鈣拮抗劑降壓治療地位進(jìn)展從循證證據(jù)和國際治療指南的角度

1、鈣拮抗劑降壓治療地位進(jìn)展從循證證據(jù)和國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 禁忌癥 循證醫(yī)學(xué)證據(jù) 不良反應(yīng)和治療持續(xù)性 效益/費(fèi)用 種族各類降壓藥物的禁忌癥(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)動員和強(qiáng)體力活動者 二氫吡啶類CCB 快速性心律失常、心力衰竭 非二氫吡啶類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)腎動脈狹窄醛固酮拮抗劑 腎功能衰竭 高血鉀癥 絕對(強(qiáng)制) 相對(可能) SBP difference b

2、etween randomized groups (mmHg)Relative risk of outcome event1.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.251.501.251.000.750.500.25StrokeMajor CVDCHDCVD deathTotal mortality-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024-10-8-6-4-2024BP-Lowe

3、ring Treatment Trialists (WHO/ISH, 2003)Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.0.51.02.0Relative Risk RR (95% CI)BP Difference(mm Hg)FavorsFirst ListedFavorsSecond ListedMajor CV eventsCV mortalityTotal mortality 1.02 (0.98, 1.07)2/0 ACEI vs D/BB 1.03 (

4、0.95, 1.11)2/0 ACEI vs D/BB 1.00 (0.95, 1.05)2/0 ACEI vs D/BB 1.04 (0.99, 1.08)1/0 CA vs D/BB 1.05 (0.97, 1.13)1/0 CA vs D/BB 0.99 (0.95, 1.04)1/0 CA vs D/BB 0.97 (0.92, 1.03)1/1 ACEI vs CA 1.03 (0.94, 1.13)1/1 ACEI vs CA 1.04 (0.98, 1.10)1/1 ACEI vs CABlood Pressure Lowering Treatment Trialists Col

5、laboration. Lancet. 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/

6、01/01/1BPLTT (2003): StrokeComparisons of different active treatmentsBlood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.0.40.60.81.01.21.40.21.82.015105-5Odds ratio for CHDACE IsALLHATACEIUKPDS39EUROPAPROGRESSPROGRESSComCAMELOTHOPEPEACECAPPPSTOP-2ACEIANBP-2Systolic

7、 BP difference between groups (mmHg) Verdecchia et al 20050NICSALLHATCCBPREVENTIDNT-2CONVINCEVHASSyst-ChinaSYSTEURCAMELOTSTONENICOLEACTIONNORDILINVESTSTOP-2CCBINSIGHT151050-5CCBsELSARelationship Between Odds Ratio for CHD and Achieved BP DifferencesCCBs and CV OutcomesNew Meta-Analysis (ACC, 2009)在B

8、PLTT的基礎(chǔ)上，納入了2003年以后發(fā)表的臨床試驗(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)無強(qiáng)制指征Stage 1 HypertensionThiazide-type diuretics for most. May consider ACEI, ARB, B

9、B,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JNC Recommendations for an Initial Antihypertensive AgentCommittee Year RecommendationJNC 1 1977 Thiazide-type diureticJNC 2 1980 DiureticJNC 3 1984 Thiazide-typ

10、e 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從JNC-6(1997)到JNC-7(2003) 利尿劑 b-阻滯劑 ACEI CCB ARB -阻滯劑用于起動和持續(xù)治療的合適降壓藥物(ESC/ESH, 2007) 利尿劑b-阻

11、滯劑鈣拮抗劑ACE抑制劑血管緊張素II受體拮抗劑降壓治療選擇單藥低劑量治療兩藥低劑量聯(lián)合治療輕度血壓升高低/中度心血管危險(xiǎn)傳統(tǒng)目標(biāo)血壓顯著血壓升高高/很高心血管危險(xiǎn)更低的目標(biāo)血壓如果沒有達(dá)到目標(biāo)血壓先前的藥物全劑量轉(zhuǎn)換低劑量的不同藥物先前聯(lián)合藥物全劑量增加低劑量的第3個(gè)藥物如果沒有達(dá)到目標(biāo)血壓全劑量的2-3個(gè)藥物聯(lián)合治療全劑量的單藥治療全劑量的2-3個(gè)藥物聯(lián)合治療2007ESH/ESC指南推薦的降壓治療模式b-blockersAngiotensin receptorantagonistsThiazide diureticsCalcium antagonistsACE inhibitors-bl

12、ockers歐洲高血壓治療指南(ESC/ESH,2007)合理的降壓聯(lián)合治療方案Younger (55yr)or BlackA: ACE Inhibitor or Angiotensin Receptor Blocker B: b-BlockerC: Calcium Channel Blocker D: Diuretic (Thiazide)Step 1A (or B*)C or DStep 3+A (or B*)CDStep 4 Resistant HTAdd: either a- blocker or spironolactone or other diureticStep 2+A (or

13、 B*)C or D* combination therapy involving B & D may induce more diabetes compared with other combination therapiesBHS IV (2001) Recommendations for Blood Pressure Lowering DrugsYounger (55yr) or Black at any AgeA: ACE Inhibitor or Angiotensin Receptor Blocker B: b-BlockerC: Calcium Channel Blocker D

14、: Diuretic (Thiazide)Step 1A C or DStep 2+AC or DStep 3+ACDStep 4 Resistant HTAdd: either a- blocker or b- blocker or spironolactone or other diureticNICE / BHS (2006)Management of Hypertension Younger (55yr) or Black at any AgeA: ACE Inhibitor or Angiotensin Receptor Blocker B: b-BlockerC: Calcium

15、Channel Blocker D: Diuretic (Thiazide)Step 1A C or DStep 2+AC or DStep 3+ACDStep 4 Resistant HTAdd: either a- blocker or b- blocker or spironolactone or other diureticIn hypertensive patients aged 55 or over, or Black patients of any age, first-choice initial therapy should be a dihydropyridine calcium channel blocker; a thiazide-type diuretic is an alternative.NICE / BHS (2006)Management of H