Blood pressure lowering and ACE inhibition for the avoidance of cardiac and cerebral events.
Blood pressure lowering and ACE inhibition for the avoidance of cardiac and cerebral events.
复制标题
降低血压和抑制 ACE 以避免心脏和大脑事件。
DOI：
10.1016/s0195-668x(02)00459-1
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发表时间：
2003
影响因子：
39.3
通讯作者：
J. Chalmers
中科院分区：
文献类型：
--
作者：
S. MacMahon;J. Chalmers
现在已经确定，血压水平，无论是收缩压还是舒张压，都是中风和心脏病发作风险的重要决定因素——不仅对高血压患者如此，而且对血压平均或低于平均水平的人也是如此。然而，尽管许多临床试验已经证明降压治疗可以降低高血压患者中风和心脏病发作的风险，但直到最近，关于这种治疗在非高血压患者中的作用的证据还很少。由于许多中风或心脏病发作风险极高的人没有高血压，因此确定降压药对血压处于平均或低于平均水平的高危人群是否有好处是一个相当大的兴趣。这个问题反映了十年前提出的另一个问题，即在胆固醇水平平均或低于平均水平的高危患者中降低血液胆固醇的效果——他汀类药物在冠心病患者中的试验明确回答了这个问题。在过去的两年中，两项主要的试验已经完成，证明了基于ACE抑制剂的方案对高血压或非高血压高危冠状动脉事件或卒中患者的重要益处。心脏结局保护评估（HOPE）研究旨在确定有血管疾病或糖尿病史的个体使用雷米普利治疗的效果。研究结果显示，治疗冠状动脉事件和中风都有明显的好处。培哚普利抗复发性卒中保护研究（PROGRESS）旨在确定在有脑血管病史的个体中，培哚普利与利尿剂吲达帕胺联合使用的方案的效果。这项研究的结果再一次证明了降血压治疗中风的明显益处，正如本期报道的那样，对冠状动脉事件和充血性心力衰竭都有明显的益处。在HOPE和PROGRESS中，卒中和冠心病风险的相对降低幅度大致相似（20-30%），总的来说，这些研究表明，基于ace抑制剂的治疗不仅在主要血管事件的二级预防方面有效，而且在此类事件的一级预防方面也有效，至少在高危患者中是如此。此外，这种对中风和心脏病发作的双重益处的证明，除了抗血小板治疗和他汀类药物之外，还建立了第三类干预措施，可避免高危患者心脑血管的灾难性事件。这三种干预措施同时提供给这些患者，预计将减少一半以上的主要血管事件的风险。HOPE和PROGRESS分别显示高血压和非高血压患者卒中风险显著降低。8,10这与流行病学证据表明血压与中风风险持续相关的预期一致，13-15尽管在HOPE中观察到的风险降低程度略大于对血压的预测
It is now well established that the level of blood pressure, whether systolic or diastolic, is an important determinant of the risks of both stroke and heart attack—not only among those with high blood pressure but also among those with average or below average blood pressure levels. 1 However, while numerous clinical trials have demonstrated that blood pressure lowering treatments reduce the risks of stroke and of heart attack in hypertensives, 2, 3 until recently there has been little evidence about the effects of such therapy in nonhypertensives. Since many individuals at very high risk of stroke or heart attack do not have hypertension, there is a considerable interest in determining whether there are benefits of blood pressure lowering agents for high-risk individuals with average or below average blood pressure levels. This question mirrors another posed a decade ago about the effects of blood cholesterol lowering in high-risk patients with average or below average cholesterol levels—a question answered decisively by trials of statins in patients with coronary heart disease. 4–6 Over the past 2 years, two major trials have been completed that have demonstrated important benefits of ACE inhibitor-based regimens for patients at high risk of coronary events or stroke, whether hypertensive or non-hypertensive. The Heart Outcomes Protection Evaluation (HOPE) study was designed to determine the effects of treatment with ramipril among individuals with a history of vascular disease or diabetes. 7 Its results showed clear benefits of treatment for both coronary events7 and stroke. 8 The Perindopril Protection Against Recurrent Stroke Study (PROGRESS) was designed to determine the effects of a regimen involving perindopril, with the discretionary use of the diuretic, indapamide, among individuals with a history of cerebrovascular disease. 9 Once again, the results of that study demonstrated clear benefits of blood pressure lowering treatment for stroke10 and, as reported in this issue, clear benefits for both coronary events and congestive heart failure. 11 In both HOPE and PROGRESS, the relative reductions in stroke and coronary disease risk were of broadly similar magnitude (20–30%) and, collectively, these studies demonstrate that ACE-inhibitor-based treatment is effective not only in the secondary prevention of major vascular events, but also in the primary prevention of such events, at least among high risk patients. Moreover, the demonstration of this duality of benefits for stroke and heart attack establishes a third category of interventions, in addition to antiplatelet therapy12 and statins, 4–6 that avert catastrophic events in both the cardiac and cerebral vasculature of high risk patients. These three interventions provided concurrently to such patients would be expected to reduce the risks of major vascular events by more than half.Both HOPE and PROGRESS demonstrated separately significant reductions in the risk of stroke among hypertensive and non-hypertensive patients. 8, 10 This is consistent with expectations from epidemiological evidence demonstrating continuous associations of blood pressure with the risk of stroke, 13–15 although the risk reduction observed in HOPE is somewhat larger than that which would have been predicted for the blood pressure