Age & Ageing:老年心衰患者如何控制血压才能很大程度降低死亡风险?

2021-07-18 MedSci原创 MedSci原创

高血压是心力衰竭(HF)最常见的可纠正危险因素

高血压是心力衰竭(HF)最常见的可纠正危险因素,因为高血压不仅会增加心脏做功而导致左心室肥厚(LVH),而且还是发生冠状动脉性心脏病(CAD)的危险因素。

高血压患者中HF的发病率因人群及随防时间不同而不同。例如,ACCOMPLISH试验中,高风险的高血压患者中约2%在3年时出现HF。ALLHAT试验纳入了32804例高风险的高血压患者,在平均9年的随防期间有1716例患者出现HF(5.4%)。

一般人群中,高血压者的预后比血压正常者差,而HF患者中,治疗前血压较高则是生存情况较好的一个预测因素。此关联很可能是由于:更严重的心功能不全导致体循环血压降低,因而低血压成为更晚期HF的标志。

由此可见,HF患者的血压管理具有复杂性和挑战性。既往研究已经证实HF患者血压水平与预后密切相关。然而目前的HF指南及高血压指南均缺乏对于HF患者血压管理的明确循证推荐。新近有研究开始探索动态血压监测参数在HF领域的价值。

近日,为了评估血压控制在140/90mmHg以下是否与老年HF患者的死亡风险降低有关。来自加拿大McGill大学流行病学系的专家开展了一项基于人群的前瞻性队列研究,最新的结果发表在《年龄与衰老》Age & Ageing杂志上。

柏林倡议研究是一个在2009年启动的社区居住的老年人的前瞻性队列,通过面对面的访谈获得临床信息。使用Cox比例危害模型估计了与HF患者非正常化血压(收缩压≥140 mmHg或舒张压≥90 mmHg)相比,正常化血压(收缩压<140 mmHg和舒张压<90 mmHg)相关的血管死亡和全因死亡的调整危险比。

结果显示,在基线时,544名患者被诊断为HF并接受降压药物治疗(平均年龄82.8岁;45.4%为女性)。在7.5年的中位随访期间,时间固定分析显示,与非正常化血压相比,正常化血压与心血管死亡(HR=1.24;95%CI:0.84-1.85)和全因死亡(HR=1. 16;95% CI:0.89-1.51)的风险类似。但在时间依赖分析中,心血管死亡(HR=1.79;95% CI:1.23-2.61)和全因死亡(HR=1.48;95% CI=1.15-1.90)的风险分别增加79%与48%。

实际上,对于现有或曾经有心衰症状和体征的高血压患者,多数指南建议降压靶目标为<130/80 mmHg。一项研究显示,更低的血压控制水平会增加患者因心衰再入院、各种原因急诊再入院及死亡的发生率。2016年发表于Lancet杂志的一项荟萃分析显示,强化降压(收缩压<120 mmHg)并未降低心衰事件发生率。而新近发表的SPRINT研究发现,强化降压与标准降压相比可有效降低心衰事件发生率。这三项研究的结果并不一致,提示:不同心功能状态患者的降压目标值可能不同,慢性心衰合并高血压的降压目标值得进一步探讨。

由此可见,血压控制<140/90 mmHg与老年HF患者的死亡风险降低无关。同时,时间依赖性分析中的风险增加需要进一步证实。

 

参考文献:

Control of blood pressure in older patients with heart failure and the risk of mortality: a population-based prospective cohort study, Age and Ageing, Volume 50, Issue 4, July 2021, Pages 1173–1181, https://doi.org/10.1093/ageing/afaa261

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