最新:钙离子拮抗剂治疗原发性高血压-中山医院-文档资料.ppt
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1、作者简介,钱菊英 主任医师,硕士研究生导师。 现任复旦大学附属中山医院心内科副主任,内科教研室副主任,心导管室副主任。 长期从事心血管病的医教研工作,擅长各种心血管疾病的诊治,尤其在冠心病的介入诊治领域有颇深的造诣,每年主刀完成冠心病介入诊治手术500多例,是中山医院急性心肌梗死患者急症介入治疗抢救“绿色通道”的主要术者之一。 历年共发表第一作者论文30多篇,SCI收录9篇,主译专著1部,参编和参译专著13部。作为主要完成人曾获得国家和省部级科技进步奖共7项。,实线表示证据支持或推荐使用的组合; 虚线表示证据不足或必要时谨慎使用的组合,噻嗪类利尿剂,血管紧张素 受体拮抗剂,钙拮抗剂,ACE 抑
2、制剂,-阻滞剂,-阻滞剂,CCB是目前各指南中推荐使用的五大类降压药物之一,CCB的种类,二氢吡啶类: 第一代:短效 第二代:长效制剂,非洛地平,尼卡地平,拜新同,尼索地平,依拉地平 第三代:长效制剂,氨氯地平,乐卡地平 非二氢吡啶类 维拉帕米 地尔硫卓,CCB的种类,阻断L-型通道 二氢吡啶类:血管扩张作用强,对血管通透性无或有增加作用,对心肌收缩和传导无或仅轻微影响 短效: 长效制剂,对心肌收缩轻微影响:非洛地平,尼卡地平,拜新同,尼索地平,依拉地平 长效制剂,对心肌收缩无影响:氨氯地平,乐卡地平 非二氢吡啶类:血管扩张作用相对小,降低血管通透性,抑制心肌收缩力和传导 维拉帕米 地尔硫卓,
3、CCB降低收缩期高血压最有效,Am J Hypentens 2001,14:241,CCB降压的临床试验,Lancet June 2004,amlodipine perindopril,Atenolol bendroflumethiazide,19,257 hypertensive patients,PROBE design,ASCOT Design,ASCOT:Amlodipine group is better than Atenolol group,(amlodipine perindopril vs Atenolol bendroflumethiazide ),* P0.05,-35,
4、-30,-25,-20,-15,-10,-5,0,*,*,*,*,*,*,*,Non fatal MI+ Fatal CHD,CV death,All mortality,All CHD,fatal/ nonfatal stroke,All CHD+ intervention,New onset DM,Renal impairment,Dahlof B, Sever P, et al. Lancet. 2005;366:895-906.,*,Percentage of reduction %,ASCOT: CV events reduction,Major Outcomes in High R
5、isk Hypertensive Patients Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Channel Blocker vs Diuretic,The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT),The ALLHAT Collaborative Research Group Sponsored by the National Heart, Lung, and Blood Ins
6、titute (NHLBI),JAMA. 2002;288:2981-2997,0.20 0.15 0.10 0.05 0.00,0 1 2 3 4 5 6 7,With CHD,amlodipine Lisinopril.,time(y),L/A 1.06(0.99-1.32) 0.69,RR(95%Cl) P,Cumulative CHD,0.20 0.15 0.10 0.05 0.00,0 1 2 3 4 5 6 7,Without CHD,氨氯地平 Lisinopril.,L/A 0.98(0.88-1.13) 0.78,RR(95%Cl) P,tiem(y),Frans H.H. L
7、eenen et al. Hypertension. 2006;48:374-384.,ALLHAT: for patients with CHD at baseline, amlodipine has similar effect of prevention of MI as ACEI,JAMA 2004,Placebo-controlled, multicenter, randomised, double-blind, comparative, parallel trial,CAMELOT: Study Design,Results BP Data,BP reductions in the
8、 amlodipine and enalapril groups were statistically significant vs placebo (P0.001) There was no statistically significant difference between amlodipine and enalapril,CAMELOT ResultsCumulative Event Rates,Cumulative events, proportion,Months,0,6,12,18,24,0,0.25,0.20,0.15,0.10,0.5,placebo enalapril a
9、mlodipine,No. at risk Placebo 655 588 558 525 488 Enalapril 673 608 572 553 529 Amlodipine 663 623 599 574 535,31% Risk reduction for amlodipine vs placebo (P=0.003) 19% Risk reduction for amlodipine vs enalapril (P=0.10) 15% Risk reduction for enalapril vs placebo (P=0.16),Rates for coronary revasc
10、ularisation,27% reduction,Rates for hospitalisation for angina,42% reduction,CAMELOT ResultsSubgroup Analyses amlodipine vs placebo,All patients,Lipid-lowering therapy Treated with statin Not treated with statin Age Age mean,Hazard Ratio (95% CI),amlodipine,placebo,2-year event rates,30.9% 0.003 16.
11、6% 23.1%,33.9% 0.002 16.9% 24.5% 4.1% 0.91 15.2% 15.5% 22.9% 0.07 17.2% 21.9% 49.3% 0.006 14.8% 26.8% 26.8% 0.03 17.4% 23.0% 42.8% 0.03 14.0% 23.2% 32.2% 0.03 15.0% 21.4% 29.6% 0.04 18.3% 24.7%,0.5,0.75,1.0,1.5,2.0,Favors amlodipine,Favors placebo,% Relative Risk Reduction,P value,0.25,Amlodipine ve
12、rsus Nifedipine,SAME STRENGTH,Journal of Human Hypertension 2002; 16: 805813.,-20.1,-11.7,-21.8*,-12.1*,-25,-20,-15,-10,-5,0,Day SBP,Day DBP,Norvasc(n=97),Adalat GITS(n=104),*p=0,26;*p=0.72 *p=0,44;*p=0.38,BPmmHg,-20.4,-18.3*,-11.7,-10.2*,Night SBP,Night DBP,Key clinical trails of CCBs on CV events
13、reduction,ASCOT: vs atenolol ALLHAT: vs hydro- vs irbesartan VALUE: vs valsartan CASE-J: vs candesartan ACCOMPLISH: vs hydrochlorothiazide ,INSIGHT: vs hydrochlorothiazide ACTION: vs placebo ,Norvasc,Adalat GITS,Norvasc on MI,Franz H. Messerli et al. Hypertension. 2006;48:359-361.,0.20 0.15 0.10 0.0
14、5 0.00,0 1 2 3 4 5 6 7,With CHD,amlodipine Lisinopril.,time(y),L/A 1.06(0.99-1.32) 0.69,RR(95%Cl) P,Cumulative CHD,0.20 0.15 0.10 0.05 0.00,0 1 2 3 4 5 6 7,Without CHD,氨氯地平 Lisinopril.,L/A 0.98(0.88-1.13) 0.78,RR(95%Cl) P,ALLHAT: for patiens with CHD at baseline, amlodipine has similar effect of pre
15、vention of MI as ACEI,tiem(y),Frans H.H. Leenen et al. Hypertension. 2006;48:374-384.,Time to first occurrence of clinical events,0.0,0.2,0.4,0.6,0.8,1.0,0,2,4,6,年,Survival %,nifedipine GITS placebo,All cause mortality (p=0.41),Primary efficacy end point (death,MI, RA, HF, CVA, PREV,P=0.54),Primary
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