鈣拮抗劑降壓治療地位進展課件

影響不同種類降壓藥物治療地位的決定因素禁忌癥循證醫(yī)學證據(jù)不良反應和治療持續(xù)性效益/費用種族影響不同種類降壓藥物治療地位的決定因素禁忌癥各類降壓藥物的禁忌癥(ESC/ESH,2007)

噻嗪類利尿劑痛風代謝綜合癥、糖耐量減低妊娠-阻滯劑哮喘、外周血管病、代謝綜合癥

糖耐量異常、慢阻肺

A-V阻滯(2或3度)運動員和強體力活動者

二氫吡啶類CCB——快速性心律失常、心力衰竭

非二氫吡啶類CCBA-V阻滯(2或3度)

心力衰竭ACEI和ARB妊娠、高血鉀癥雙側(cè)腎動脈狹窄醛固酮拮抗劑腎功能衰竭高血鉀癥

絕對(強制)相對(可能)

各類降壓藥物的禁忌癥(ESC/ESH,2007) SBPdifferencebetweenrandomizedgroups(mmHg)Relativeriskofoutcomeevent1.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.25StrokeMajorCVDCHDCVDdeathTotalmortality-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024BP-LoweringTreatmentTrialists(WHO/ISH,2003)BloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.SBPdifferencebetweenrandomi0.51.02.0RelativeRisk

RR(95%CI)BPDifference

(mmHg)Favors

FirstListedFavors

SecondListedMajorCVeventsCVmortalityTotalmortality1.02(0.98,1.07)2/0ACEIvsD/BB1.03(0.95,1.11)2/0ACEIvsD/BB1.00(0.95,1.05)2/0ACEIvsD/BB1.04(0.99,1.08)1/0CAvsD/BB1.05(0.97,1.13)1/0CAvsD/BB0.99(0.95,1.04)1/0CAvsD/BB0.97(0.92,1.03)1/1ACEIvsCA1.03(0.94,1.13)1/1ACEIvsCA1.04(0.98,1.10)1/1ACEIvsCABloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.BP-LoweringTreatmentTrialists

ComparisonsofDifferentActiveTreatments0.51.02.0RelativeRiskRR(95%

RR(95%CI)

Favoursfirstlisted

Favourssecondlisted0.51.02.0RelativeRiskBPdifference(mmHg)

1.09(1.00,1.18)

ACEIvs.D/BB

0.93(0.86,1.01)

CAvs.D/BB

1.12(1.01,1.25)

ACEIvs.CA2/01/01/1BPLTT(2003):Stroke

ComparisonsofdifferentactivetreatmentsBloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.RR(95%CI)FavoursFavou0.40.60.81.01.21.40.21.82.015105-5OddsratioforCHDACEI’sALLHATACEIUKPDS39EUROPAPROGRESSPROGRESSComCAMELOTHOPEPEACECAPPPSTOP-2ACEIANBP-2SystolicBPdifferencebetweengroups(mmHg)Verdecchiaetal20050NICSALLHATCCBPREVENTIDNT-2CONVINCEVHASSyst-ChinaSYSTEURCAMELOTSTONENICOLEACTIONNORDILINVESTSTOP-2CCBINSIGHT151050-5CCB’sELSARelationshipBetweenOddsRatioforCHDandAchievedBPDifferences0.40.60.81.01.21.40.21.82.0151CCBsandCVOutcomesNewMeta-Analysis(ACC,2009)在BPLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗：ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPACCBsandCVOutcomes在BPLTT的基礎(chǔ)上妊娠BloodPressureLoweringTreatmentTrialists’Collaboration.BP-LoweringTreatmentTrialists

ComparisonsofDifferentActiveTreatmentsfirstlisted非二氫吡啶類CCBA-V阻滯(2或3度)CCBARB-阻滯劑SystolicBPdifferencebetweengroups(mmHg)BlackatanyAgeJNC61997DiureticorBBNewMeta-Analysis(ACC,2009)ACEIvsD/BBAdd:eithera-blockerorb-blockerTotalmortalityRelationshipBetweenOddsRatioCVmortalityBHSIV(2001)Favors

SecondListedNICE/BHS(2006)OR(95%CI)OddsratioforCHDCCBsandCVOutcomesNewMeta-Analysis(ACC,2009)CCBvs.ACEI

OR(95%CI)Stroke0.87(0.78-0.97)MI1.06(0.98-1.18)妊娠CCBsandCVOutcomesCCBvs.無強制指征Stage1Hypertension

Thiazide-typediureticsformost.

