Impact of increased heart rate on clinical outcomes in hypertension - Implications for antihypertensive drug therapy
Impact of increased heart rate on clinical outcomes in hypertension - Implications for antihypertensive drug therapy
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DOI：
10.2165/00003495-200666020-00001
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发表时间：
2006-01-01
期刊：
影响因子：
11.5
通讯作者：
Julius, S
中科院分区：
文献类型：
--
作者：
Palatini, P;Benetos, A;Julius, S
到目前为止，已经发表了38项关于心率升高和死亡率之间关系的研究。在调整了其他风险因素后，只有两项关于全原因死亡率的研究和四项关于心血管死亡率的研究报告称，男性人群的心率和死亡率之间没有关联。研究发现，这种关系在女性中普遍较弱。这些研究大多调查了普通人群的样本。在高血压男性中进行的四项研究发现，心率与全原因死亡率(风险比从1.9到2.0)或心血管死亡率(风险比从1.3到1.7)呈正相关。尽管有这些证据，心率升高在两个性别中仍然是一个被忽视的心血管危险因素。许多研究也阐明了高心率、高血压、动脉粥样硬化和心血管事件的发病机制。心率加快是由于交感神经张力增加而副交感神经张力降低。这种自主神经系统张力平衡的改变可以解释为什么心率增加会增加事件的发生。然而，与高心率相关的血流变化也被证明有利于动脉粥样硬化病变的形成和心血管事件的发生。心率加快的高血压患者的心率减慢可能是抗高血压治疗的另一个目标。一些试验回顾表明，心脏减慢药物，如P-肾上腺素能受体拮抗剂(β-阻滞剂)和非二氢吡啶钙通道拮抗剂，对死亡率有好处，尤其是在患有冠心病的患者中，但没有公布的数据适用于没有冠心病的高血压患者。其他已被证明可以降低心率的抗高血压药物是中枢作用药物和血管紧张素受体拮抗剂，但它们的减慢作用相当弱。F-通道拮抗剂伊夫拉定是一种选择性降心率药物，对血压没有影响。尽管目前的试验还没有证实这一点，但对于心率高于每分钟80-85次的高血压患者，推荐使用降压药似乎是合理的。由于快心率本身会导致心血管损害，所有降低心率的药物都有可能进一步减少心率升高患者的心血管事件。不幸的是，降低心率并不是临床公认的目标。有必要进行前瞻性试验，调查高心率治疗是否可以预防心血管事件，尤其是高血压患者。
Thirty-eight studies have been published to date on the association between elevated heart rate and mortality. After adjustment for other risk factors, only two studies for all-cause mortality and four studies for cardiovascular mortality reported an absence of association between heart rate and mortality in male populations. This relationship has been found to be generally weaker among females. Most of these studies investigated samples of general populations. The four studies performed in hypertensive men found a positive association between heart rate and all-cause mortality (hazard ratios ranging from 1.9 to 2.0) or cardiovascular mortality (hazard ratios ranging from 1.3 to 1.7). In spite of this evidence, elevated heart rate remains a neglected cardiovascular risk factor in both genders.The pathogenetic mechanisms connecting high heart rate, hypertension, atherosclerosis and cardiovascular events have also been explicated in many studies. Elevated heart rate is due to an increased sympathetic and decreased parasympathetic tone. This altered balance of the autonomic nervous system tone could explain the increase in events with the increased heart rate. However, it has also been proved that blood flow changes associated with high heart rate favour both the formation of the atherosclerotic lesion and the occurrence of the cardiovascular event.Reduction of heart rate in hypertensive patients with increased heart rate could be an additional goal of antihypertensive therapy. Several trials retrospectively showed the beneficial effect of cardiac-slowing drugs, such as P-adrenoceptor antagonists (beta-blockers) and non-dihydropyridine calcium channel antagonists, on mortality, notably in patients with coronary heart disease, but no published data are available in patients with hypertension free of coronary heart disease. Other antihypertensive drugs that have been shown to reduce the heart rate are centrally acting drugs and angiotensin It receptor antagonists, but their bradycardic effect is rather weak. The f-channel antagonist ivabradine is a selective heart rate-lowering agent with no effect on blood pressure.Although it has not been proven in existing trials, it would seem reasonable to recommend anti hypertensive agents that decrease the heart rate in hypertensive patients with a heart rate higher than 80-85 beats per minute. Since the fast heart rate per se causes cardiovascular damage, all drugs that lower the heart rate have the potential of further reducing cardiovascular events in patients with elevated heart rate. Unfortunately, lowering of the heart rate is not a clinically recognised goal. Prospective trials investigating whether treatment of high heart rate can prevent cardiovascular events, notably in hypertensive patients, are warranted.