1、影响不同种类降压药物治疗地位的决定因素影响不同种类降压药物治疗地位的决定因素 禁忌症禁忌症 循证医学证据循证医学证据 不良反应和治疗持续性不良反应和治疗持续性 效益效益/费用费用 种族种族各类降压药物的禁忌症各类降压药物的禁忌症(ESC/ESH,2007)(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
2、衰竭 高血钾症 绝对(强制)相对(可能)BP-Lowering Treatment Trialists(WHO/ISH,2003)Blood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.0.51.02.0Relative RiskBlood Pressure Lowering Treatment Trialists Collaboration.Lancet.2003;362:1527-1535.BP-Lowering Treatment TrialistsComparisons of
3、 Different Active Treatments RR(95%CI)Favours first listed Favours second listed0.51.02.0Relative RiskBP 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.CA2/01/01/1BPLTT(2003):StrokeComparisons of different active treatmentsBlood Pressure Lowering Treatm
4、ent Trialists Collaboration.Lancet.2003;362:1527-1535.Odds ratio for CHDACE IsSystolic BP difference between groups(mmHg)Verdecchia et al 2005CCBsRelationship Between Odds Ratio for CHD and Achieved BP DifferencesCCBs and CV OutcomesNew Meta-Analysis(ACC,2009)在在BPLTT的基础上，纳入了的基础上，纳入了2003年以后发表的年以后发表的临
5、床试验：临床试验：ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPA妊娠Blood Pressure Lowering Treatment Trialists Collaboration.BP-Lowering Treatment TrialistsComparisons of Different Active Treatmentsfirst listed非二氢吡啶类CCB A-V阻滞(2或3度)CCB ARB -阻滞剂Systolic BP difference between groups(mmHg)Black
6、at any AgeJNC 6 1997 Diuretic or BBNew Meta-Analysis(ACC,2009)ACEI vs D/BBAdd:either a-blocker or b-blockerTotal mortalityRelationship Between Odds RatioCV mortalityBHS IV(2001)FavorsSecond ListedNICE/BHS(2006)OR(95%CI)Odds ratio for CHDCCBs and CV OutcomesNew Meta-Analysis(ACC,2009)CCB vs.ACEI OR(9
7、5%CI)Stroke 0.87(0.78-0.97)MI 1.06(0.98-1.18)无强制指征无强制指征Stage 1 HypertensionThiazide-type diuretics for most.May consider ACEI,ARB,BB,CCB,or combination.Stage 2 Hypertension2-drug combination for most(thiazide-type diuretic and ACEI,or ARB,or BB,or CCB)JNC-7：降压治疗流程：降压治疗流程JNC Recommendations for an In
8、itial Antihypertensive AgentCommittee Year RecommendationJNC 1 1977 Thiazide-type diureticJNC 2 1980 DiureticJNC 3 1984 Thiazide-type diuretic or BBJNC 4 1988 Diuretic or BB or CCB or ACEIJNC 5 1993 Diuretic or BBJNC 6 1997 Diuretic or BBJNC 7 2003 Thiazide-type diuretic,either alone or in combinati
9、on with ACEI.ARB,BB,or CCB 各类降压药物治疗高血压的地位各类降压药物治疗高血压的地位 利尿剂 -阻滞剂 ACEI CCB ARB -阻滞剂(ESC/ESH,2007)利尿剂-阻滞剂钙拮抗剂ACE抑制剂血管紧张素II受体拮抗剂两药低剂量联合治疗两药低剂量联合治疗2007ESH/ESC2007ESH/ESC指南推荐的降压治疗模式指南推荐的降压治疗模式-blockersAngiotensin receptorantagonistsThiazide diureticsCalcium antagonistsACE inhibitors-blockers合理的降压联合治疗方案合理
10、的降压联合治疗方案A:ACE Inhibitor or Angiotensin Receptor Blocker B:-BlockerC:Calcium Channel Blocker D:Diuretic(Thiazide)BHS IV(2001)Recommendations for Blood Pressure Lowering DrugsNICE/BHS(2006)Management of Hypertension In hypertensive patients aged 55 or over,or Black patients of any age,first-choice in
11、itial therapy should be a dihydropyridine calcium channel blocker;a thiazide-type diuretic is an alternative.NICE/BHS(2006)Management of HypertensionJapanese Guidelines for the Management of Hypertension(JSH,2004 and 2009)对对大多数高血压患者，推荐钙拮抗大多数高血压患者，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