MayconsiderACEI,ARB,BB,CCB,orcombination.Stage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,orBB,orCCB)JNC-7：降壓治療流程無強制指征Stage1Hypertension

ThiaJNCRecommendations

foranInitialAntihypertensiveAgentCommitteeYearRecommendationJNC11977Thiazide-typediureticJNC21980DiureticJNC31984Thiazide-typediureticorBBJNC41988DiureticorBBorCCBorACEIJNC51993DiureticorBBJNC61997DiureticorBBJNC72003Thiazide-typediuretic,eitheraloneorincombinationwithACEI.ARB,BB,orCCB

JNCRecommendations

foranIn各類降壓藥物治療高血壓的地位從JNC-6(1997)到JNC-7(2003)

利尿劑b-阻滯劑

ACEI CCBARB-阻滯劑各類降壓藥物治療高血壓的地位利尿劑b-阻滯用于起動和持續(xù)治療的合適降壓藥物(ESC/ESH,2007)

利尿劑

b-阻滯劑 鈣拮抗劑

ACE抑制劑 血管緊張素II受體拮抗劑用于起動和持續(xù)治療的合適降壓藥物利尿劑降壓治療選擇單藥低劑量治療兩藥低劑量聯(lián)合治療輕度血壓升高低/中度心血管危險傳統(tǒng)目標血壓顯著血壓升高高/很高心血管危險更低的目標血壓如果沒有達到目標血壓先前的藥物全劑量轉(zhuǎn)換低劑量的不同藥物先前聯(lián)合藥物全劑量增加低劑量的第3個藥物如果沒有達到目標血壓全劑量的2-3個藥物聯(lián)合治療全劑量的單藥治療全劑量的2-3個藥物聯(lián)合治療2007ESH/ESC指南推薦的降壓治療模式降壓治療選擇單藥低劑量治療兩藥低劑量聯(lián)合治療輕度血壓升高顯著b-blockersAngiotensinreceptorantagonistsThiazidediureticsCalciumantagonistsACEinhibitorsα-blockers歐洲高血壓治療指南(ESC/ESH,2007)合理的降壓聯(lián)合治療方案b-blockersAngiotensinreceptorYounger(<55yr)&Non-BlackOlder(>55yr)orBlackA:ACEInhibitororAngiotensinReceptorBlocker B:b-BlockerC:CalciumChannelBlocker D:Diuretic(Thiazide)Step1A(orB*)CorDStep3++A(orB*)CDStep4–ResistantHTAdd:eithera-blockerorspironolactoneorotherdiureticStep2+A(orB*)CorD*combinationtherapyinvolvingB&DmayinducemorediabetescomparedwithothercombinationtherapiesBHSIV(2001)

RecommendationsforBloodPressureLoweringDrugsYounger(<55yr)Older(>55yr)A:Younger(<55yr)Older(>55yr)orBlackatanyAgeA:ACEInhibitororAngiotensinReceptorBlocker B:b-BlockerC:CalciumChannelBlocker D:Diuretic(Thiazide)Step1ACorDStep2+ACorDStep3++ACDStep4–ResistantHTAdd:eithera-blockerorb-blocker

orspironolactoneorotherdiureticNICE/BHS(2006)ManagementofHypertensionYounger(<55yr)Older(>55yr)oYounger(<55yr)Older(>55yr)orBlackatanyAgeA:ACEInhibitororAngiotensinReceptorBlocker B:b-BlockerC:CalciumChannelBlocker D:Diuretic(Thiazide)Step1ACorDStep2+ACorDStep3++ACDStep4–ResistantHTAdd:eithera-blockerorb-blockerorspironolactoneorotherdiureticInhypertensivepatientsaged55orover,orBlackpatientsofanyage,first-choiceinitialtherapyshouldbeadihydropyridinecalciumchannelblocker;athiazide-typediureticisanalternative.NICE/BHS(2006)ManagementofHypertensionYounger(<55yr)Older(>55yr)oJapaneseGuidelinesfortheManagementofHypertension(JSH,2004and2009)

