Fagard Robert H, Staessen Jan A, Thijs Lutgarde, Celis Hilde, Bulpitt Christopher J, de Leeuw Peter W, Leonetti Gastone, Tuomilehto Jaakko, Yodfat Yair
Hypertension and Cardiovascular Rehabilitation Unit, University of Leuven, B-3000 Leuven, Belgium.
Arch Intern Med. 2007 Sep 24;167(17):1884-91. doi: 10.1001/archinte.167.17.1884.
It has been suggested that low diastolic blood pressure (BP) while receiving antihypertensive treatment (hereinafter called on-treatment BP) is harmful in older patients with systolic hypertension. We examined the association between on-treatment diastolic BP, mortality, and cardiovascular events in the prospective placebo-controlled Systolic Hypertension in Europe Trial.
Elderly patients with systolic hypertension were randomized into the double-blind first phase of the trial, after which all patients received active study drugs (phase 2). We assessed the relationship between outcome and on-treatment diastolic BP by use of multivariate Cox regression analysis during receipt of placebo (phase 1) and during active treatment (phases 1 and 2).
Rates of noncardiovascular mortality, cardiovascular mortality, and cardiovascular events were 11.1, 12.0, and 29.4, respectively, per 1000 patient-years with active treatment (n = 2358) and 11.9, 12.6, and 39.0, respectively, with placebo (n = 2225). Noncardiovascular mortality, but not cardiovascular mortality, increased with low diastolic BP with active treatment (P < .005) and with placebo (P < .05); for example, hazard ratios for lower diastolic BP, that is, 65 to 60 mm Hg, were, respectively, 1.15 (95% confidence interval, 1.00-1.31) and 1.28 (95% confidence interval, 1.03-1.59). Low diastolic BP with active treatment was associated with increased risk of cardiovascular events, but only in patients with coronary heart disease at baseline (P < .02; hazard ratio for BP 65-60 mm Hg, 1.17; 95% confidence interval, 0.98-1.38).
These findings support the hypothesis that antihypertensive treatment can be intensified to prevent cardiovascular events when systolic BP is not under control in older patients with systolic hypertension, at least until diastolic BP reaches 55 mm Hg. However, a prudent approach is warranted in patients with concomitant coronary heart disease, in whom diastolic BP should probably not be lowered to less than 70 mm Hg.
有观点认为，老年收缩期高血压患者在接受抗高血压治疗时（以下简称治疗期间血压）舒张压过低是有害的。我们在欧洲收缩期高血压前瞻性安慰剂对照试验中研究了治疗期间舒张压与死亡率及心血管事件之间的关联。
老年收缩期高血压患者被随机分配至试验的双盲第一阶段，之后所有患者均接受活性研究药物治疗（第二阶段）。我们在接受安慰剂治疗期间（第一阶段）以及活性治疗期间（第一和第二阶段），使用多变量Cox回归分析评估结局与治疗期间舒张压之间的关系。
在接受活性治疗的患者中（n = 2358），每1000患者年的非心血管死亡率、心血管死亡率和心血管事件发生率分别为11.1、12.0和29.4；在接受安慰剂治疗的患者中（n = 2225），相应发生率分别为11.9、12.6和39.0。在活性治疗和安慰剂治疗中，非心血管死亡率均随舒张压降低而增加（活性治疗组P <.005，安慰剂组P <.05）；例如，舒张压较低时，即65至60 mmHg，风险比分别为1.15（95%置信区间，1.00 - 1.31）和1.28（95%置信区间，1.03 - 1.59）。活性治疗时舒张压过低与心血管事件风险增加相关，但仅在基线患有冠心病的患者中如此（P <.02；血压65 - 60 mmHg时的风险比为1.17；95%置信区间，0.98 - 1.38）。
这些发现支持以下假设，即对于老年收缩期高血压患者，当收缩压未得到控制时，可强化抗高血压治疗以预防心血管事件，至少直到舒张压降至55 mmHg。然而，对于合并冠心病的患者，应采取谨慎的方法，其舒张压可能不应降至低于70 mmHg。
