降压治疗研究新动态回顾与展望.ppt

降压治疗研究新动态 回顾与展望, 80岁以上高龄高血压 (HYVET) 高血压前期 (TROPH, PHARAO) 心房颤动 (ADVANCE post hoc),新动态(一): 扩展降压治疗获益人群,PHARAO Study: Primary Endpoint Development of Hypertension,Hazard ratio 0.656(0.533-0.807),Luders S, et al. J Hypertens. 2008;26:1487-1496,* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *,60,40,20,0,90,100,120,130,140,160,170,180,190,200,220,230,240,Prehypertension,Uncertainty Range, 55 75% of the general population,% of screened population,Normotension Prehypertension Masked Hypertension Sustained Hypertension,Mixed population with White Coat Hypertension and Sustained Hypertension (FPs & TPs),Masked Hypertension (office BP 140/90 mmHg) (FNs),ADVANCE-AF 研究,11140例2型糖尿病，心房颤动占7.6%。 perindopril / indapamide 降压治疗4.3 年， 治疗组血压比对照组降低 5.3 / 2.3 mmHg。 心房颤动患者降压治疗后总死亡率与心 血管死亡率分别降低14%与18%，NTT 42。,Eur Heart J. 2009; March 12. online publication.,The ACTIVE Steering Committee. Am Heart J. 2006; 151:1187-93,Atrial fibrillation Clopidogrel Trial with Irbesartan for prevention of Vascular Events, 脑卒中史 (PROGRESS再分析, WASID) 糖尿病 (ADVANCE),新动态(二): 心血管高危患者强化血压控制,100,80,60,40,20,0,120,120-139,140-159,60,100,80,60,40,20,0,70,70-79,80-89,90,Achieved systolic blood pressure levels (mmHg),Achieved diastolic blood pressure levels (mmHg),Age-and sex-adjusted incidence rate,CKD: P trend=0.004 Non-CKD: P trend0.0001,CKD: P trend=0.001 Non-CKD: P trend0.0001,CKD Non-CKD,Incidence rate (1000 person-years),PROGRESS - CKD Substudy: SBP and CVD,WASID Trial (Warfarin-Aspirin Symtomatic Intracranial Disease) Relationship Between Blood Pressure and Strke Recurrence in Patients With Intracranial Arterial Stenosis,Turan TN, et al.Circulation.2007;115:2969-2975,Turan NT, et al. Circulation. 2007;115:2969-2975,WASID Hazard Ratios for Ischemic Stroke According to SBP and DBP,ADVANCE: Baseline BP and Outcome Events,De Galan BE, et al. J Am Soc Nephrol. 2009; Feb.18, online,ADVANCE: Achieved BP levels and all renal events,De Galan BE, et al. J Am Soc Nephrol. 2009; Feb.18, online, 降压治疗模式的历史演进 优化联合治疗方案 纠正噻嗪类利尿剂代谢缺点,新动态(三): 优化降压治疗方案,降压治疗模式的历史演进,序贯治疗(Sequential Monotherapy) 阶梯治疗(Stepped-care) 联合治疗(Combination),处方联合 单片联合,Combination Therapy Versus Monotherapy Meta-analysis from 42 trials,Wald DS, et al. Am J Med. 2009;122:290-300.,Diuretics,ACE inhibitors or ARBs,Calcium antagonists,Initial Combinations of Medications for Management of Hypertension,SHEP Trial: Unadjusted incidence rate of diabetes in year 1 by change in serum potassium,Shafi T, et al. Hypertension. 2008;52:1022-29.,噻嗪类利尿剂引起血糖升高的可能机制,Carter BL, et al. Hypertension. 2008;52:30-36, 强调收缩压目标 多效性作用的单片联合治疗(SPC),新动态(四): 简化降压治疗目标和模式,简化降压治疗的血压目标：收缩压,50岁以上患者应该以收缩压水平为唯一的诊断依据和关键的治疗目标。,William B, Lindholm LH, Sever P. Lancet. Published Online June 17, 2008,简化降压治疗: STITCH研究 (Simplified Treatment Intervention to Control Hypertension),Feldman RD, et al. Hypertension. 2009;53:646-653,主要终点(治疗6个月时血压达标患者比例)：STITCH 64.7% vs. CHEP 52.7% p=0.026 次要终点(治疗6个月时SBP和DBP的变化)： STITCH 22.6/10.4 mmHg vs. CHEP 17.5/8.2 mmHg p=0.002/0.03,新动态(五): 挑战顽固性高血压, 顽固性或难治性高血压约占整个高血压人群10%-15%。除了纠正能查明的各种原因(继发性、容量或干扰因素等)外，目前还缺乏有效的策略和治疗方案。 脉冲刺激调节压力感受器或射频消融切断肾交感神经(ACC 2009)，从干预病理生理环节进行临床探索，方向是积极有益的。然而，其成功率和长期疗效以及并发症均有待进一步深入研究。,降压治疗研究正在向扩展治疗人群，强化血压控制，优化降压治疗方案，简化降压目标和模式，挑战顽固性高血压的方向发展。,结束语,