對大多數(shù)高血壓患者，推薦鈣拮抗劑作為初始治療或聯(lián)合治療的藥物，除了禁忌癥和不能耐受治療的患者。JapaneseGuidelines對大心血管病預防指南(WHO/ISH,2007)

降壓藥物的選擇選擇低劑量利尿劑、血管緊張素轉(zhuǎn)換酶抑制劑或鈣拮抗劑作為降壓治療的初始治療藥物。

β-阻滯劑在強適應癥時可作為一線治療藥物使用。限制使用血管緊張素受體拮抗劑。心血管病預防指南(WHO/ISH,2007)

降壓藥物的選擇CCBsandCVOutcomesNewMeta-Analysis(ACC,2009)在BPLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗：ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPACCBsandCVOutcomes在BPLTT的基礎(chǔ)上CCBsandCVOutcomesNewMeta-Analysis(ACC,2009)CCBvs.ACEI

OR(95%CI)Stroke0.87(0.78-0.97)MI1.06(0.98-1.18)CCBsandCVOutcomesCCBvs.ACfortheManagementofHypertensionAdd:eithera-blockerorforCHDandAchievedBPDifferencesOR(95%CI)(JSH,2004and2009)血管緊張素II受體拮抗劑forCHDandAchievedBPDifferencesAdd:eithera-blockerorb-blockerNICE/BHS(2006)Add:eithera-blockerorb-blockerCAvsD/BBNewMeta-Analysis(ACC,2009)合理的降壓聯(lián)合治療方案JNC51993DiureticorBBNICE/BHS(2006)Add:eithera-blockerorb-blockerNICE/BHS(2006)CCBARB-阻滯劑OddsratioforCHDStage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,orBB,orCCB)JNC-7：降壓治療流程ACEinhibitorsMajorCVeventsJNC11977Thiazide-typediuretic(JSH,2004and2009)CAvsD/BBManagementofHypertension絕對(強制)相對(可能)NewMeta-Analysis(ACC,2009)Stroke0.antagonistsRelativeRiskPROGRESSComJNC-7：降壓治療流程ACEIvsD/BB2003;362:1527-1535.fortheManagementofHypertension(JSH,2004and2009)(JSH,2004and2009)NICE/BHS(2006)Stroke0.ManagementofHypertensionNICE/BHS(2006)Older(>55yr)or糖耐量異常、慢阻肺ARB,BB,orCCBJNC11977Thiazide-typediureticRelativeRisk2007ESH/ESC指南推薦的降壓治療模式BlackatanyAgeCCBsandCVOutcomesStage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,orBB,orCCB)各類降壓藥物的禁忌癥(ESC/ESH,2007)(ESC/ESH,2007)Younger(<55yr)NICE/BHS(2006)BP-LoweringTreatmentTrialists(WHO/ISH,2003)(JSH,2004and2009)2007ESH/ESC指南推薦的降壓治療模式Y(jié)ounger(<55yr)MayconsiderACEI,ARB,BB,CCB,orcombination.醛固酮拮抗劑腎功能衰竭firstlistedAdd:eithera-blockerorJNC51993DiureticorBB限制使用血管緊張素受體拮抗劑。NICE/BHS(2006)非二氫吡啶類CCBA-V阻滯(2或3度)Younger(<55yr)Stage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,orBB,orCCB)利尿劑b-阻滯劑Older(>55yr)orResistantHTOlder(>55yr)循證醫(yī)學證據(jù)BloodPressureLoweringTreatmentTrialists’Collaboration.各類降壓藥物治療高血壓的地位C:CalciumChannelBlocker D:Diuretic(Thiazide)TotalmortalityJNC41988DiureticorBBorCCBorACEICAvsD/BBBlackatanyAgeStage1Hypertension

