JACC:同时考虑收缩压和舒张压,控制目标该如何定?

2021-10-20 MedSci原创 MedSci原创

JACC:ALLHAT研究中收缩压和舒张压对心血管事件结果的贡献

收缩压和舒张压与血管事件有重要关联,但很少同时考虑。目前指南将高血压治疗的目标定在140/90(或130/80)mmHg以下,卒中预防的收缩压控制目标更低,与此同时对于冠心病患者,舒张压又不能降太低。那当把考虑收缩压和舒张压同时考虑时,对心脑血管保护的降压靶目标具体是多少?

本研究试图同时分析收缩压(SBP)和舒张压(DBP)测量值与全因死亡、心肌梗死(MI)、充血性心力衰竭(CHF)或卒中等主要综合结局的相关风险。

该研究分析了ALLHAT试验的数据,该试验将成年人随机分为氯噻酮、氨氯地平或赖诺普利。评估收缩压和舒张压同时与主要复合终点的关联,每个终点使用比例风险回归,根据高风险和低风险收缩压和舒张压组合用“热图”表示风险比。

结果表明在平均4.4年的随访期间(四分位范围:3.6-5.4年),33357名参与者经历了2636个心肌梗死时间, 866个充血性心力衰竭事件,936次中风和3700例死亡;8138例患者(24.4%)至少发生过1次事件。对于综合结局、全因死亡率、心肌梗死和充血性心力衰竭,观察到收缩压和舒张压呈u型相关,但与最低危险相关的收缩压和舒张压在每个结局中不同。例如,收缩压/舒张压为140-155/70-80 mm Hg的全因死亡率最低,而心肌梗死为110-120/85-90 mm Hg, 充血性心力衰竭为125-135/70-75 mm Hg。相反,收缩压与卒中呈线性相关。

综上,研究证实血压和卒中的关联是线性的,在ALLHAT 研究中,卒中风险与收缩压或舒张压之间没有J型曲线,在110/55mmHg的水平下还保持线性关系。因此,对于卒中预防,“越低越好”是正确的。与大脑灌注相反,不适当的低舒张压会影响到心肌灌注。结果表明对于心梗预防,血压120/80mmHg左右的风险最低。

总的来说,收缩压和舒张压的风险模式因临床结局而异,且收缩压和舒张压与最低风险相关。本研究结果表明,血压目标的个性化可能部分取决于患者最危险的心血管事件,即患者面临哪个心血管风险最高,可能需要采取个体化的不同降压目标值。

 

原文来源:

Nathan K. Itoga,et al.Contributions of Systolic and Diastolic Blood Pressures to Cardiovascular Outcomes in the ALLHAT Study

J Am Coll Cardiol, 78 (17) 1671–1678

https://www.jacc.org/doi/10.1016/j.jacc.2021.08.035

 

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    2021-12-30 hbwxf
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    2021-10-22 14757fdfm46暂无昵称

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