降压治疗的策略和目标

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)Lancet2002,360:1903血压、年龄与脑卒中死亡率(100万人群资料分析)Strokemortality(floatingabsoluteriskand95%CI)2561286432168421120140160180UsualsysytolicbloodPressure(mmHg)UsualdiastolicbloodPressure(mmHg)2561286432168421708010011090Strokemortality(floatingabsoluteriskand95%CI)A:SystolicbloodpressureB:DiastolicbloodpressureAgeatrist:80-89Years70-79Yaes60-69years50-59YearsAgeatrist:80-89Years70-79Yaes60-69years50-59YearsIHDmortality(floatingabsoluteriskand95%CI)2561286432168421120140160180UsualsysytolicbloodPressure(mmHg)UsualdiastolicbloodPressure(mmHg)2561286432168421708010011090IHDmortality(floatingabsoluteriskand95%CI)A:SystolicbloodpressureB:DiastolicbloodpressureAgeatrist:80-89Years70-79Yaes60-69years50-59Years40-49yearsAgeatrist:80-89Years70-79Yaes60-69years50-59Years40-49yearsLancet2002,360:1903血压、年龄与冠心病死亡率(100万人群资料分析)CauseAgeatNumberofOfdeathrisk(years)deathsStroke40-494140.36(0.32-0.40)50-5913720.38(0.35-0.40)60-6929390.43(0.41-0.45)70-7943270.50(0.48-0.52)80-8926360.67(0.63-0.71)IHD40-4913220.49(0.45-0.53)50-5955940.50(0.49-0.52)60-69104500.54(0.53-0.55)70-79108520.60(0.58-0.61)80-8956490.67(0.64-0.70)Other40-493860.43(0.38-0.48)vascular50-5913770.50(0.47-0.54)60-6925490.53(0.51-0.56)70-7932270.64(0.61-0.67)80-8922510.70(0.65-0.75)0.250.350.50.71.0A:usualsystolicbloodpressure(115mmHg)Hazardratio(95%CI)for20mmHgLowerusualsystolicbloodpressureLancet2002,360:1903收缩压20mmHg差值对心血管危险影响CauseAgeatNumberofOfdeathrisk(years)deathsStroke40-493480.35(0.30-0.40)50-5912430.34(0.32-0.37)60-6926460.40(0.38-0.42)70-7939150.48(0.45-0.51)80-8923400.63(0.58-0.69)IHD40-4911140.47(0.43-0.51)50-5949450.52(0.50-0.55)60-6992890.56(0.54-0.58)70-7997270.62(0.60-0.64)80-8950680.70(0.65-0.74)Other40-493160.43(0.37-0.50)vascular50-5911400.48(0.44-0.52)60-6922200.49(0.46-0.53)70-7928530.61(0.57-0.66)80-8919760.71(0.64-0.79)0.250.350.50.71.0B:usualdiastolicbloodpressure(75mmHg)Hazardratio(95%CI)for10mmHgLowerusualdiastolicbloodpressureLancet2002,360:1903舒张压10mmHg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SBP89%93%DBP83%73%PP37%43%MAP100%97%MidBP100%100%Lancet2002,360:1903ESRD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61089515.31.0正常81621866.61.2(0.8-1.7)正常高值7379813411.11.9(1.4-2.7)高血压1级（轻度）8568427521.03.1(2.3-4.3)2级（中度）2345915843.66.0(4.3-8.4)3级（重度）54647396.111.2(7.7-16.2)4级（极重度）142937187.122.1(14.2-34.3)KlagMJ,WheltonPK,RandaliBLetal,NewEngJMed.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血压水平的分类和定义(ESH/ESC2003)分类收缩压(mmHg)舒张压(mmHg)理想血压12080正常血压120-12980-84正常高值130-13985-891级高血压(轻度)140-15990-992级高血压(中度)160-179100-1093级高血压(重度)≥160≥110单纯收缩期高血压≥14090SBP,mmHg%ofmen302520151050Adjustedrelativerisk543210DBP,mmHg%ofmen302520151050Adjustedrelativerisk32.521.510.50MRFIT:ArchInternMed1993;153:598正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(TecumschStudy,3年随访)降压治疗临床试验荟萃分析结果T=treatmentC=controlNon-fataleventsFataleventsTCTCTCTCNumbersindividuals020040060080010001200%reductioninoddsStroke39%CHD16%Vasculardeaths21%Allotherdeaths2%0.080.060.040.020012345YearsafterrandomizationIschemicStrokeHemorrhagicStrokePlaceboTreatmentActiveTreatmentCumulativeStrokeRateSHEPstudy:JAMA2000;284:265Anti-hypertensivetherapy&incidenceofHF1.82.310.90.811.41.10.50.60.3600.511.522.5EWPHESTOPSHEPSyst-EurUKPDSPlaceboTherapyn8401,6274,7364,6951,148F.U.(mths)56255324101Reduction17%51%54%29%56%pns0.010.001ns0.0043TrialNumberofendpointsTreat:ControlOddsrationsandconfidencelimitsSHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.38ReductionandSDTreatmentbetterTreatmentworse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82Allcardiovascularendpoints199:289137:18674:94410:56932%SD52P=0.001Fatalandnon-fatalstroke103:15944:7745:59195:29537%SD62P=0.00125%SD82P=0.004SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.96Fatalandnon-fatalMI(includingsuddendeath)90:11259:7733:44182:233EurHeartJ1999:1(suppl):p3EurHeartJ1999:1(suppl):p3TrialNumberofendpointsTreat:ControlOddsrationsandconfidencelimitsSHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.38ReductionandSDTreatmentbetterTreatmentworse0.51.01.5SHEPSYST-EURSYST-CHINAALLHeterogeneity:P=0.82Totalmortality213:242133:13761:82397:46117%SD62P=0.008Cardiovascularmortality90:11259:7733:44182:23325%SD82P=0.005PROGRESS: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%)P0.0001Lancet2001;358:1033-410.200.150.100.050.001234降压治疗的益处平均下降脑卒中35–40%心肌梗死20–25%心力衰竭50%TrialsNumberofOddsratiosDiferecevents/paitients(95%Cls)(SD)OldNewMIDAS/NICS/VHAS15/135815/1353STOP2/CCBs369/2213362/2196NORDIL228/5471153/3157INSIGHT152/3164153/3157ALLHAT/Aml2203/152551256/9048ELSA17/115713/1177CCBswithoutCONVINCE2984/286182030/22341-3.1%(3.2)2P=0.31HeterogeneityP=0.95CONVINCE319/8297337/8179AllCCBs3303/369152367/30520-2.3%(2.9)2P=0.42HeterogeneityP=0.95UKPDS59/35875/400STOP2/ACEIs369/2213380/2205CAPPP190/5493184/5492ALLHA/Lis2203/152551314/3044ANBP2210/3039195/3044HYVET/AD30/42627/431AllACEIs3061/267842175/20626-0.4%(3.1)2P=0