单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,#,高血压的药物治疗种族因素,上海交通大学医学院附属瑞金医院,上海市高血压研究所,王继光,2008,年,3,月,8,日，北京,Relative risk reductions by antihypertensive treatment in early trials,Progression,to severe HT,CHF,Stroke,CHD,Total,mortality,CV,mortality,-94,*,-53%*,-40%*,-16%*,-13%,-21%*,*,P,0.05,Collins R et al.Br Med Bull 1994;50:272-298.,BPLTTC.Lancet 2003;362:1527-45.,0,-5,-10,-15,-20,-25,-30,Stroke,CHD,CHF,Total mortality,-23%,-15%,-16%,-14%,4/3 mmHg,N,20 888,Major CV events,-15%,Relative risk reductions by antihypertensive treatment in recent trials,HOT study,Hypertension Optimal Treatment trial,80,vs,85,vs,90 mm Hg,Lancet 1998;351:1755-1762,.,HOT:Antihypertensive drug treatment,Step 15 mg felodipine,Step 25 mg felodipine+low dose ACE inhibitor or,b,-blocker,Step 310 mg felodipine+low dose ACE inhibitor or,b,-blocker,Step 410 mg felodipine+high dose ACE inhibitor or,b,-blocker,Step 510 mg felodipine+high dose ACE inhibitor or,b,-blocker+low dose alternative addition or HCTZ,Hansson L et al.Lancet 1998;351:1755-1762.,Mean DBP measured from 6 months and onwards,0,5,10,15,20,25,Target,80:81.1(5.3),Target,85:83.2(4.8),Target,90:85.2(5.1),Frequency%,60,Achieved DBP,mm Hg,70,80,90,100,110,Hansson L et al.Lancet 1998;351:1755-1762.,Target,80:139.7(11.7),Mean SBP measured from 6 months and onwards,100,0,5,10,15,20,25,Frequency%,110,120,130,140,150,160,170,180,190,Target,85:141.4(11.7),Target,90:143.7(11.3),Achieved SBP,mm Hg,Hansson L et al.Lancet 1998;351:1755-1762.,Major CV events in relation to target BP groups,902329.990 vs.850.99(0.83-1.19),85 23410.085 vs.801.08(0.89-1.29),80 2179.30.5090 vs.801.07(0.89-1.28),Events No.of Events/1000 P-value Comparison Risk(95%CI),events p-yrs trend,Hansson L et al.Lancet 1998;351:1755-1762.,n=18,790,0,5,10,15,20,25,Major CV events/,1000 p-yrs,Target DBP mm Hg,n=1501,p=0.005 for trend,90,85,80,Major CV events in patients with DM at Rx in relation to target BP groups,HYVET,Hypertension in the Very Elderly Trial,Indapamide,vs.,placebo,Drugs Aging 2001;18:151-64,.,收缩压差别,10 mm Hg,脑卒中,(no.events,100),40%,总死亡率,(no.events,300),15%,Personal communications,HYVET 2007-7,Any diabetes related endpoint,Number of endpoints,1401 of 3867 patients(36%),0%,20%,40%,60%,0,3,6,9,12,15,%of patients with an event,Years from randomisation,Intensive(n=2729),Conventional(n=1138),Risk reduction 12%,(95%CI:1%to 21%),p=0.029,UKPDS 33.Lancet 1998;352:837-53,Risk reduction 24%p=0.0046,Any diabetes related endpoint,%of patients with