Thiazide-typediureticsformost.2003;362:1527-1535.BloodPressureLoweringTreatmentTrialists’Collaboration.ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPACCBsandCVOutcomesJNC21980Diuretic(JSH,2004and2009)MI1.(JSH,2004and2009)SystolicBPdifferencebetweengroups(mmHg)Younger(<55yr)心力衰竭在BPLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗：fortheManagementofHypertension在BPLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗：antagonists限制使用血管緊張素受體拮抗劑。JNC11977Thiazide-typediureticNICE/BHS(2006)SystolicBPdifferencebetweengroups(mmHg)JNCRecommendations

foranInitialAntihypertensiveAgentCommitteeYearRecommendationJNC11977Thiazide-typediureticJNC21980DiureticJNC31984Thiazide-typediureticorBBJNC41988DiureticorBBorCCBorACEIJNC51993DiureticorBBJNC61997DiureticorBBJNC72003Thiazide-typediuretic,eitheraloneorincombinationwithACEI.ARB,BB,orCCB

fortheManagementofHyperten影響不同種類降壓藥物治療地位的決定因素禁忌癥循證醫(yī)學證據(jù)不良反應和治療持續(xù)性效益/費用種族影響不同種類降壓藥物治療地位的決定因素禁忌癥各類降壓藥物的禁忌癥(ESC/ESH,2007)

噻嗪類利尿劑痛風代謝綜合癥、糖耐量減低妊娠-阻滯劑哮喘、外周血管病、代謝綜合癥

糖耐量異常、慢阻肺

A-V阻滯(2或3度)運動員和強體力活動者

二氫吡啶類CCB——快速性心律失常、心力衰竭

非二氫吡啶類CCBA-V阻滯(2或3度)

心力衰竭ACEI和ARB妊娠、高血鉀癥雙側(cè)腎動脈狹窄醛固酮拮抗劑腎功能衰竭高血鉀癥

絕對(強制)相對(可能)

各類降壓藥物的禁忌癥(ESC/ESH,2007) SBPdifferencebetweenrandomizedgroups(mmHg)Relativeriskofoutcomeevent1.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.25StrokeMajorCVDCHDCVDdeathTotalmortality-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024BP-LoweringTreatmentTrialists(WHO/ISH,2003)BloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.SBPdifferencebetweenrandomi0.51.02.0RelativeRisk

RR(95%CI)BPDifference

(mmHg)Favors

FirstListedFavors

SecondListedMajorCVeventsCVmortalityTotalmortality1.02(0.98,1.07)2/0ACEIvsD/BB1.03(0.95,1.11)2/0ACEIvsD/BB1.00(0.95,1.05)2/0ACEIvsD/BB1.04(0.99,1.08)1/0CAvsD/BB1.05(0.97,1.13)1/0CAvsD/BB0.99(0.95,1.04)1/0CAvsD/BB0.97(0.92,1.03)1/1ACEIvsCA1.03(0.94,1.13)1/1ACEIvsCA1.04(0.98,1.10)1/1ACEIvsCABloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.BP-LoweringTreatmentTrialists

ComparisonsofDifferentActiveTreatments0.51.02.0RelativeRiskRR(95%

RR(95%CI)

Favoursfirstlisted

Favourssecondlisted0.51.02.0RelativeRiskBPdifference(mmHg)

1.09(1.00,1.18)

ACEIvs.D/BB

0.93(0.86,1.01)

CAvs.D/BB

1.12(1.01,1.25)

