GW-ICC 2016:孙英贤教授谈高血压治疗的新近进展与争议

2016-10-17 MedSci MedSci原创

2016年,长城会首次与世界心力衰竭大会2016(WHFC 2016)和国际心血管药物治疗学会年会(ISCP)联合召开。会议上来自中国医科大学附属第一医院的孙英贤教授分析了《高血压治疗的最新进展与争议》。孙教授1985年毕业于中国医科大学医疗系获学士学位,现任中华心电生理和起搏学会青年委员,心电生理专业委员,中国实用内科组织编委会编委,全国射频消融治疗快速心律失常指南编制专家组成员。▲孙英贤教

2016年,长城会首次与世界心力衰竭大会2016(WHFC 2016)和国际心血管药物治疗学会年会(ISCP)联合召开。会议上来自中国医科大学附属第一医院的孙英贤教授分析了《高血压治疗的最新进展与争议》。

孙教授1985年毕业于中国医科大学医疗系获学士学位,现任中华心电生理和起搏学会青年委员,心电生理专业委员,中国实用内科组织编委会编委,全国射频消融治疗快速心律失常指南编制专家组成员。


▲孙英贤教授

争议一:60~80岁患者降压目标140mmHg还是150mmHg?

1.2013年欧洲高血压指南(ESC)



2.2014年美国承认高血压管理指南(JNC8)

降压目标值(相对简化)
<60岁患者的目标值为<140/90mmHg
≥60岁患者的目标值为<150/90mmHg
≥18岁合并CKD或糖尿病高血压患者的目标值为<140/90mmHg

3.2014年日本高血压管理指南(JSH)

⊙降压目标:
⊙中青年、早期老年高血压患者的目标<140/90mmHg
⊙晚期老年高血压患者的降压目标<150/90mmHg(如果能耐受,建议<140/90mmHg)
⊙合并糖尿病、有蛋白尿的CKD患者,目标<130/80mmHg
⊙合并卒中或冠心病患者,目标<140/90mmHg

指南依据:

SHEP、EWPHE、Syst-Eur和Syst-China等研究,预设和最终达到的降压目标SBP均在140mmHg以上,除SHEP研究实现SBP控制143mmHg,其余研究最终均将SBP控制到150mmHg左右。绝大部分将SBP降至140~150mmHg的老年高血压研究结果均显示通过降压治疗显著减少患者主要心血管终点风险,因而SBP控制为140~150mmHg成为多数指南推荐的老年高血压控制目标。

指南依据—JATOS(ESC、JNC8):

日本老年高血压最佳收缩压研究(JATOS)将患者的平均收缩压降至136mmHg,与对照组相比(收缩压降至145mmHg),终点事件有下降趋势,但未达到统计学意义。

指南依据---FEVER(ESC):

FEVER研究中老年亚组的结果:65岁以上将SBP降至<140mmHg(139.7mmHg)相比于<150mmHg(145.5mmHg),主要终点脑卒中发生危险降至44%(p<0.001);本级终点也有明显下降(p<0.001)。该亚组分析显示的结果提示在65岁以上的老年患者中,收缩压控制为1400mmHg以下有更好的心血管终点获益。

讨论:140mmHg还是150mmHg?

ESC:SBP≤140mmHg
JNC8:SBP≤150mmHg

⊙我们团队的研究发现,中国老年人或许不适合150mmHg这个目标值,<140/90mmHg或更适宜
⊙该研究共纳入5066例乡村地区≥60岁高血压患者,平均年龄69.5岁,平均随访4.8年,776人死亡,其中536人死于心血管病。同期发生491例脑卒中和278例冠心病事件
⊙与将血压降低在<140/90mmHg相比,血压降低在<140~149/90mmHg的老年患者全因死亡风险增加2.7倍,心血管死亡风险增加2.7倍

故推荐140mmHg

争议二:高危患者是否需要将血压降至120mmHg

1.SPRINT研究

⊙纳入了9631名心血管高危分享的高血压患者的多中心、随机、对照试验
⊙随机分为强化减压组(SBP<120mmHg)和标准治疗组(SBP<140mmHg)
⊙随访3.26年,由于强化减压组的心血管事件明显减少而试验提前终止(预期随访5年)
⊙主要心血管事件包括:急性心肌梗死、急性冠脉综合征、卒中、急性失代偿性心衰、心源性死亡;时间发生率相比,强化减压组发生率为1.65%/年,明显低于治疗组的2.19%/年(HR,0.75;95%CI,0.64_0.89)
⊙强化治疗组平均2.7种降压药,而标准治疗组为1.8种

