Health outcomes associated with antihypertensive therapies used as first-line agents. A systematic review and meta-analysis.
Health outcomes associated with antihypertensive therapies used as first-line agents. A systematic review and meta-analysis.
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DOI：
10.1001/jama.1997.03540330061036
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发表时间：
1997-03
期刊：
影响因子：
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通讯作者：
B. Psaty;N. Smith;D. Siscovick;T. Koepsell;N. Weiss;S. Heckbert;R. Lemaitre;Edward H. Wagner;C. Furberg
中科院分区：
文献类型：
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作者：
B. Psaty;N. Smith;D. Siscovick;T. Koepsell;N. Weiss;S. Heckbert;R. Lemaitre;Edward H. Wagner;C. Furberg
目的回顾各种抗高血压药物作为一线药物的安全性和有效性的科学证据，并根据主要疾病终点进行评价。数据来源：MEDLINE检索和1980年至1995年的既往荟萃分析。资料选择我们选择了长期研究，评估主要疾病终点作为结果。对于荟萃分析，我们选择了安慰剂对照随机试验。对于使用替代终点（如血压）的随机试验，我们选择了评估多种药物的最大研究。在缺乏临床试验证据的情况下，我们依赖于观察性研究的信息。资料综合利尿剂和β受体阻滞剂已在18项长期随机试验中进行了评价。与安慰剂相比，β受体阻滞剂治疗可有效预防卒中（相对风险[RR]，0.71; 95%置信区间[CI]，0.59-0.86）和充血性心力衰竭（RR，0.58; 95% CI，0.40-0.84）。高剂量利尿剂治疗的结果相似（卒中，RR，0.49; 95%CI，0.39-0.62;充血性心力衰竭，RR，0.17; 95%CI，0.07-0.41）。低剂量利尿剂治疗不仅可以预防卒中（RR，0.66; 95%CI，0.55-0.78）和充血性心力衰竭（RR，0.58; 95%CI，0.44-0.76），还可以预防冠心病（RR，0.72; 95%CI，0.61-0.85）和总死亡率（RR，0.90; 95%CI，0.81-0.99）。虽然钙通道阻滞剂和血管紧张素转换酶（ACE）抑制剂可降低高血压患者的血压，但在健康结局方面的临床试验证据很少。对于几种短效二氢吡啶类钙通道阻滞剂，现有证据表明可能存在危害。长效制剂和非二氢吡啶类钙通道阻滞剂是否安全，是否能预防高血压患者的主要心血管事件，尚未得到验证，因此尚不清楚。结论在评价钙通道阻滞剂和ACE抑制剂对心血管疾病发病率影响的大型长期临床试验结果完成之前，现有的科学证据为现行国家指南提供了强有力的支持，该指南建议将利尿剂和β受体阻滞剂作为一线药物，所有降压药物均应采用低剂量治疗。
OBJECTIVE To review the scientific evidence concerning the safety and efficacy of various antihypertensive therapies used as first-line agents and evaluated in terms of major disease end points. DATA SOURCES MEDLINE searches and previous meta-analyses for 1980 to 1995. DATA SELECTION We selected long-term studies that assessed major disease end points as an outcome. For the meta-analysis, we chose placebo-controlled randomized trials. For randomized trials using surrogate end points such as blood pressure, we selected the largest studies that evaluated multiple drugs. Where clinical trial evidence was lacking, we relied on information from observational studies. DATA SYNTHESIS Diuretics and beta-blockers have been evaluated in 18 long-term randomized trials. Compared with placebo, beta-blocker therapy was effective in preventing stroke (relative risk [RR], 0.71; 95% confidence interval [CI], 0.59-0.86) and congestive heart failure (RR, 0.58; 95% CI, 0.40-0.84). The findings were similar for high-dose diuretic therapy (for stroke, RR, 0.49; 95% CI, 0.39-0.62; and for congestive heart failure, RR, 0.17; 95% CI, 0.07-0.41). Low-dose diuretic therapy prevented not only stroke (RR, 0.66; 95% CI, 0.55-0.78) and congestive heart failure (RR, 0.58; 95% CI, 0.44-0.76) but also coronary disease (RR, 0.72; 95% CI, 0.61-0.85) and total mortality (RR, 0.90; 95% CI, 0.81-0.99). Although calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure in hypertensive patients, the clinical trial evidence in terms of health outcomes is meager. For several short-acting dihydropyridine calcium channel blockers, the available evidence suggests the possibility of harm. Whether the long-acting formulations and the nondihydropyridine calcium channel blockers are safe and prevent major cardiovascular events in patients with hypertension remains untested and therefore unknown. CONCLUSION Until the results of large long-term clinical trials evaluating the effects of calcium channel blockers and ACE inhibitors on cardiovascular disease incidence are completed, the available scientific evidence provides strong support for the current national guidelines, which recommend diuretics and beta-blockers as firstline agents and low-dose therapy for all antihypertensive agents.