ACEIvs.CA2/01/01/1BPLTT(2003):Stroke

ComparisonsofdifferentactivetreatmentsBloodPressureLoweringTreatmentTrialists’Collaboration.Lancet.2003;362:1527-1535.RR(95%CI)FavoursFavou0.40.60.81.01.21.40.21.82.015105-5OddsratioforCHDACEI’sALLHATACEIUKPDS39EUROPAPROGRESSPROGRESSComCAMELOTHOPEPEACECAPPPSTOP-2ACEIANBP-2SystolicBPdifferencebetweengroups(mmHg)Verdecchiaetal20050NICSALLHATCCBPREVENTIDNT-2CONVINCEVHASSyst-ChinaSYSTEURCAMELOTSTONENICOLEACTIONNORDILINVESTSTOP-2CCBINSIGHT151050-5CCB’sELSARelationshipBetweenOddsRatioforCHDandAchievedBPDifferences0.40.60.81.01.21.40.21.82.0151CCBsandCVOutcomesNewMeta-Analysis(ACC,2009)在BPLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗：ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPACCBsandCVOutcomes在BPLTT的基礎(chǔ)上妊娠BloodPressureLoweringTreatmentTrialists’Collaboration.BP-LoweringTreatmentTrialists

ComparisonsofDifferentActiveTreatmentsfirstlisted非二氫吡啶類CCBA-V阻滯(2或3度)CCBARB-阻滯劑SystolicBPdifferencebetweengroups(mmHg)BlackatanyAgeJNC61997DiureticorBBNewMeta-Analysis(ACC,2009)ACEIvsD/BBAdd:eithera-blockerorb-blockerTotalmortalityRelationshipBetweenOddsRatioCVmortalityBHSIV(2001)Favors

SecondListedNICE/BHS(2006)OR(95%CI)OddsratioforCHDCCBsandCVOutcomesNewMeta-Analysis(ACC,2009)CCBvs.ACEI

OR(95%CI)Stroke0.87(0.78-0.97)MI1.06(0.98-1.18)妊娠CCBsandCVOutcomesCCBvs.無強制指征Stage1Hypertension

Thiazide-typediureticsformost.

MayconsiderACEI,ARB,BB,CCB,orcombination.Stage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,orBB,orCCB)JNC-7：降壓治療流程無強制指征Stage1Hypertension

ThiaJNCRecommendations

foranInitialAntihypertensiveAgentCommitteeYearRecommendationJNC11977Thiazide-typediureticJNC21980DiureticJNC31984Thiazide-typediureticorBBJNC41988DiureticorBBorCCBorACEIJNC51993DiureticorBBJNC61997DiureticorBBJNC72003Thiazide-typediuretic,eitheraloneorincombinationwithACEI.ARB,BB,orCCB

JNCRecommendations

foranIn各類降壓藥物治療高血壓的地位從JNC-6(1997)到JNC-7(2003)

利尿劑b-阻滯劑

ACEI CCBARB-阻滯劑各類降壓藥物治療高血壓的地位利尿劑b-阻滯用于起動和持續(xù)治療的合適降壓藥物(ESC/ESH,2007)

利尿劑

b-阻滯劑 鈣拮抗劑

ACE抑制劑 血管緊張素II受體拮抗劑用于起動和持續(xù)治療的合適降壓藥物利尿劑降壓治療選擇單藥低劑量治療兩藥低劑量聯(lián)合治療輕度血壓升高低/中度心血管危險傳統(tǒng)目標血壓顯著血壓升高高/很高心血管危險更低的目標血壓如果沒有達到目標血壓先前的藥物全劑量轉(zhuǎn)換低劑量的不同藥物先前聯(lián)合藥物全劑量增加低劑量的第3個藥物如果沒有達到目標血壓全劑量的2-3個藥物聯(lián)合治療全劑量的單藥治療全劑量的2-3個藥物聯(lián)合治療2007ESH/ESC指南推薦的降壓治療模式降壓治療選擇單藥低劑量治療兩藥低劑量聯(lián)合治療輕度血壓升高顯著b-blockersAngiotensinreceptorantagonistsThiazidediureticsCalciumantagonistsACEinhibitorsα-blockers歐洲高血壓治療指南(ESC/ESH,2007)合理的降壓聯(lián)合治療方案b-blockersAngiotensinreceptorYounger(<55yr)&Non-BlackOlder(>55yr)orBlackA:ACEInhibitororAngiotensinReceptorBlocker B:b-BlockerC:CalciumChannelBlocker D:Diuretic(Thiazide)Step1A(orB*)CorDStep3++A(orB*)CDStep4–ResistantHTAdd:eithera-blockerorspironolactoneorotherdiureticStep2+A(orB*)CorD*combinationtherapyinvolvingB&DmayinducemorediabetescomparedwithothercombinationtherapiesBHSIV(2001)

