Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease.
Tight blood pressure control and cardiovascular outcomes among hypertensive patients with diabetes and coronary artery disease.
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DOI：
10.1001/jama.2010.884
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发表时间：
2010-07-07
影响因子：
120.7
通讯作者：
Pepine, Carl J.
中科院分区：
文献类型：
--
作者：
Cooper-DeHoff, Rhonda M.;Gong, Yan;Handberg, Eileen M.;Bavry, Anthony A.;Denardo, Scott J.;Bakris, George L.;Pepine, Carl J.
高血压指南提倡将糖尿病患者的收缩压（BP）治疗至低于130 mm Hg;然而，缺乏日益增长的冠心病（CAD）患者的数据。确定糖尿病合并CAD患者队列中收缩压控制与不良心血管结局之间的关系。国际维拉帕米SR-群多普利研究（INVEST）中22576例参与者中6400例的观察性亚组分析。在这项分析中，参与者至少50岁，患有糖尿病和CAD。参与者于1997年9月至2000年12月期间从14个国家的862个地点招募，并通过美国参与者的国家死亡指数随访至2003年3月，并延长随访至2008年8月。患者接受钙拮抗剂或β受体阻滞剂一线治疗，随后接受血管紧张素转换酶抑制剂、利尿剂或两者联合治疗，以实现收缩压低于130 mmHg和舒张压低于85 mmHg。如果患者能够将收缩压维持在130 mm Hg以下，则将其归类为严格控制;如果收缩压范围为130 mm Hg至140 mm Hg以下，则将其归类为常规控制;如果收缩压为140 mm Hg或更高，则将其归类为未控制。不良心血管结局，包括首次发生全因死亡、非致死性心肌梗死或非致死性卒中的主要结局。在16893患者-年的随访中，286例（12.7%）保持严格控制的患者、249例（12.6%）正常控制的患者和431例（19.8%）收缩压不受控制的患者发生了主要结局事件。常规对照组患者的心血管事件发生率为12.6%，而非对照组患者的心血管事件发生率为19.8%（调整后的风险比[HR]，1.46; 95%置信区间[CI]，1.25-1.71; P<0.001）。然而，在那些通常控制和那些严格控制之间存在的差异不大。他们各自的事件发生率分别为12.6%和12.7%（校正的HR，1.11; 95% CI，0.93-1.32; P= 0.24）。严格控制组的全因死亡率为11.0%，常规控制组为10.2（调整后的HR，1.20; 95% CI，0.99-1.45; P= 0.06）;然而，当包括延长随访时，严格控制组的全因死亡风险为22.8%，而常规控制组为21.8%（调整后的HR，1.15; 95% CI，1.01-1.32; P= 0.04）。与常规控制相比，严格控制糖尿病合并CAD患者的收缩压与心血管结局改善无关。
Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD). To determine the association of systolic BP control achieved and adverse cardiovascular outcomes in a cohort of patients with diabetes and CAD. Observational subgroup analysis of 6400 of the 22 576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003 with an extended follow-up through August 2008 through the National Death Index for US participants. Patients received first-line treatment of either a calcium antagonist or β-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if it ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if it was 140 mm Hg or higher. Adverse cardiovascular outcomes, including the primary outcomes which was the first occurrence of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. During 16 893 patient-years of follow-up, 286 patients (12.7%) who maintained tight control, 249 (12.6%) who had usual control, and 431 (19.8%) who had uncontrolled systolic BP experienced a primary outcome event. Patients in the usual-control group had a cardiovascular event rate of 12.6% vs a 19.8% event rate for those in the uncontrolled group (adjusted hazard ratio [HR], 1.46; 95% confidence interval [CI], 1.25–1.71; P<.001). However, little difference existed between those with usual control and those with tight control. Their respective event rates were 12.6% vs 12.7% (adjusted HR, 1.11; 95% CI, 0.93–1.32; P=.24). The all-cause mortality rate was 11.0% in the tight-control group vs 10.2% in the usual-control group (adjusted HR, 1.20; 95% CI, 0.99–1.45; P=.06); however, when extended follow-up was included, risk of all-cause mortality was 22.8% in the tight control vs 21.8% in the usual control group (adjusted HR, 1.15; 95% CI, 1.01–1.32; P=.04). Tight control of systolic BP among patients with diabetes and CAD was not associated with improved cardiovascular outcomes compared with usual control.
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