SPRINT研究的研究标准:

⊙50岁以上
⊙收缩压水平:130~180mmHg
⊙附加心血管危险因素:(以下至少一项)
临床或亚临床心血管疾病(除外卒中)
慢性肾脏疾病(eGFR20 - <60ml/min1.73㎡)
Framingham Risk Score for 10-year CVD risk≥15%
年龄≥75岁

2.2016年加拿大高血压指南

普通患者:
80岁以下的降压目标:<140/90mmHg
80岁以上的降压目标:<150mmHg

高危患者的降压目标:(该指南的更新内容,其证据源于SPRINT研究结果)

年龄≥50岁、SBP≥130mmHg者,推荐进行强化的降压目标:SBP≤120mmHg
血压以诊室自动血压监测值(AOBP)为准
指南指出,在进行强化药物干预时需慎重选择

3.HOPE-3 降压分支研究结论(2016年ACC年会报告了HOPE-3研究结果并于NEJM在线发表)

⊙固定剂量坎地沙坦16mg+氢氯噻嗪12.5mg/天可降低血压6.0/3.0mmHg,但不能显著降低中危人群的总体心血管终点事件
⊙仅在血压最高的1/3人群中显著降低心血管终点事件-基线SBP>143.5mmHg,均值154mmHg
⊙中位1/3血压者无影响
⊙低位1/3血压者反而呈有害趋势
⊙降压治疗可导致眩晕/低血压发生率显著上升,但昏厥和肾功能不全与安慰剂无显著差异。

讨论:是否需要将血压降至120mmHg

⊙SPRINT研究:CVD高危人群≤120mmHg
⊙加拿大指南:CVD高危人群≤120mmHg
⊙HOPE3:在CVD中危人群中,除非明确合并高血压,否则没有必要采用降压药物治疗

慎重采用

争议三:老老年高血压患者降压目标

ESC、JNC8、加拿大:SBP<150mmHg

目前指南对老年人高血压的降压目标不一

1.ESC指南:
推荐80岁及以上老年人血压超过160mmHg开始降压

2.JNC8:

推荐60岁及以上老人SBP应<150mmHg,然而一些成员另发表文章建议SBP应<140mmHg

3.HYVET(高龄老年高血压试验):老年人降压治疗可显著减少心脑血管风险

3854例、年龄≥80岁高血压患者入选实验,活性药物组(n=1933),安慰剂组(n=1933)平均随访1.8年

4.SPRINT研究最新分析:75岁及以上老年人降压目标

(旨在对比75岁以上老年高血压降压SBP<120mmHg vs SBP<140mmHg结局,没有包括糖尿病、卒中及心力衰竭患者,且生活能自理)

研究结果:

⊙强化降压组和标准降压组基本特征除了虚弱程度和阿司匹林使用之外,无明显差异
平均3.14年随访
⊙主要结局事件:强化降压组发生102事件,标准降压组发生148事件;HR,0.66[95%CI,0.51-0.85]
⊙全因死亡:强化降压组73死亡,标准降压组107死亡;HR,0.67[95%CI,0.49-0.91]
⊙严重不良事件两组间无明显差异(强化降压组48.4%,标准降压组48.3%;HR,0.99[95%CI,0.89-1.11]
⊙低血压发生率:强化降压组2.4%,标准降压组1.4%;HR,1.71[95%CI,0.97-3.09]
⊙晕厥发生率:强化降压组3.0%,标准降压组2.4%;HR,1.23[95%CI,0.76-2.00]
⊙离子异常发生率:强化降压组4.0%,标准降压组2.7%;HR,1.51[95%CI,0.99-2.33]
⊙急性肾损伤发生率:强化降压组5.5%,标准降压组4.0%;HR,1.41[95%CI,0.98-2.04]
⊙跌倒发生率:强化降压组4.9%,标准降压组5.5%;HR,0.91[95%CI,0.65-1.29]

讨论:120mmHg还是150mmHg?

