高血壓的藥物治療種族因素課件

1、高血壓的藥物治療種族因素上海交通大學(xué)醫(yī)學(xué)院附屬瑞金醫(yī)院上海市高血壓研究所王繼光2008年3月8日，北京Relative risk reductions by antihypertensive treatment in early trialsProgression to severe HTCHFStrokeCHDTotal mortalityCV mortality-94*-53%*-40%*-16%*-13%-21%*P0.05Collins R et al. Br Med Bull 1994;50:272-298.BPLTTC. Lancet 2003;362:1527-45.0-5-10

2、-15-20-25-30StrokeCHDCHFTotal mortality -23%-15%-16%-14%4/3 mmHgN20 888Major CV events -15%Relative risk reductions by antihypertensive treatment in recent trialsHOT study Hypertension Optimal Treatment trial 80 vs 85 vs 90 mm HgLancet 1998;351:1755-1762.HOT: Antihypertensive drug treatmentStep 15 m

3、g felodipineStep 25 mg felodipine+ low dose ACE inhibitor or b-blockerStep 310 mg felodipine+ low dose ACE inhibitor or b-blockerStep 410 mg felodipine+ high dose ACE inhibitor or b-blockerStep 510 mg felodipine+ high dose ACE inhibitor or b-blocker+ low dose alternative addition or HCTZHansson L et

4、 al. Lancet 1998;351:1755-1762.Mean DBP measured from 6 months and onwards0510152025Target 80 : 81.1 (5.3)Target 85 : 83.2 (4.8) Target 90 : 85.2 (5.1)Frequency %60Achieved DBP, mm Hg708090100110Hansson L et al. Lancet 1998;351:1755-1762.Target 80 : 139.7 (11.7)Mean SBP measured from 6 months and on

5、wards100 0510152025Frequency %110 120 130 140 150 160 170 180 190 Target 85 : 141.4 (11.7) Target 90 : 143.7 (11.3)Achieved SBP, mm HgHansson L et al. Lancet 1998;351:1755-1762.HYVET Hypertension in the Very Elderly Trial Indapamide vs. placebo Drugs Aging 2001;18:151-64.收縮壓差別 10 mm Hg腦卒中 (no. event

6、s100) 40% 總死亡率 (no. events300) 15%Personal communicationsHYVET 2007-7Any diabetes related endpointNumber of endpoints1401 of 3867 patients (36%) 0%20%40%60%03691215% of patients with an eventYears from randomisationIntensive (n=2729)Conventional (n=1138)Risk reduction 12% (95% CI: 1% to 21%) p=0.029

7、UKPDS 33. Lancet 1998;352:837-53指南推薦利尿劑阻滯劑鈣離子拮抗劑轉(zhuǎn)換酶抑制劑血管緊張素受體拮抗劑J Hypertens 2007;25:1105-87.到底該如何選擇降壓藥物 ?特別注意應(yīng)該堅(jiān)持使用指南推薦使用的降壓藥物。5大類(lèi)藥物均可作為起始治療藥物使用，并不意味著可以不加選擇地使用藥物，當(dāng)然也不是每類(lèi)藥物都應(yīng)該有同等即20%機(jī)會(huì)作為一線(xiàn)藥物使用。應(yīng)該根據(jù)臨床試驗(yàn)的證據(jù)原則、降壓作用與副作用，選擇對(duì)患者最為合適的藥物。CCBs vs. 利尿劑/阻滯劑: 致死性與非致死性腦卒中利尿劑/阻滯劑CCBs試驗(yàn)事件數(shù) / 研究對(duì)象人數(shù)異質(zhì)性檢驗(yàn) 危險(xiǎn)比 (95%可信區(qū)間

8、)差別 (SD)0CCBs較好123利尿劑/阻滯劑較好MIDAS/NICS/VHASSTOP2/CCBsNORDILINSIGHTALLHAT/AmlodipineELSACCBs without CONVINCEp = 0.68CONVINCE所有CCBsp = 0.3915/1358237/2213196/547174/3164675/1525514/11571211/28618118/82971329/3691519/1353207/2196159/541067/3157377/90489/1177838/22341133/8179971/3052010.2% (4.8) 2p = 0.

9、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. The BHS-NICE guideline.uk55 years55 years or black patients of any ageAC or DStep 1A+C or A+DStep 2Step 3A+C+DStep 4Add: further diuretic therapy, -blocker, -blockerConsider seeking spec

10、ialist advice Systemic rotationABCD or AB/CD ruleCDDickerson JEC et al. Lancet 1999; 353: 2008-2013. Black-ChlorBlackAmlodBlackLisinNonblackChlorNonblackAmlodNonblackLisinBP by treatment group and ethnicityWright JT et al. JAMA 2005:293:1595-1608.ALLHAT: % on 3+ antihypertensive drugs by randomized

11、group and ethnicity at 5 yWright JT et al. JAMA 2005:293:1595-1608.ALLHAT: BP control (140/90 mm Hg) by randomized group and ethnicity at 5 y135/78136/76139/79133/74134/74134/74Wright JT et al. JAMA 2005:293:1595-1608.不同種族患者對(duì)降壓藥物的反應(yīng)Khan JM et al. Heart. 2005;91;1105-1109.HOT：舒張壓下降0-5-10-15-20-25-309

12、08580舒張壓下降mm Hgmm Hg p0.0001 p0.0001 p0.0001目標(biāo)舒張壓亞洲病人其他病人HOT：收縮壓下降亞洲病人其他病人0-5-10-15-20-25-30-35-40908580收縮壓mm Hgmm Hg p0.0001 p0.01 p0.0001目標(biāo)舒張壓HOT: 不良反應(yīng)p0.001p0.05p0.01p0.05nsnsnsnsnsnsp 160/90 mmHgFEVER：研究流程 Liu LS et al. J Hypertens 2005;23:2157-2172.-606121824303642485460120130140150160170 SBP (

13、mmHg)隨訪(fǎng) (月)142.5137.3141.6138.1安慰劑非洛地平SR平均差異 4mmHgFEVER：收縮壓非洛地平+HCTZ vs HCTZ Liu LS et al. J Hypertens 2005;23:2157-2172.7580859095100 DBP (mmHg) 隨訪(fǎng) (月)85.082.583.982.3安慰劑非洛地平平均差異 2mmHg-606121824303642485460SRFEVER：舒張壓非洛地平+HCTZ vs HCTZ Liu LS et al. J Hypertens 2005;23:2157-2172.02468100612182430364

14、248546026.8%FEVER：主要終點(diǎn)事件HCTZ非洛地平+HCTZ隨訪(fǎng)時(shí)間（月）主要終點(diǎn)（%）Liu LS et al. J Hypertens 2005;23:2157-2172.次要終點(diǎn)-27.4%-34.6%-32.5%-30.4%-17.0%-36.4%-40%-35%-30%-25%-20%-15%-10%-5%0%心血管事件所有心臟事件冠脈事件全因死亡率心血管死亡率癌癥發(fā)生率FEVER：終點(diǎn)事件Liu LS et al. J Hypertens 2005;23:2157-2172.降壓治療是最有效的心血管藥物治療手段，因此，高血壓一旦確診，應(yīng)及早開(kāi)始降壓治療。降低血壓是抗高血壓治療獲益的根本原因。在密切注意降壓治療的安全的情況下，應(yīng)盡可能把血壓