events,0%,10%,20%,30%,40%,50%,0,3,6,9,Years from randomisation,Tight BP control(n=758),Less tight BP control(n=390),UKPDS 38.BMJ 1998;317:703-713,Prevention of cardiovascular,events in diabetic patients,A,ction in,D,iabetes and,V,ascular disease:,preter,A,x and diamicro,N,MR,C,ontrolled,E,valuation,ADVANCE:,主要终点,Major macro or microvascular event,0,10,20,Follow-up(months),0,6,12,18,24,30,36,42,48,54,60,Placebo,Perindopril-Indapamide,Relative risk reduction,9%:95%CI:0 to 17%,p=0.041,Cumulative incidence(%),Patel A et al.Lancet 2007;370:829-40.,指南推荐,利尿剂,阻滞剂,钙离子拮抗剂,转换酶抑制剂,血管紧张素受体拮抗剂,J Hypertens 2007;25:1105-87.,到底该如何选择降压药物,?,特别注意,应该坚持使用指南推荐使用的降压药物。,5,大类药物均可作为起始治疗药物使用，并不意味着可以不加选择地使用药物，当然也不是每类药物都应该有同等即,20%,机会作为一线药物使用。,应该根据临床试验的证据原则、降压作用与副作用，选择对患者最为合适的药物。,CCBs,vs,.,利尿剂,/,阻滞剂,:,致死性与非致死性脑卒中,利尿剂,/,阻滞剂,CCBs,试验,事件数,/,研究对象人数,异质性检验,危险比,(,95%,可信区间,),差别,(,SD,),0,CCBs,较好,1,2,3,利尿剂,/,阻滞剂较好,MIDAS/NICS/VHAS,STOP2/CCBs,NORDIL,INSIGHT,ALLHAT/Amlodipine,ELSA,CCBs without CONVINCEp=0.68,CONVINCE,所有,CCBsp=0.39,15/1358,237/2213,196/5471,74/3164,675/15255,14/1157,1211/28618,118/8297,1329/36915,19/1353,207/2196,159/5410,67/3157,377/9048,9/1177,838/22341,133/8179,971/30520,10.2%(4.8)2p=0.02,7.6%(4.4)2p=0.07,Staessen JA,et al.Lancet 2001;37:1305-15.Staessen JA et al.J Hypertens 2003;21:1055-76.,Possible combinations of antihypertensive drugs,J Hypertens 2007;25:1105-87.,Thiazide diuretics,ACEIs,ARBs,CCBs,-blockers,-blockers,The BHS-NICE guideline,www.nice.org.uk,55 years,55 years or black patients of any age,A,C or D,Step 1,A+C or A+D,Step 2,Step 3,A+C+D,Step 4,Add:further diuretic therapy,-blocker,-blocker,Consider seeking specialist advice,Systemic rotationABCD or AB/CD rule,CD,Dickerson JEC et al.Lancet 1999;353:2008-2013.,Black-Chlor,BlackAmlod,BlackLisin,NonblackChlor,NonblackAmlod,NonblackLisin,BP by treatment group and ethnicity,Wright JT et al.,JAMA,2005:293:1595-1608.,ALLHAT:%on 3+antihypertensive drugs by randomized group and ethnicity at 5 y,Wright JT et al.,JAMA,2005:293:1595-1608.,ALLHAT:BP control(140/90 mm Hg)by randomized group and ethnicity at 5 y,135/78,136/76,139/79,133/74,134/74,134/74,Wright JT et al.,JAMA,2005:293:1595-1608.,不同种族患者对降压药物的反应,Khan JM et al.Heart.2005;91;1105-1109,.,HOT,：舒张压下降,0,-5,-10,-15,-20,-25,-30,90,85,80,舒张压下降,mm Hg,mm Hg,p0.0001,p0.0001,p0.0001,目标舒张压,亚洲病人,其他病人,HOT,：收缩压下降,亚洲病人,其他病人,0,-5,-10,-15,-20,-25,-30,-35,-40,90,85,80,收缩压,mm Hg,mm Hg,p0.0001,p0.01,p0.0001,目标舒张压,HOT:,不良反应,p0.001,p0.05,p0.01,p0.05,ns,ns,ns,ns,ns,ns,p 160/90 mmHg,FEVER,：研究流程,Liu LS et al.J Hypertens 2