Response by Itoga et al to Letter Regarding Article, "Association of Blood Pressure Measurements With Peripheral Arterial Disease Events".
Response by Itoga et al to Letter Regarding Article, "Association of Blood Pressure Measurements With Peripheral Arterial Disease Events".
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Itoga 等人对有关文章“血压测量与外周动脉疾病事件的关联”的信件的回应。
DOI：
10.1161/circulationaha.119.039293
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发表时间：
2019
期刊：
影响因子：
37.8
通讯作者：
Chang,TaraI
中科院分区：
文献类型：
--
作者：
Itoga,NathanK;Tawfik,DanielS;Leeper,NicholasJ;Chang,TaraI
我们感谢梅瑟利和班加罗尔博士使用ALLHAT(抗高血压和降脂治疗预防心脏病试验)数据对血压和外周动脉疾病(PAD)事件进行分析的兴趣。1他们提到了对使用β阻滞剂治疗可能加剧PAD的担忧。目前的临床实践指南不建议优先使用(或避免)任何特定类别的降压药来降低患有高血压和PAD的成人患者的血压，2，3包括β阻滞剂，但确实注意到血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂在这一人群中减少心血管事件的有效性。很少有临床试验比较β阻滞剂和其他降压药类别来具体检查PAD事件。2013年对6项随机临床试验进行的荟萃分析发现，没有证据表明β阻滞剂会加重PAD的症状，如跛行或最大步行距离，尽管纳入的研究通常被确定为低质量。4为了更好地阐明这一主题，梅瑟利和班加罗尔博士建议使用ALLHAT的数据分析阿替洛尔在PAD事件中的使用情况。在ALLHAT中，如果参与者不能通过分配的随机药物达到目标血压，那么他们可以由治疗医生酌情给予≥1开放标签药物。阿替洛尔、可乐定和利血平是该研究提供的二线开放标签药物，在我们的分析队列中，34.4%的人在随访期间记录了阿替洛尔的使用情况。该研究方案还允许使用其他开放标签的降压药物，包括除阿替洛尔外的其他β阻滞剂。直到1996年(研究登记开始2年后)，修订后的研究方案才开始要求说明使用了哪些类别的开放标签药物(如果有的话)，但这一变量几乎完全没有出现在公开可用的ALLHAT数据集中。考虑到研究队列中有50%的人在基线时患有动脉粥样硬化性心血管疾病，而且在随访期间还有数千名参与者经历了冠心病事件，我们假设许多参与者很有可能使用了除阿替洛尔之外的未记录的β阻滞剂。由于对不完整数据的担忧，以及在试验随访期间缺乏关于开始和停药的具体时间的详细信息，我们选择在分析中不包括随访期间的用药情况。
We appreciate the interest of Drs Messerli and Bangalore in our analysis of blood pressure and peripheral artery disease (PAD) events using data from ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial). 1 They cite concerns that treatment with β-blockers could exacerbate PAD. Current clinical practice guidelines do not recommend the preferential use (or avoidance) of any particular class of antihypertensive medication to lower blood pressure in adults with hypertension and PAD, 2, 3 including β-blockers, but do note the effectiveness of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers to reduce cardiovascular events in this population.There are few clinical trials comparing β-blockers with other antihypertensive medication classes to examine PAD events specifically. A 2013 meta-analysis of 6 randomized, clinical trials found no evidence that β-blockers worsened symptoms of PAD, such as claudication or maximal walking distance, although the included studies were generally determined to be of low quality. 4 To shed more light on this topic, Drs Messerli and Bangalore suggest an analysis examining atenolol use with PAD events using data from ALLHAT. In ALLHAT, if participants were not able to achieve the target blood pressure with the assigned randomization drug, then they could be given≥ 1 open-label medications at the discretion of the treating physician. Atenolol, clonidine, and reserpine were the second-line open-label medications provided by the study, and 34.4% of the cohort in our analysis had documented use of atenolol during follow-up. The study protocol also allowed the use of other open-label antihypertensive medications, including other β-blockers besides atenolol. Only beginning in 1996 (2 years after study enrollment began) did the revised study protocol begin to request specification of which classes of open-label medications were used (if any), but this variable is almost entirely missing from the publically available ALLHAT data set. Given that> 50% of the study cohort had atherosclerotic cardiovascular disease at baseline and that several thousand more participants experienced a coronary heart disease event during follow-up, we posit a high likelihood that many participants may have had undocumented use of β-blockers other than atenolol. With these concerns about incomplete data, as well as a lack of detailed information on specific timing of medication initiation and discontinuation during trial follow-up, we chose not to include medication use during follow-up in our analysis.