从高血压到心力衰竭挑战与对策幻灯.pptx

从高血压到心力衰竭从高血压到心力衰竭挑战与对策挑战与对策1.McKee et al.N Engl J Med.1971;285:1441-1446.2.Levy D.JAMA 1996;275:1557-1562.高血压高血压:心力衰竭的主要危险因素心力衰竭的主要危险因素Framingham Heart Study Framingham 随访研究的资料显示，高血压随访研究的资料显示，高血压 是心力衰竭发生的主要危险因素。是心力衰竭发生的主要危险因素。约约90%90%的心力衰竭患者，在发生的心力衰竭患者，在发生心力衰竭前心力衰竭前 曾有高血压史。曾有高血压史。160/100BP(mm Hg)Lloyd-Jones et al.Circulation 2002;106:3068-3072.3343 men and 4199 women followed for 25 years no HF at baseline血压水平与心力衰竭危险血压水平与心力衰竭危险AgeMaleFemaleMaleFemaleMaleFemale051015202530Lifetime risk(%)40 years80 years60 yearsYears Normal LV Subclinical Clinical heartLV structure remodeling LV dysfunction failure&function Heart failureObesityDiabetesHTNSmokingDyslipidemiaDiabetesMILVHDiastolicdysfunctionYears/months SystolicdysfunctionDeathVasan RS et al.Arch Intern Med.1996;156:1789-1796.HTN=HypertensionMI=Myocardial InfarctionLVH=Left ventricle hypertrophy高血压如何进展到心力衰竭高血压如何进展到心力衰竭因心力衰竭首次住院患者因心力衰竭首次住院患者左心室射血分数左心室射血分数ALLHATHF BY EF LEVELN=1399EF50%心力衰竭预后：人群研究心力衰竭预后：人群研究随访随访(年年)死亡率死亡率(%)(%)HF-REF HF-PEFOlmsted(1998)5.0 65 65Framingham(1999)6.2 75 46Helsinki(1997)4.0 54 43心力衰竭预后：临床研究荟萃分析心力衰竭预后：临床研究荟萃分析(Somaratne,2008)17 17项研究，项研究，2450124501例，平均治疗随访例，平均治疗随访4747个月个月 38%38%患者死亡，患者死亡，RF-REF 40%RF-REF 40%，HF-PEF 32%HF-PEF 32%降压治疗有效降低心、脑血管病事件降压治疗有效降低心、脑血管病事件17 17项临床试验荟萃分析项临床试验荟萃分析-50-40-30-20-100Heart failure1Fatal/Nonfatalstroke1Fatal/NonfatalCHD1Risk reduction(%)1.Moser and Herbert.J Am Coll Cardiol.1996;2.Collins R et al.Lancet 1990.Vascular deaths-52%-38%-16%-21%HYVET:Heart Failureplaceboactive-Placebo_ ActiveStrokeStrokeSystolic BP Difference Between Systolic BP Difference Between Randomized Groups(mm Hg)Randomized Groups(mm Hg)0.250.250.500.500.750.751.001.001.251.251.501.50-1010-8 8-6-6-4-4-2-20 02 24 4Systolic BP Difference Between Systolic BP Difference Between Randomized Groups(mm Hg)Randomized Groups(mm Hg)0.250.250.500.500.750.751.001.001.251.251.501.50-10-10-8-8-6-6-4-4-2-20 02 24 4CHDCHDA=CA vs placebo;B=ACE inhibitor vs placebo;C=more intensive vs less intensive blood-pressure-lowering;D=ARB vs control;E=ACE inihibitor vs CA;F=CA vs diuretic or-blocker;G=ACE inhibitor vs diuretic and-blocker.Blood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.RR of Outcome EventRR of Outcome EventRR of Outcome EventRR of Outcome EventA AB BC CD DE E F F GGA AB BC CD DE E F F GGBP-Lowering Treatment TrialistsHeart FailureHeart FailureSystolic BP Difference BetweenSystolic BP Difference BetweenRandomized Groups(mm Hg)Randomized Groups(mm Hg)RR of Outcome EventRR of Outcome Event-10-10-8-8-6-6-4-4-2-20 02 24 40.250.250.500.500.750.751.001.001.251.251.501.50A AB BC CD DE E F F GGA=CA vs placebo;B=ACE inhibitor vs placebo;C=more intensive vs less intensive blood-pressure-lowering;D=ARB vs control;E=ACE inihibitor vs CA;F=CA vs diuretic or-blocker;G=ACE inhibitor vs diuretic and-blocker.Blood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.BP-Lowering Treatment TrialistsACEI vs.placeboCA vs.placeboMore vs.lessARB vs.controlACEI vs.D/BBCA vs.D/BBACEI vs.CA219/8233104/338254/7494302/5935547/12498732/23425502/10357269/824688/327472/13394359/5919809/18652850/29734609/10345-5/-2-8/-4-4/-3-2/-1+2/0+1/0+1/+10.82(0.69-0.98)1.21(0.93-1.58)0.84(0.59-1.18)0.84(0.72-0.97)1.07(0.96-1.19)1.33(1.21-1.47)0.82(0.73-0.92)0.51.02.0Heart FailureEvents/participants1st Listed2nd ListedDifference in BP(Mean,mmHg)Relative risk(95%CI)Relative