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1、钙拮抗剂降压治疗地位进展 从循证证据和国际治疗指南的角度,影响不同种类降压药物治疗地位的决定因素, 禁忌症 循证医学证据 不良反应和治疗持续性 效益/费用 种族,各类降压药物的禁忌症(ESC/ESH,2007),噻嗪类利尿剂 痛风 代谢综合症、糖耐量减低 妊娠 -阻滞剂 哮喘、 外周血管病、代谢综合症 糖耐量异常、慢阻肺 A-V阻滞(2或3度) 运动员和强体力活动者 二氢吡啶类CCB 快速性心律失常、心力衰竭 非二氢吡啶类CCB A-V阻滞(2或3度) 心力衰竭 ACEI和ARB 妊娠、高血钾症 双侧肾动脉狭窄 醛固酮拮抗剂 肾功能衰竭 高血钾症,绝对(强制) 相对(可能),SBP diffe
2、rence between randomized groups (mmHg),Relative risk of outcome event,BP-Lowering Treatment Trialists (WHO/ISH, 2003),Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,0.5,1.0,2.0,Relative Risk,RR (95% CI),BP Difference (mm Hg),Favors First Listed,Favors Second L
3、isted,Major CV events,CV mortality,Total mortality,1.02 (0.98, 1.07),2/0,ACEI vs D/BB,1.03 (0.95, 1.11),2/0,ACEI vs D/BB,1.00 (0.95, 1.05),2/0,ACEI vs D/BB,1.04 (0.99, 1.08),1/0,CA vs D/BB,1.05 (0.97, 1.13),1/0,CA vs D/BB,0.99 (0.95, 1.04),1/0,CA vs D/BB,0.97 (0.92, 1.03),1/1,ACEI vs CA,1.03 (0.94,
4、1.13),1/1,ACEI vs CA,1.04 (0.98, 1.10),1/1,ACEI vs CA,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,BP-Lowering Treatment Trialists Comparisons of Different Active Treatments,RR (95% CI),Favours first listed,Favours second listed,0.5,1.0,2.0,Relative Risk,BP
5、difference (mm Hg),1.09 (1.00,1.18),ACEI vs. D/BB,0.93 (0.86,1.01),CA vs. D/BB,1.12 (1.01,1.25),ACEI vs. CA,2/0,1/0,1/1,BPLTT (2003): Stroke Comparisons of different active treatments,Blood Pressure Lowering Treatment Trialists Collaboration. Lancet. 2003;362:1527-1535.,0.2,1.8,2.0,15,10,5,-5,Odds r
6、atio for CHD,ACE Is,Systolic BP difference between groups (mmHg),Verdecchia et al 2005,0,Relationship Between Odds Ratio for CHD and Achieved BP Differences,CCBs and CV Outcomes New Meta-Analysis (ACC, 2009),在BPLTT的基础上，纳入了2003年以后发表的临床试验： ACTION, ASCOT-BPLA, CAMELOT, CASE-J, FEVER, INVEST, MOSES, HIC
7、OLE, VESPA,CCBs and CV Outcomes New Meta-Analysis (ACC, 2009),CCB vs. ACEI,OR ( 95% CI ),Stroke 0.87 (0.78-0.97) MI 1.06 (0.98-1.18),无强制指征,Stage 1 Hypertension Thiazide-type diuretics for most. May consider ACEI, ARB, BB,CCB, or combination.,Stage 2 Hypertension 2-drug combination for most ( thiazid
8、e-type diuretic and ACEI, or ARB, or BB, or CCB),JNC-7：降压治疗流程,JNC Recommendations for an Initial Antihypertensive Agent,Committee Year Recommendation,JNC 1 1977 Thiazide-type diuretic JNC 2 1980 Diuretic JNC 3 1984 Thiazide-type diuretic or BB JNC 4 1988 Diuretic or BB or CCB or ACEI JNC 5 1993 Diur
9、etic or BB JNC 6 1997 Diuretic or BB JNC 7 2003 Thiazide-type diuretic, either alone or in combination with ACEI.ARB,BB,or CCB,各类降压药物治疗高血压的地位 从JNC-6(1997)到JNC-7(2003),利尿剂 b-阻滞剂 ACEI CCB ARB -阻滞剂,用于起动和持续治疗的合适降压药物 (ESC/ESH, 2007),利尿剂 b-阻滞剂 钙拮抗剂 ACE抑制剂 血管紧张素II受体拮抗剂,2007ESH/ESC指南推荐的降压治疗模式,b-blockers,Ang
10、iotensin receptor antagonists,Thiazide diuretics,Calcium antagonists,ACE inhibitors,-blockers,欧洲高血压治疗指南(ESC/ESH,2007) 合理的降压联合治疗方案,Younger (55yr) & Non-Black,Older (55yr) or Black,BHS IV (2001) Recommendations for Blood Pressure Lowering Drugs,A: ACE Inhibitor or Angiotensin Receptor Blocker B: b-Blo
11、cker C: Calcium Channel Blocker D: Diuretic (Thiazide),NICE / BHS (2006) Management of Hypertension,A: ACE Inhibitor or Angiotensin Receptor Blocker B: b-Blocker C: Calcium Channel Blocker D: Diuretic (Thiazide),In hypertensive patients aged 55 or over, or Black patients of any age, first-choice ini
12、tial therapy should be a dihydropyridine calcium channel blocker; a thiazide-type diuretic is an alternative.,NICE / BHS (2006) Management of Hypertension,Japanese Guidelines for the Management of Hypertension (JSH, 2004 and 2009), 对大多数高血压患者，推荐钙拮抗剂作为初始治疗或联合治疗的药物，除了禁忌症和不能耐受治疗的患者。,心血管病预防指南(WHO/ISH,2007) 降压药物的选择,选择低剂量利尿剂、血管紧张素转换酶抑制剂或钙拮抗剂作为降压治疗的初始治疗药物。 -阻滞剂在强适应症时可作为一线治疗药物使用。 限制使用血管紧张素受体拮抗剂。,