降压治疗的策略和目标

40-49 50-59 60-69 70-79 80-89
386 1377 2549 3227 2251
0.43 (0.38-0.48) 0.50 (0.47-0.54) 0.53 (0.51-0.56) 0.64 (0.61-0.67) 0.70 (0.65-0.75)
Lancet 2002,360:1903
Usual sysytolic blood Pressure (mmHg)
70 80 90 100 110
Usual diastolic blood Pressure (mmHg)
血压、年龄与冠心病死亡率(100万人群资料分析)
A: Systolic blood pressure
256
CI) 128
Treat:Control
SHEP SYST-EUR SYST-CHINA ALL Heterogeneity:P=0.38
Total mortality 213:242 133:137 61:82 397:461
SHEP SYST-EUR SYST-CHINA ALL Heterogeneity:P=0 .82
Cause Of death
Age at risk(years)
Number of deaths
Stroke
40-49 50-59 60-69 70-79 80-89
414 1372 2939 4327 2636
0.36 (0.32-0.40) 0.38 (0.35-0.40) 0.43 (0.41-0.45) 0.50 (0.48-0.52) 0.67 (0.63-0.71)
SHEP study: JAMA 2000; 284:265
Anti-hypertensive therapy & incidence of HF
2.5
2
1.8
1.5
1.4
1
0.5
0 EWPHE
n F.U. (mths) Reduction p<
840 56 17% ns
2.3
1.1
STOP
1,627 25 51%
140 160 180
Usual sysytolic blood Pressure (mmHg)
70 80 90 100 110
Usual diastolic blood Pressure (mmHg)
收缩压 20 mmHg 差值对心血管危险影响
A: usual systolic blood pressure (? 115 mmHg)
1.2 (0.8-1.7)
正常高值
73798 134
11.1
1.9 (1.4-2.7)
高血压
1级（轻度） 85684 275
21.0
3.1 (2.3-4.3)
2级（中度） 23459 158
43.6
6.0 (4.3-8.4)
3级（重度） 5464
73
96.1
11.2 (7.7-16.2)
4级（极重度）1429
.82 SHEP
Fatal and non-fatal MI (including sudden death)
90:112
SYST-EUR SYST-CHINA ALL Heterogeneity:P=0
59:77 33:44 182:233
.96
Βιβλιοθήκη Baidu
Eur Heart J 1999:1(suppl):p3
Cardiovascular mortality 90:112 59:77 33:44 182:233
Odds rations and confidence limits
Treatment better
Treatment worse
Reduction and SD
17%SD 6 2P=0.008
25%SD 8 2P=0.005
256
CI) 128
%
95
ortality m D IH
and risk absolute
(floating
64 32 16
8 4
2
1
Age at rist: 80-89 Years
70-79 Yaes
60-69 years
50-59 Years
40-49 years
120
Lancet 2002,360:1903
21%
All other deaths
2%
0.08
Rate 0.06
Stroke
0.04
ulative m
0.02
u
C
0 0
Placebo Treatment Active Treatment
Ischemic Stroke
Hemorrhagic Stroke
1
2
3
4
5
Years after randomization
%
95
ortality m D IH
and risk absolute
(floating
64 32 16
8 4
2
1
Age at rist: 80-89 Years
70-79 Yaes
60-69 years
50-59 Years
40-49 years
B: Diastolic blood pressure
Other vascular
40-49 50-59 60-69 70-79 80-89
Lancet 2002,360:1903
316 1140 2220 2853 1976
0.25 0.35 0.5 0.7 1.0
Hazard ratio (95% CI) for 10 mmHg Lower usual diastolic blood pressure
5068
0.35 (0.30-0.40) 0.34 (0.32-0.37) 0.40 (0.38-0.42) 0.48 (0.45-0.51) 0.63 (0.58-0.69)
0.47 (0.43-0.51) 0.52 (0.50-0.55) 0.56 (0.54-0.58) 0.62 (0.60-0.64) 0.70 (0.65-0.74)
0.25 0.35 0.5 0.7 1.0
Hazard ratio (95% CI) for 20 mmHg Lower usual systolic blood pressure
舒张压 10 mmHg 差值对心血管危险影响
B: usual diastolic blood pressure ( ?75 mmHg)
93% 73% 43% 97% 100%
Lancet 2002,360:1903
