213 362/2196 NORDIL 228/5471 153/3157 INSIGHT 152/3164 153/3157 ALLHAT/Aml 2203/15
10、255 1256/9048 ELSA 17/1157 13/1177 CCBs without CONVINCE 2984/28618 2030/22341 -3.1% (3.2) 2P=0.31 Heterogeneity P=0.95 CONVINCE 319/8297 337/8179 All CCBs 3303/36915 2367/30520 -2.3% (2.9) 2P=0.42 Heterogeneity P=0.95 UKPDS 59/358 75/400 STOP2/ACEIs 369/2213 380/2205 CAPPP 190/5493 184/5492 ALLHA/L
11、is 2203/15255 1314/3044 ANBP2 210/3039 195/3044 HYVET/AD 30/426 27/431 All ACEIs 3061/26784 2175/20626 -0.4% (3.1) 2P=0.89 Heterogeneity P=0.90 LIFE 431/4588 383/4605 SCOPE 266/2460 259/2477 All ARBs 697/7048 642/7082 -9.2% (5.9) 2P=0.09 Heterogeneity P=0.42 ALLHAT/Dox 851/15268 514/9067 All trias 4
12、489/53279 5698/67295 -1.8% (2.1) 2P=0.38 Heterogeneity P=0.96,降压治疗临床试验汇萃分析：总死亡率 （CCB、ACEI、ARB vs 利尿剂/b阻滞剂）,New drugs better,Old drugs better,Total mortality,Staessen JA. J Hypertens 2003,21:1055,Trials Number of Odds ratios Diferece vents/paitients (95% Cls) (SD) Old New MIDAS/NICS/VHAS 7/1358 10/13
13、53 STOP2/CCBs 221/2213 212/2196 NORDIL 115/5471 131/5410 INSIGHT 52/3164 60/3157 ALLHAT/Aml 992/15255 592/9048 ELSA 8/1157 4/1177 CCBs without CONVINCE 1438/30947 1039/24685 2.0% (4.4) 2P=0.64 Heterogeneity P=0.59 CONVINCE 143/8297 152/8179 All CCBs 1581/39244 1191/32864 2.7% (4.1) 2P=0.51 Heterogen
14、eity P=0.68 UKPDS 32/358 48/400 STOP2/ACEIs 221/2213 226/2205 CAPPP 95/5493 76/5492 ALLHA/Lis 992/15255 609/9054 ANBP2 82/3039 84/3044 HYVET/AD 23/426 22/431 All ACEIs 1539/23146 1365/19126 2.2% (4.3) 2P=0.61 Heterogeneity P=0.50 LIFE 234/4588 204/4605 SCOPE 152/2460 145/2477 All ARBs 386/7048 349/7082 -10.6% (8.1) 2P=0.15 Heterogeneit
