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1、从高血压到心力衰竭 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: 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 是心力衰竭发生的主要危险因素。 约90%的心力衰竭患者，在发生心力衰竭前 曾有高血压史。,Lloyd-Jones et al. Circulation 2002;106: 3068-3072.,3343 men and 4199 women followed for
2、 25 years no HF at baseline,血压水平与心力衰竭危险,Years,Normal LV Subclinical Clinical heart LV structure remodeling LV dysfunction failure & function,Heart failure,Obesity Diabetes,HTN,Smoking Dyslipidemia Diabetes,MI,LVH,Diastolic dysfunction,Years/months,Systolic dysfunction,Death,Vasan RS et al. Arch Inte
3、rn Med. 1996;156:1789-1796.,HTN = Hypertension MI = Myocardial Infarction LVH = Left ventricle hypertrophy,高血压如何进展到心力衰竭,因心力衰竭首次住院患者 左心室射血分数,HF BY EF LEVEL,N=1399,EF40%,EF 40-49%,EF50%,心力衰竭预后：人群研究,随访(年) 死亡率(%),HF-REF HF-PEF,Olmsted(1998) 5.0 65 65 Framingham(1999) 6.2 75 46 Helsinki(1997) 4.0 54 43,心
4、力衰竭预后：临床研究荟萃分析 (Somaratne, 2008),17项研究，24501例，平均治疗随访47个月 38%患者死亡，RF-REF 40%，HF-PEF 32%,降压治疗有效降低心、脑血管病事件 17项临床试验荟萃分析,-50,-40,-30,-20,-10,0,Heart failure1,Fatal/Nonfatal stroke1,Fatal/Nonfatal CHD1,Risk reduction (%),1. Moser and Herbert. J Am Coll Cardiol. 1996; 2. Collins R et al. Lancet 1990.,Vascu
5、lar deaths,-52%,-38%,-16%,-21%,HYVET: Heart Failure,placebo active,- Placebo _ Active,Stroke,Systolic BP Difference Between Randomized Groups (mm Hg),Systolic BP Difference Between Randomized Groups (mm Hg),0.25,0.50,0.75,1.00,1.25,1.50,CHD,A = CA vs placebo; B = ACE inhibitor vs placebo; C = more i
6、ntensive 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 Event,RR of Outcome Even
7、t,BP-Lowering Treatment Trialists,A = 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 Treatmen
8、t Trialists Collaboration. Lancet. 2003;362:1527-1535.,BP-Lowering Treatment Trialists,ACEI vs. placebo CA vs. placebo More vs. less ARB vs. control ACEI vs. D/BB CA vs. D/BB ACEI vs. CA,219/8233 104/3382 54/7494 302/5935 547/12498 732/23425 502/10357,269/8246 88/3274 72/13394 359/5919 809/18652 850
9、/29734 609/10345,-5/-2 -8/-4 -4/-3 -2/-1 +2/0 +1/0 +1/+1,0.82 (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),Heart Failure,Events/participants,1st Listed,2nd Listed,Difference in BP (Mean, mmHg),Relative risk (95% CI),Relative Risk,F
10、avours 1st listed,Favours 2nd listed,1. 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 inhibitor CA = calcium antagonist ARB = angiotensin receptor blocker D/BB = diuretic or beta bl
11、ocker,Effects of antihypertensive treatment on the development of HF in hypertensive patients,ALLHAT: 住院心力衰竭发生率,Davis BR, et al. Circulation 2008;118:,Chlorthalidone,Lisinopril,Amlodipine,ALLHAT: 住院HF-REF发生率,Davis BR, et al. Circulation 2008;118:,Chlorthalidone,Amlodipine,Lisinopril,ALLHAT-HF: 住院HF-
12、PEF发生率,Davis BR, et al. Circulation 2008;118:,Chlorthalidone,Amlodipine,Lisinopril,Lewis et al. N Engl J Med. 2001;345:851-860.,Proportion With Death From Any Cause (%),Follow-up (months),0.6,0.5,0.4,0.3,0.2,0.1,0.0,0,6,12,18,24,30,36,42,48,54,Amlodipine,Placebo,Irbesartan,IDNT: No Significant Diffe
13、rence in Death From Any Cause,0,6,12,18,24,30,36,42,48,54,Follow-up (mo),60,30,0,10,20,Irbesartan Amlodipine Control,RRR 37% p 0.001,RRR 23% p = 0.15,Subjects (%),Lewis EJ et al. N Engl J Med 2001;345(12):851-60.,IDNT: Time to CHF,Meta-regression analysis: Relation between odds ratios for CHF and di
14、fferences in achieved SBP between randomized groups,Verdecchia P, et al. Eur Heart J. 2009;30:679-688., 病程早期 阻止病情进展和逆转靶器官结构与功能损害, 病程中晚期 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: 不同病程阶段的目标,Devereux R, et al. JAMA. 2004;292:2350-2356,Hazard Ratio: 0.58 (0.38-0.86) p .008,LIFE-ECHO substudy Impact on LVH regression on outcomes,Long-term antihypertensive treatment with hydrochlorothiazide reduces left atrial size,Circulation 1998;98:40,从高血压到心力衰竭 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。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。 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RAS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生的优化治疗方案。,