ESRD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
61089
51
5.3
1.0
正常
81621
86
6.6
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)
血压、年龄与脑卒中死亡率(100万人群资料分析)
A: Systolic blood pressure
0.43 (0.37-0.50) 0.48 (0.44-0.52) 0.49 (0.46-0.53) 0.61 (0.57-0.66) 0.71 (0.64-0.79)
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
SBP DBP PP MAP Mid BP
89% 83% 37% 100% 100%
Cause Of death
Age at risk(years)
Number of deaths
Stroke
40-49 50-59 60-69 70-79 80-89
348 1243 2646 3915 2340
IHD
40-49
1114
50-59
4945
60-69
9289
70-79
9727
80-89
0.5
1.0
1.5
Eur Heart J 1999:1(suppl):p3
PROGRESS: 预防脑卒中再发
0.20
0.15
例 比 的
者 0.10
患 件 事 生
发 0.05
危险下降 28% (95%的可信限 17-38%)
P<0.0001
安慰剂组 治疗组
0.00
1
2
3
4
随访时间（年）
Lancet 2001; 358: 1033-41
0
0
3 2.5 2
1.5Adjust
1 0.5 0
DBP, mm Hg
MRFIT: Arch Intern Med 1993; 153:598
临界高血压转归
(Tecumsch Study, 3年随访)
正常血压者 90%
临界血压者
10% 47% 53%
正常血压者
临界血压者
降压治疗临床试验荟萃分析结果
140 - 159 160 - 179
≥ 160
≥ 140
< 80 80 - 84 85 - 89
90 - 99 100 - 109
≥ 110
< 90
30
25
en m
20
of 15
%
10
5
0
SBP, mm Hg
5
30
4
25
3
en m
20
Adjuofste1d5 relative risk
2%
10
1 5
All cardiovascular
end points 199:289 137:186 74:94 410:569
SHEP
Fatal and non-fatal stroke
103:159
SYST-EUR
44:77
SYST-CHINA ALL Heterogeneity:P=0
45:59 195:295
256
CI) 128
%
95
ortality
and risk
64 32
m Stroke
absolute
(floating
16 8 4
2
1
Age at rist:
80-89 Years 70-79 Yaes 60-69 years 50-59 Years
B: Diastolic blood pressure
Numbers individuals
1200
1000
800
600
400
200
0 % reduction in odds
C T
Stroke 39%
T = treatment C = control
Non-fatal events Fatal events
C T
C T
TC
CHD 16%
Vascular deaths
256
CI) 128
%
95
ortality
and risk
64 32
m Stroke
absolute
(floating
16 8 4
2
1
Age at rist: 80-89 Years 70-79 Yaes 60-69 years 50-59 Years
120
Lancet 2002,360:1903
140 160 180
37
187.1
22.1 (14.2-34.3)
Klag MJ, Whelton PK, Randali BL et al, New Eng J Med. 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
0.01
1 0.5
Placebo Therapy
0.9 0.6
0.81 0.36
SHEP
4,736 53 54%
0.001
Syst-Eur
4,695 24
29% ns
UKPDS
1,148 101
56% 0.0043
Trial
Number of end points
Treat:Control
SHEP SYST-EUR SYST-CHINA ALL Heterogeneity:P=0.38
高血压1级 高血压2级
140 - 159 或 90 - 99
≥160
或 ≥100
血压水平的分类和定义 (ESH/ESC 2003)
分类
收缩压(mmHg) 舒张压(mmHg)
理想血压 正常血压 正常高值
1级高血压(轻度) 2级高血压(中度) 3级高血压(重度)
单纯收缩期高血压
< 120 120 - 129 130 - 139
IHD
40-49
1322
50-59
5594
60-69 70-79
10450 10852
80-89
5649
0.49 (0.45-0.53) 0.50 (0.49-0.52) 0.54 (0.53-0.55) 0.60 (0.58-0.61) 0.67 (0.64-0.70)
Other vascular
降压治疗的益处
脑卒中 心肌梗死 心力衰竭
平均下降 35–40% 20–25%
Odds rations and confidence limits
Treatment better
Treatment worse
Reduction and SD
32%SD 5 2P=0.001
37%SD 6 2P=0.001
25%SD 8 2P=0.004
0.5
1.0
1.5
Trial
Number of end points