Step for breaking free from clinical inertia
Step for breaking free from clinical inertia
复制标题
摆脱临床惰性的步骤
作者：
H. Rakugi
2021年8月，STEP（两组老年高血压患者血压目标比较）的主要结果发表[1]。STEP是美国SPRINT研究[2]的中国版本，该研究显示了强化治疗的益处。然而，STEP与SPRINT相比有一些显著的差异。STEP包括糖尿病患者（19%），使用标准办公室血压测量，而不是自动办公室血压测量，与家庭血压测量结合使用，比较了可能影响实践行为的应用程序的影响。自2017年以来，美国[3]、欧洲[4]、日本[5]、国际高血压学会[6]和世界卫生组织[7]的多个组织已发布了高血压治疗指南。STEP将对未来高血压治疗指南的修订产生重大影响。STEP研究比较了60-80岁（平均年龄66.3岁）无卒中史的高血压患者合并心血管事件的发生率，分为两组：收缩压110- 129 mmHg组（强化治疗组）和收缩压130- 149 mmHg组（标准治疗组）。该研究比较了强化治疗组和标准治疗组的合并心血管事件的发生率。强化治疗组中3.5%的患者发生心血管事件，与标准治疗组4.6%相比，风险显著降低26%。STEP通过症状和肾功能不全评估血压过度降低的风险，然后确认强化降压治疗的安全性。STEP的这些结果可能需要重新考虑他们的降压目标或年龄类别。由于STEP强化治疗组达到了127.5 mmHg的目标血压，欧洲指南[4]可能会重新考虑删除65-79岁人群中130-139 mmHg的推荐目标血压下限。ISH的指南[6]建议<65岁的患者<130 mmHg，≥65岁的患者<140 mmHg，但可能会重新考虑65岁以上老年人的分离年龄。同样重要的是要注意，STEP受试者的年龄最大为80岁，尚未有研究证明在80岁以上的高血压患者中将血压降至130 mmHg以下的获益和安全性。从老年医学的角度来看，正是在70岁以后，各种器官储备和多器官功能的下降往往会发生。因此，有必要考虑按年龄或替代生物指标分类的血压目标，而不是没有年龄分类的血压目标。日本高血压学会[8]进行的一项系统性综述旨在检查75岁及以上人群的降压目标，发现每项纳入研究中受试者的平均年龄范围为76 - 80岁，比SPRINT的67.9岁和STEP的66.2岁大10岁。在这篇系统性综述中，作者选择了6项随机对照试验。他们对这些试验进行了荟萃分析，以使我们能够检查是否应推荐75岁或以上（一些年龄为70岁或以上）的高血压患者使用比收缩压低于150 mmHg更强化的降压目标。这项荟萃分析显示，更强化的抗高血压治疗对降低心血管和全因死亡率更好，并且没有足够的证据推荐低于130 mmHg。因此，日本指南建议75岁及以上高血压患者的降压目标为小于140 mmHg。此外，日本指南的荟萃分析未能显示积极抗高血压措施对脑血管和心血管事件复合终点的获益（P= 0.13）[8]。我们进行了一项新的荟萃分析，增加了70-80岁年龄组STEP的数据。如图1所示，有 * Hiromi Rakugi rakugi@geriat.med.osaka-u.ac.jp
In August 2021, the main results of STEP, a comparison of blood pressure targets for older hypertensive patients between two groups, were published [1]. STEP is a Chinese version of the US SPRINT study [2], which showed the benefits of intensive treatment. However, STEP has a couple of significant differences compared to SPRINT. STEP included diabetic patients (19%), used standard office blood pressure measurements, not automated office blood pressure measurements, used combination with home blood pressure measurements, compared the influence of apps, which may affect practice behavior. Several organizations have published hypertension treatment guidelines since 2017 from the USA [3], Europe [4], Japan [5], the International Society of Hypertension [6], and WHO [7]. The STEP will have a significant impact on the future revision of the guidelines for the treatment of hypertension. The STEP study compared the incidence of combined cardiovascular events in hypertensive patients aged 60–80 years (mean age 66.3 years) without previous stroke, divided into two groups: the 110–129mmHg systolic blood pressure group (intensive treatment group) and the 130–149mmHg systolic blood pressure group (standard treatment group). The study compared the incidence of combined cardiovascular events in the intensive treatment group and the standard treatment group. Cardiovascular events occurred in 3.5% of patients in the intensive treatment group with a significant risk reduction of 26% compared with 4.6% in the standard treatment group. STEP assessed the risk of excessive blood pressure reduction by symptoms and renal dysfunction, then confirmed the safety of intensive antihypertensive treatment. These results of the STEP may require reconsidering their antihypertensive blood pressure targets or age categories. Since the STEP intensive treatment group achieved a target blood pressure of 127.5 mmHg, the guidelines from Europe [4] may reconsider removing a lower range for target blood pressure of the recommendation of 130–139 mmHg in the 65–79 years. The guidelines from ISH [6] recommend <130 mmHg for <65 years and <140 mmHg for ≥65 years, but may reconsider the age of separation for older people from 65 to higher. It is also important to note that the STEP subjects are up to 80 years of age, and no studies have yet demonstrated the benefit and safety of lowering blood pressure to less than 130 mmHg in hypertensive patients aged over 80 years. From a geriatric point of view, it is precisely after the age of late 70 years that the decline in various organ reserves and multimorbidity often occurs. Therefore it is necessary to consider blood pressure targets classified by age or alternative biological indicators rather than those without age classification. A systematic review by the Japanese Society of Hypertension [8] conducted to examine antihypertensive targets for people aged 75 years, and over found that the mean age of subjects in each included study ranged from 76 to 80 years, about 10 years older than the 67.9 years in SPRINT and 66.2 years in STEP. In this systematic review, the authors selected six randomized controlled trials. They performed a metaanalysis of these trials to enable us to examine, whether a more intensive antihypertensive target than a systolic blood pressure of less than 150mmHg should recommend for hypertensive patients aged 75 years or older (some aged 70 years or older). This meta-analysis showed that more intensive antihypertensive treatment is better for reducing cardiovascular and all-cause mortality, and that there is insufficient evidence to recommend less than 130mmHg. Therefore, the Japanese guidelines recommended an antihypertensive target of less than 140mmHg for hypertensive patients aged 75 years and over. In addition, the metaanalysis for the Japanese guidelines failed to show a benefit of active antihypertensive measures for the composite of cerebral-vascular and cardiovascular events (P= 0.13) [8]. We conducted a new meta-analysis by adding data from STEP in the 70–80 age group. As shown in Fig. 1, there were * Hiromi Rakugi rakugi@geriat.med.osaka-u.ac.jp