12、。了禁忌症和不能耐受治疗的患者。心血管病预防指南心血管病预防指南(WHO/ISH,2007)(WHO/ISH,2007)降压药物的选择降压药物的选择 选择低剂量利尿剂、血管紧张素转换选择低剂量利尿剂、血管紧张素转换酶抑制剂或钙拮抗剂作为降压治疗的初酶抑制剂或钙拮抗剂作为降压治疗的初始治疗药物。始治疗药物。-阻滞剂在强适应症时可作为一线治阻滞剂在强适应症时可作为一线治疗药物使用。疗药物使用。限制使用血管紧张素受体拮抗剂。限制使用血管紧张素受体拮抗剂。CCBs and CV OutcomesNew Meta-Analysis(ACC,2009)在在BPLTT的基础上，纳入了的基础上，纳入了2003
13、年以后发表的年以后发表的临床试验：临床试验：ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VESPACCBs and CV OutcomesNew Meta-Analysis(ACC,2009)CCB vs.ACEI OR(95%CI)Stroke 0.87(0.78-0.97)MI 1.06(0.98-1.18)for the Management of HypertensionAdd:either a-blocker orfor CHD and Achieved BP DifferencesOR(95%CI)(JSH,
14、2004 and 2009)血管紧张素II受体拮抗剂for CHD and Achieved BP DifferencesAdd:either a-blocker or b-blockerNICE/BHS(2006)Add:either a-blocker or b-blockerCA vs D/BBNew Meta-Analysis(ACC,2009)合理的降压联合治疗方案JNC 5 1993 Diuretic or BBNICE/BHS(2006)Add:either a-blocker or b-blockerNICE/BHS(2006)CCB ARB -阻滞剂Odds ratio fo
15、r CHDStage 2 Hypertension2-drug combination for most(thiazide-type diuretic and ACEI,or ARB,or BB,or CCB)JNC-7：降压治疗流程ACE inhibitorsMajor CV eventsJNC 1 1977 Thiazide-type diuretic(JSH,2004 and 2009)CA vs D/BBManagement of Hypertension绝对(强制)相对(可能)New Meta-Analysis(ACC,2009)Stroke 0.antagonistsRelativ
16、e RiskPROGRESSComJNC-7：降压治疗流程ACEI vs D/BB2003;362:1527-1535.for the Management of Hypertension(JSH,2004 and 2009)(JSH,2004 and 2009)NICE/BHS(2006)Stroke 0.Management of HypertensionNICE/BHS(2006)Older(55yr)or糖耐量异常、慢阻肺ARB,BB,or CCBJNC 1 1977 Thiazide-type diureticRelative Risk2007ESH/ESC指南推荐的降压治疗模式Bl
17、ack at any AgeCCBs and CV OutcomesStage 2 Hypertension2-drug combination for most(thiazide-type diuretic and ACEI,or ARB,or BB,or CCB)各类降压药物的禁忌症(ESC/ESH,2007)(ESC/ESH,2007)Younger(55yr)NICE/BHS(2006)BP-Lowering Treatment Trialists(WHO/ISH,2003)(JSH,2004 and 2009)2007ESH/ESC指南推荐的降压治疗模式Younger(55yr)Ma
18、y consider ACEI,ARB,BB,CCB,or combination.醛固酮拮抗剂 肾功能衰竭first listedAdd:either a-blocker orJNC 5 1993 Diuretic or BB 限制使用血管紧张素受体拮抗剂。NICE/BHS(2006)非二氢吡啶类CCB A-V阻滞(2或3度)Younger(55yr)orResistant HTOlder(55yr)循证医学证据Blood Pressure Lowering Treatment Trialists Collaboration.各类降压药物治疗高血压的地位C:Calcium Channel B
19、locker D:Diuretic(Thiazide)Total mortalityJNC 4 1988 Diuretic or BB or CCB or ACEICA vs D/BBBlack at any AgeStage 1 HypertensionThiazide-type diuretics for most.2003;362:1527-1535.Blood Pressure Lowering Treatment Trialists Collaboration.ACTION,ASCOT-BPLA,CAMELOT,CASE-J,FEVER,INVEST,MOSES,HICOLE,VES
20、PACCBs and CV OutcomesJNC 2 1980 Diuretic(JSH,2004 and 2009)MI 1.(JSH,2004 and 2009)Systolic BP difference between groups(mmHg)Younger(55yr)心力衰竭在BPLTT的基础上，纳入了2003年以后发表的临床试验：for the Management of Hypertension在BPLTT的基础上，纳入了2003年以后发表的临床试验：antagonists 限制使用血管紧张素受体拮抗剂。JNC 1 1977 Thiazide-type diureticNICE
21、/BHS(2006)Systolic BP difference between groups(mmHg)JNC Recommendations for an Initial Antihypertensive AgentCommittee Year RecommendationJNC 1 1977 Thiazide-type diureticJNC 2 1980 DiureticJNC 3 1984 Thiazide-type diuretic or BBJNC 4 1988 Diuretic or BB or CCB or ACEIJNC 5 1993 Diuretic or BBJNC 6 1997 Diuretic or BBJNC 7 2003 Thiazide-type diuretic,either alone or in combination with ACEI.ARB,BB,or CCB
