降压治疗策略的核心

uu——uuuu0.51.02.0RelativeRiskRR(95%CI)RR(95%CI)BPDifferenceBPDifference(mmHg)(mmHg)FavorsFavorsFirstListedFirstListedFavorsFavorsSecondListedSecondListedMajorCVeventsMajorCVeventsCVmortalityCVmortalityTotalmortalityTotalmortality1.02(0.98,1.07)1.02(0.98,1.07)2/02/0ACEIACEIvsvsD/BBD/BB1.03(0.95,1.11)1.03(0.95,1.11)2/02/0ACEIACEIvsvsD/BBD/BB1.00(0.95,1.05)1.00(0.95,1.05)2/02/0ACEIACEIvsvsD/BBD/BB1.04(0.99,1.08)1.04(0.99,1.08)1/01/0CACAvsvsD/BBD/BB1.05(0.97,1.13)1.05(0.97,1.13)1/01/0CACAvsvsD/BBD/BB0.99(0.95,1.04)0.99(0.95,1.04)1/01/0CACAvsvsD/BBD/BB0.97(0.92,1.03)0.97(0.92,1.03)1/11/1ACEIACEIvsvsCACA1.03(0.94,1.13)1.03(0.94,1.13)1/11/1ACEIACEIvsvsCACA1.04(0.98,1.10)1.04(0.98,1.10)1/11/1ACEIACEIvsvsCACABloodPressureLoweringTreatmentBloodPressureLoweringTreatmentTrialistsTrialists’’Collaboration.Collaboration.LancetLancet.2003;362:1527.2003;362:1527--1535.1535.BP-LoweringTreatmentTrialistsComparisonsofDifferentActiveTreatmentsINVEST:primaryendpoint(MIandstrokefreesurvival)PepineetalJAMA2003;290:2805-2816logrankp=0.6210095908580750612182430364248546066CCBbasedregimenverapamilSR240mgodBetablockerbasedregimenatenolol50mgCumulativeendpoint(%)Months22576hypertensiveCADpatients,24months,openlabelFatal/Non-fatalcardiaceventsFatal/Non-fatalstrokeAll-causedeathMyocardialinfarctionHeartfailurehospitalisations0.40.60.81.01.21.4Controlledpatients*(n=10755)Non-controlledpatients(n=4490)HazardRatio95%CI*SBP140mmHgat6months.PooledTreatmentGroups**********P0.01.0.75(0.67–0.83)0.55(0.46–0.64)0.79(0.71–0.88)0.86(0.73–1.01)0.64(0.55–0.74)OddsRatioWeberMAetal.Lancet.2004;363:2047–49.VALUE:61.01.0g/24hg/24h125/75mmHg125/75mmHg130/80mmHg130/80mmHg140/90mmHg140/90mmHg2004üü15.05.72.410.84.32.39.23.81.68.13.11.1161412108642025%25%50%50%75%75%n3838375766648316P0.0011511159208111425%25%50%50%75%75%n3838124637571127666417918316223620151050Majorcardiovascularevents(per100patients-years)inalltreatedhypertensiveandinhypertensivepatientswithdiabetesinrelationtotargetbloodpressuresof90.85,and80mmHg.302520151050£80£85£90£90£85£80P=0.50fortrendP=0.005fortrendAllhypertensivepatients(n=18790)Hypertensivewithdiabetes(n=1501)TargetbloodpressuregroupsMajorcardiovascularevents/1000patients-yearsMAP=meanarterialpressure.MAP=meanarterialpressure.BakrisBakrisetal.etal.AmJKidneyDisAmJKidneyDis.2000;36:646.2000;36:646--661.661.GFRGFRDD((mL/min/ymL/min/y))--1414--1212--1010--88--66--44--220095959898101101104104107107110110113113116116119119MAP(mmHg)MAP(mmHg)rr=0.69;=0.69;PP.05.05UntreatedUntreatedhypertensionhypertension140/90140/90130/85130/859ClinicalTrialsofDiabeticandNondiabeticNephropathyRelationshipBetweenAchievedRelationshipBetweenAchievedBPandGFRDeclineBPandGFRDeclineuu——uuuuGAP:13111224263435414172%ICE:ICE:(1(1))**JHasfordetal.JournalofHumanHypertension.2002;16:569-575uu——uuuuq22qqqJournalofHypertension2003,Vol21No6P1030“2/3”JNC7“140/90mmHg6030”ALLHAT“”2005uu40%40%80%80%uuuuuu(())UKSPDS(85mmHg)MDRS(92mmHg,)HOT(80mmHg,)AASK(92mmHg,)RENAAL(140/90mmHg)IDNT(135/85mmHg)1234PoolJLAmJHypertension2003;16:36SDiureticsb-blockersAT1-receptorblockersa-blockersCalciumantagonistsACEinhibitors3-42003ABCDABCDDiureticsβBACEI/ARBCCBBMJ2004,328;63420032003uu++bbuu+ACEI+ACEIARBARBuuCCB+CCB+bbuuCCB+ACEICCB+ACEIARBARBuuCCB+CCB+uuaa++bbaal(aB)lbBal=+CCB=b+ACEI=ACEI+ARB=a+b=b+qqqqqqqqqqqquu®®4(mmHg)®150mg/d(n=89)5mg/d(n=92)0-10-20-12.2-12P=NS®150mg/d(n=89)5mg/d(n=92)-9.4P=NS-9.6NeutelJ,etal.AmJHypertens().1999;12:128A.488SeDBP(mmHg)SeDBP(mmHg)†00114488-12-12-10-10-8-8-6-6-4-4-2-200**SeDBPSeDBPKassler-TaubKetal.AmJHypertens1998;11:445-53.Kassler-TaubKetal.AmJHypertens1998;11:445-53.*p0.01vs.†p0.02vs.150mg(n=129)300mg(n=134)100mg(n=131)(n=138)®®8(mmHg)®300mg/d(n=134)®150mg/d(n=129)100mg/d(n=131)(n=138)®300mg/d(n=134)®150mg/d(n=129)100mg/d(n=131)(n=138)0-10-20-16.4-12.1-11.3-3.7-11.7-9.7-8.7-4.95.1mmHgP0.0145%3mmHgP0.0134%Kassler-TaubK,etal.AmJHypertens().1998;11:445-53.8®®ManciaG,etal.BloodPressMonit().2002;7(2):135-42.8(mmHg)0-4-16-6.7-4.8-11.6-7.51.9mmHgP=0.03540%-12-8()4.1mmHgP0.0155%-10.5-7.3-16.2-10.0-6.3-3.8-10.2-7.03.2mmHgP0.0144%6.2mmHgP0.0162%2.5mmHgP0.0166%3.2mmHgP0.0145%8®150mg(n=211)80mg(n=215)SBP¯(mmHg)DBP¯(mmHg)Losartan8.05.5Valsartan7.54.0Irbesartan10.06.5Telmisartan9.56.0Candesartan10.06.0ConlinPR,etal.JClinHypertens.2000;2:253-257––ARB+ARB+uuRAASRAASuuuuARBARBRAASRAASuuuuuuATAT11uuPohlMC,etal.JAmSocNephrol2005;16:3027-3037IDNT:ImpactofBPControlandAT1BlockadeonRenalOutcomes1490.8001.2001.800134134-140141-149ÒvsRR=0.67(P=0.0002)T.WGressetalNEngJMed2000;342:905-12*p0.0500.20.40.60.811.21.4ACEICCBB-12.5mg/HCTZ/HCTZ-0.4-0.3-0.2-0.100.10.2HCTZ(mg/d)(mg/d)06.2512.525037.51003008(mEq/L)/HCTZ/HCTZHCTZ(mg/d)(mg/d)(mg/dL)2512.56.25030010037.50-0.500.512004AssociationBetweenAdherenceandGoalAttainmentinAntihypertensiveTherapySturkenboomM,etal.15thESHmeeting,Milan,Italy,June17-21,2005Rotterdam,TheNetherlandsPatientAdherenceandPersistencewithAntihypertensiveTherapy:One-versusTwo-pillCombinationSturkenboomM,etal.15thESHmeeting,Milan,It