RiskFavours 1st listedFavours 2nd listed1.Table adapted from Blood Pressure Lowering Trialists Collaboration.Lancet.2003;362:1527-1535.2.Gottdiener JS et al.Ann Intern Med.2002;137:631-639.ACEI=ACE inhibitorCA =calcium antagonistARB =angiotensin receptor blockerD/BB=diuretic or beta blockerEffects of antihypertensive treatment on the development of HF in hypertensive patients0.060.060.030.000123456Cumulative HF RateNo.at RiskChlorthalidone 152551456313980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HF0.050.040.020.01ALLHAT:住院心力衰竭发生率住院心力衰竭发生率Davis BR,et al.Circulation 2008;118:ChlorthalidoneLisinoprilAmlodipine0.020.010.000123456Cumulative HF RateNo.at RiskChlorthalidone 152551456313980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HFALLHAT:住院住院HF-REF发生率发生率Davis BR,et al.Circulation 2008;118:ChlorthalidoneAmlodipineLisinopril0.020.010.000123456Cumulative HF RateNo.at RiskChlorthalidone 152551456313980133251162465863212Amlodipine9048858782687904688939121899Lisinopril9054854881817790681139091907Years to HFALLHAT-HF:住院住院HF-PEF发生率发生率Davis BR,et al.Circulation 2008;118:ChlorthalidoneAmlodipineLisinoprilLewis et al.N Engl J Med.2001;345:851-860.Proportion With Proportion With Death From Any Cause(%)Death From Any Cause(%)Follow-up(months)Follow-up(months)0.60.60.50.50.40.40.30.30.20.20.10.10.00.00 06 612121818242430303636424248485454AmlodipineAmlodipinePlaceboPlaceboIrbesartanIrbesartanIDNT:No Significant Difference in Death From Any Cause006612121818242430303636424248485454Follow-up(mo)606030300010102020IrbesartanAmlodipineControlRRR 37%p 0.001RRR 23%p=0.15Subjects(%)Lewis EJ et al.N Engl J Med 2001;345(12):851-60.IDNT:Time to CHFMeta-regression analysis:Relation between odds ratios for CHF and differences in achieved SBP between randomized groups 5.03.02.221.81.61.41.00.80.60.40.2-5-2.52.557.51000-5-2.52.557.52.55107.52.55Systolic blood pressure difference between randomized groups(mmHg)Odds ratio for congestive heart failureACE inhibitors orangiotensin-receptor blockersCalcium channel blockersMIDASMIDASDREAMDREAMVHASVHASINSIGHTINSIGHTALLHAT/CCB-DALLHAT/CCB-DCONVINCECONVINCEIDNT/CCB-PLBIDNT/CCB-PLBSHELLSHELLINVESTINVESTSYST-EURSYST-EURACTIONACTIONASCOTASCOTSTOP2/CCB-BBSTOP2/CCB-BBFEVERFEVERCamelot/CCB-PLBCamelot/CCB-PLBSYST-ChinaSYST-ChinaSTONESTONEPREVENTNICSTRANSCENDTRANSCENDALLHAT/ACE-DALLHAT/ACE-DUKPDS39UKPDS39LIFELIFESTOP2/ACE-BBSTOP2/ACE-BBRENAACRENAACIDNT/ARB-PLBIDNT/ARB-PLBCamelot/CCB-PLBCamelot/CCB-PLBEUROPAEUROPA1.2CAPPPANBP2ANBP2DIABHYCARDIABHYCARPEACEPEACEPART-2PART-2HOPEHOPENORDILNORDILVerdecchia P,et al.Eur Heart J.2009;30:679-688.病程早期病程早期阻止病情进展和逆转靶器官结构与功能损害阻止病情进展和逆转靶器官结构与功能损害 病程中晚期病程中晚期 预防心、脑血管病和肾脏病终点事件预防心、脑血管病和肾脏病终点事件降压治疗目标的演进与转移降压治疗目标的演进与转移:不同病程阶段的目标不同病程阶段的目标Devereux R,et al.JAMA.2004;292:2350-2356Hazard Ratio:0.58(0.38-0.86)p.008LIFE-ECHO substudyImpact on LVH regression on outcomes210-1-2-3-4-5HCTZAtenololCaptoprilClonidine DiltiazemPrazosinChange in left atrial size(mm)Time since randomisation8 weeks1 year2 yearsLong-term antihypertensive treatment with hydrochlorothiazide reduces left atrial sizeCirculation 1998;98:40从高血压到心力衰竭从高血压到心力衰竭心力衰竭的预防策略心力衰竭的预防策略 高血压是心力衰竭最常见的重要危险因素。高血压是心力衰竭最常见的重要危险因素。大多数患者心力衰竭的发生与发展归因于血大多数患者心力衰竭的发生与发展归因于血压和神经内分泌激素未获得有效控制。压和神经内分泌激素未获得有效控制。早期积极控制血压水平能显著降低心力衰早期积极控制血压水平能显著降低心力衰竭的发生率与死亡率，以竭的发生率与死亡率，以RAS阻滞剂和利尿阻滞剂和利尿剂为基础的降压治疗可能是预防心力衰竭发剂为基础的降压治疗可能是预防心力衰竭发生的优化治疗方案。生的优化治疗方案。