鈣拮抗劑降壓治療地位進(jìn)展課件

1、鈣拮抗劑降壓治療地位進(jìn)展鈣拮抗劑降壓治療地位進(jìn)展 從循證證據(jù)和國(guó)際治療指南的角度從循證證據(jù)和國(guó)際治療指南的角度影響不同種類降壓藥物治療地位的決定因素影響不同種類降壓藥物治療地位的決定因素 禁忌癥禁忌癥 循證醫(yī)學(xué)證據(jù)循證醫(yī)學(xué)證據(jù) 不良反應(yīng)和治療持續(xù)性不良反應(yīng)和治療持續(xù)性 效益效益/ /費(fèi)用費(fèi)用 種族種族各類降壓藥物的禁忌癥各類降壓藥物的禁忌癥(ESC/ESH,2007)(ESC/ESH,2007)噻嗪類利尿劑 痛風(fēng) 代謝綜合癥、糖耐量減低 妊娠-阻滯劑 哮喘、 外周血管病、代謝綜合癥 糖耐量異常、慢阻肺 A-V阻滯(2或3度) 運(yùn)動(dòng)員和強(qiáng)體力活動(dòng)者 二氫吡啶類CCB 快速性心律失常、心力衰竭 非

2、二氫吡啶類CCB A-V阻滯(2或3度) 心力衰竭 ACEI和ARB 妊娠、高血鉀癥 雙側(cè)腎動(dòng)脈狹窄醛固酮拮抗劑 腎功能衰竭 高血鉀癥 絕對(duì)(強(qiáng)制) 相對(duì)(可能) BP-Lowering Treatment Trialists (WHO/ISH, 2003)Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.0.51.02.0Relative RiskBlood Pressure Lowering Treatment Trialists Collaboration. Lanc

3、et. 2003;362:1527-1535.BP-Lowering Treatment TrialistsComparisons of Different Active Treatments RR (95% CI) Favours first listed Favours second listed0.51.02.0Relative RiskBP difference(mm Hg) 1.09 (1.00,1.18) ACEI vs. D/BB 0.93 (0.86,1.01) CA vs. D/BB 1.12 (1.01,1.25) ACEI vs. CA2/01/01/1BPLTT (20

4、03): StrokeComparisons of different active treatmentsBlood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.Odds ratio for CHDACE IsSystolic BP difference between groups (mmHg) Verdecchia et al 2005CCBsRelationship Between Odds Ratio for CHD and Achieved BP Differences

5、CCBs and CV OutcomesNew Meta-Analysis (ACC, 2009)在在BPLTT的基礎(chǔ)上，納入了的基礎(chǔ)上，納入了2003年以后發(fā)表的年以后發(fā)表的臨床試驗(yàn)：臨床試驗(yàn)：ACTION, ASCOT-BPLA, CAMELOT, CASE-J, FEVER, INVEST, MOSES, HICOLE, VESPACCBs and CV OutcomesNew Meta-Analysis (ACC, 2009)CCB vs. ACEI OR ( 95% CI )Stroke 0.87 (0.78-0.97)MI 1.06 (0.98-1.18)無(wú)強(qiáng)制指征無(wú)強(qiáng)制指征Sta

6、ge 1 HypertensionThiazide-type diuretics for most. May consider ACEI, ARB, BB,CCB, or combination.Stage 2 Hypertension2-drug combination for most ( thiazide-type diuretic and ACEI, or ARB, or BB, or CCB)JNC-7：降壓治療流程：降壓治療流程JNC Recommendations for an Initial Antihypertensive AgentCommittee Year Recomm

7、endationJNC 1 1977 Thiazide-type diureticJNC 2 1980 DiureticJNC 3 1984 Thiazide-type diuretic or BBJNC 4 1988 Diuretic or BB or CCB or ACEIJNC 5 1993 Diuretic or BBJNC 6 1997 Diuretic or BBJNC 7 2003 Thiazide-type diuretic, either alone or in combination with ACEI.ARB,BB,or CCB 各類降壓藥物治療高血壓的地位各類降壓藥物治

8、療高血壓的地位 利尿劑 -阻滯劑 ACEI CCB ARB -阻滯劑(ESC/ESH, 2007) 利尿劑-阻滯劑鈣拮抗劑ACE抑制劑血管緊張素II受體拮抗劑兩藥低劑量聯(lián)合治療兩藥低劑量聯(lián)合治療2007ESH/ESC2007ESH/ESC指南推薦的降壓治療模式指南推薦的降壓治療模式 -blockersAngiotensin receptorantagonistsThiazide diureticsCalcium antagonistsACE inhibitors-blockers合理的降壓聯(lián)合治療方案合理的降壓聯(lián)合治療方案A: ACE Inhibitor or Angiotensin Rece

9、ptor Blocker B: -BlockerC: Calcium Channel Blocker D: Diuretic (Thiazide)BHS IV (2001) Recommendations for Blood Pressure Lowering DrugsNICE / BHS (2006)Management of Hypertension In hypertensive patients aged 55 or over, or Black patients of any age, first-choice initial therapy should be a dihydro

10、pyridine calcium channel blocker; a thiazide-type diuretic is an alternative.NICE / BHS (2006)Management of HypertensionJapanese Guidelines for the Management of Hypertension(JSH, 2004 and 2009) 對(duì)對(duì)大多數(shù)高血壓患者，推薦鈣拮抗大多數(shù)高血壓患者，推薦鈣拮抗劑作為初始治療或聯(lián)合治療的藥物，除劑作為初始治療或聯(lián)合治療的藥物，除了禁忌癥和不能耐受治療的患者。了禁忌癥和不能耐受治療的患者。心血管病預(yù)防指南心血管病預(yù)防指南(WHO/ISH,2007)(WHO/ISH,2007)降壓藥物的選擇降