⊙SPRINT研究在JAMA上发表的结果:年龄≥75岁,推荐进行强化的降压目标:SBP<120mmHg慎重采用
⊙ESC、JNC8、加拿大:SBP<150mmHg

总结:

争议一:60~80岁患者降压目标
孙英贤教授:中国老年人或许不适合150mmHg这个目标值,<140/90mmHg或更适宜

争议二:高危患者是否需要将血压降至120mmHg
孙英贤教授:慎重采用

争议三:老老年高血压患者降压目标
孙英贤教授:慎重采用120mmHg

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    2016-10-28 镱鉎鉌釚

    SHEP、EWPHE、Syst-Eur和Syst-China等研究,预设和最终达到的降压目标SBP均在140mmHg以上,除SHEP研究实现SBP控制143mmHg,其余研究最终均将SBP控制到150mmHg左右。绝大部分将SBP降至140~150mmHg的老年高血压研究结果均显示通过降压治疗显著减少患者主要心血管终点风险,因而SBP控制为140~150mmHg成为多数指南推荐的老年高血压控制目标。

    0

  2. 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GetPortalCommentsPageByObjectIdResponse(id=149294, encodeId=1ddd149294d4, content=大赞?如此详细,值得好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Pw2csslt7CukWiabqiblnQAXaDEiaxhu025c3P0XshccTrbvGWBjKvnHIxbK3vqa80P7WGIFuicCFet97TicrNKpgB3TdabxP1vMh/0, createdBy=28851960965, createdName=榄枷檬, createdTime=Mon Oct 17 22:40:48 CST 2016, time=2016-10-17, status=1, ipAttribution=)]
    2016-10-21 1e0d99ddm02(暂无匿称)

    学习啦!分享一下!

    0

  3. 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    2016-10-19 zhs3884
  4. 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    2016-10-19 chenwq12
  5. 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    2016-10-18 有备才能无患

    复合制剂受推崇

    0

  6. 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    2016-10-18 CardioK

    学习!

    0

  7. 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    2016-10-18 doctorJiangchao

    继续关注

    0

  8. 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channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Wed Oct 19 08:18:00 CST 2016, time=2016-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149545, encodeId=644a149545e1, content=复合制剂受推崇, beContent=null, objectType=article, channel=null, level=null, likeNumber=149, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Tue Oct 18 19:54:13 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149491, encodeId=131f14949190, content=学习!, 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ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149468, encodeId=f140149468a1, content=继续学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Tue Oct 18 11:09:35 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149342, encodeId=c9d0149342d2, content=写得不错,赞一个。, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=87421705485, createdName=1de8ed50m80(暂无匿称), createdTime=Tue Oct 18 00:35:48 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149294, encodeId=1ddd149294d4, content=大赞?如此详细,值得好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Pw2csslt7CukWiabqiblnQAXaDEiaxhu025c3P0XshccTrbvGWBjKvnHIxbK3vqa80P7WGIFuicCFet97TicrNKpgB3TdabxP1vMh/0, createdBy=28851960965, createdName=榄枷檬, createdTime=Mon Oct 17 22:40:48 CST 2016, time=2016-10-17, status=1, ipAttribution=)]
    2016-10-18 doctorJiangchao