RecommendationsforBloodPressureLoweringDrugsYounger(<55yr)Older(>55yr)A:Younger(<55yr)Older(>55yr)orBlackatanyAgeA:ACEInhibitororAngiotensinReceptorBlocker B:b-BlockerC:CalciumChannelBlocker D:Diuretic(Thiazide)Step1ACorDStep2+ACorDStep3++ACDStep4–ResistantHTAdd:eithera-blockerorb-blocker

orspironolactoneorotherdiureticNICE/BHS(2006)ManagementofHypertensionYounger(<55yr)Older(>55yr)oYounger(<55yr)Older(>55yr)orBlackatanyAgeA:ACEInhibitororAngiotensinReceptorBlocker B:b-BlockerC:CalciumChannelBlocker D:Diuretic(Thiazide)Step1ACorDStep2+ACorDStep3++ACDStep4–ResistantHTAdd:eithera-blockerorb-blockerorspironolactoneorotherdiureticInhypertensivepatientsaged55orover,orBlackpatientsofanyage,first-choiceinitialtherapyshouldbeadihydropyridinecalciumchannelblocker;athiazide-typediureticisanalternative.NICE/BHS(2006)ManagementofHypertensionYounger(<55yr)Older(>55yr)oJapaneseGuidelinesfortheManagementofHypertension(JSH,2004and2009)

對大多數(shù)高血壓患者，推薦鈣拮抗劑作為初始治療或聯(lián)合治療的藥物，除了禁忌癥和不能耐受治療的患者。JapaneseGuidelines對大心血管病預防指南(WHO/ISH,2007)

降壓藥物的選擇選擇低劑量利尿劑、血管緊張素轉(zhuǎn)換酶抑制劑或鈣拮抗劑作為降壓治療的初始治療藥物。

β-阻滯劑在強適應癥時可作為一線治療藥物使用。限制使用血管緊張素受體拮抗劑。心血管病預防指南(WHO/ISH,2007)

降壓藥物的選擇CCBsandCVOutcomesNewMeta-Analysis(ACC,2009)在BPLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗：ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPACCBsandCVOutcomes在BPLTT的基礎(chǔ)上CCBsandCVOutcomesNewMeta-Analysis(ACC,2009)CCBvs.ACEI

OR(95%CI)Stroke0.87(0.78-0.97)MI1.06(0.98-1.18)CCBsandCVOutcomesCCBvs.ACfortheManagementofHypertensionAdd:eithera-blockerorforCHDandAchievedBPDifferencesOR(95%CI)(JSH,2004and2009)血管緊張素II受體拮抗劑forCHDandAchievedBPDifferencesAdd:eithera-blockerorb-blockerNICE/BHS(2006)Add:eithera-blockerorb-blockerCAvsD/BBNewMeta-Analysis(ACC,2009)合理的降壓聯(lián)合治療方案JNC51993DiureticorBBNICE/BHS(2006)Add:eithera-blockerorb-blockerNICE/BHS(2006)CCBARB-阻滯劑OddsratioforCHDStage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,orBB,orCCB)JNC-7：降壓治療流程ACEinhibitorsMajorCVeventsJNC11977Thiazide-typediuretic(JSH,2004and2009)CAvsD/BBManagementofHypertension絕對(強制)相對(可能)NewMeta-Analysis(ACC,2009)Stroke0.antagonistsRelativeRiskPROGRESSComJNC-7：降壓治療流程ACEIvsD/BB2003;362:1527-1535.fortheManagementofHypertension(JSH,2004and2009)(JSH,2004and2009)NICE/BHS(2006)Stroke0.ManagementofHypertensionNICE/BHS(2006)Older(>55yr)or糖耐量異常、慢阻肺ARB,BB,orCCBJNC11977Thiazide-typediureticRelativeRisk2007ESH/ESC指南推薦的降壓治療模式BlackatanyAgeCCBsandCVOutcomesStage2Hypertension

2-drugcombinationformost(thiazide-typediureticandACEI,orARB,or