    继续学习

    0

  9. [GetPortalCommentsPageByObjectIdResponse(id=151640, encodeId=59a915164033, content=SHEP、EWPHE、Syst-Eur和Syst-China等研究,预设和最终达到的降压目标SBP均在140mmHg以上,除SHEP研究实现SBP控制143mmHg,其余研究最终均将SBP控制到150mmHg左右。绝大部分将SBP降至140~150mmHg的老年高血压研究结果均显示通过降压治疗显著减少患者主要心血管终点风险,因而SBP控制为140~150mmHg成为多数指南推荐的老年高血压控制目标。, beContent=null, objectType=article, channel=null, level=null, likeNumber=166, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160903/IMG57CA05C7ADAC62159.jpg, createdBy=ea6c1943408, createdName=镱鉎鉌釚, createdTime=Fri Oct 28 07:24:10 CST 2016, time=2016-10-28, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=150082, encodeId=7e5f150082d9, content=学习啦!分享一下!, beContent=null, objectType=article, channel=null, level=null, likeNumber=145, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cacheapi.medsci.cn/resource/upload/20160817/IMG57B3C3F6DC2FD8753.jpg, createdBy=81321934679, createdName=1e0d99ddm02(暂无匿称), createdTime=Fri Oct 21 10:27:56 CST 2016, time=2016-10-21, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1462016, encodeId=6b821462016e9, content=<a href='/topic/show?id=32fd933505' target=_blank style='color:#2F92EE;'>#ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=92, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=9335, encryptionId=32fd933505, topicName=ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=36506466438, createdName=zhs3884, createdTime=Wed Oct 19 08:18:00 CST 2016, time=2016-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1527177, encodeId=7dfd152e177d6, content=<a href='/topic/show?id=81ca834123' target=_blank style='color:#2F92EE;'>#GW-ICC#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=107, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=8341, encryptionId=81ca834123, topicName=GW-ICC)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=00e511815854, createdName=chenwq12, createdTime=Wed Oct 19 08:18:00 CST 2016, time=2016-10-19, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149545, encodeId=644a149545e1, content=复合制剂受推崇, beContent=null, objectType=article, channel=null, level=null, likeNumber=149, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo7cJ6ejWUr2nIia8qOvAKNdLHr32Df6G8iaoaOx6pHaoiacwp26DaslxZHCGbibZhhCGven4rvmWP60GahtzgFjgCjR/0, createdBy=6b111703011, createdName=有备才能无患, createdTime=Tue Oct 18 19:54:13 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149491, encodeId=131f14949190, content=学习!, beContent=null, objectType=article, channel=null, level=null, likeNumber=137, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/oLAjfB7s1ib06iaV3D9Tg5KzY0AKCuyeYpTTaavxw0sXDXf9bgFIAibrIkIibicM8SBLudBK2V7LsgwyHAE9d47dh6RjO8TnjfWkk/0, createdBy=56af1959811, createdName=CardioK, createdTime=Tue Oct 18 13:12:42 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149469, encodeId=300e1494693f, content=继续关注, beContent=null, objectType=article, channel=null, level=null, likeNumber=152, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Tue Oct 18 11:09:40 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149468, encodeId=f140149468a1, content=继续学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=74, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/jW482SpianMayicTRbRZ5RzfPkmqRTH5rHib5mcib8Wb3QdXjhfOK1UubQL2lictjJFdFJ6Lc3cnnCOSWqxXZ4Kk6y5GdzDoy764R/0, createdBy=156e1644785, createdName=doctorJiangchao, createdTime=Tue Oct 18 11:09:35 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149342, encodeId=c9d0149342d2, content=写得不错,赞一个。, beContent=null, objectType=article, channel=null, level=null, likeNumber=96, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=87421705485, createdName=1de8ed50m80(暂无匿称), createdTime=Tue Oct 18 00:35:48 CST 2016, time=2016-10-18, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=149294, encodeId=1ddd149294d4, content=大赞?如此详细,值得好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Pw2csslt7CukWiabqiblnQAXaDEiaxhu025c3P0XshccTrbvGWBjKvnHIxbK3vqa80P7WGIFuicCFet97TicrNKpgB3TdabxP1vMh/0, createdBy=28851960965, createdName=榄枷檬, createdTime=Mon Oct 17 22:40:48 CST 2016, time=2016-10-17, status=1, ipAttribution=)]
    2016-10-18 1de8ed50m80(暂无匿称)

    写得不错,赞一个。

    0

  10. 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GetPortalCommentsPageByObjectIdResponse(id=149294, encodeId=1ddd149294d4, content=大赞?如此详细,值得好好学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=79, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/Pw2csslt7CukWiabqiblnQAXaDEiaxhu025c3P0XshccTrbvGWBjKvnHIxbK3vqa80P7WGIFuicCFet97TicrNKpgB3TdabxP1vMh/0, createdBy=28851960965, createdName=榄枷檬, createdTime=Mon Oct 17 22:40:48 CST 2016, time=2016-10-17, status=1, ipAttribution=)]
    2016-10-17 榄枷檬

    大赞?如此详细,值得好好学习

    0

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