Wright Jackson T, Harris-Haywood Sonja, Pressel Sara, Barzilay Joshua, Baimbridge Charles, Bareis Charles J, Basile Jan N, Black Henry R, Dart Richard, Gupta Alok K, Hamilton Bruce P, Einhorn Paula T, Haywood L Julian, Jafri Syed Z A, Louis Gail T, Whelton Paul K, Scott Cranford L, Simmons Debra L, Stanford Carol, Davis Barry R
Department of Medicine, General Clinical Research Center, Cleveland, Ohio, USA.
Arch Intern Med. 2008 Jan 28;168(2):207-17. doi: 10.1001/archinternmed.2007.66.
Antihypertensive drugs with favorable metabolic effects are advocated for first-line therapy in hypertensive patients with metabolic/cardiometabolic syndrome (MetS). We compared outcomes by race in hypertensive individuals with and without MetS treated with a thiazide-type diuretic (chlorthalidone), a calcium channel blocker (amlodipine besylate), an alpha-blocker (doxazosin mesylate), or an angiotensin-converting enzyme inhibitor (lisinopril).
A subgroup analysis of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind hypertension treatment trial of 42 418 participants. We defined MetS as hypertension plus at least 2 of the following: fasting serum glucose level of at least 100 mg/dL, body mass index (calculated as weight in kilograms divided by height in meters squared) of at least 30, fasting triglyceride levels of at least 150 mg/dL, and high-density lipoprotein cholesterol levels of less than 40 mg/dL in men or less than 50 mg/dL in women.
Significantly higher rates of heart failure were consistent across all treatment comparisons in those with MetS. Relative risks (RRs) were 1.50 (95% confidence interval, 1.18-1.90), 1.49 (1.17-1.90), and 1.88 (1.42-2.47) in black participants and 1.25 (1.06-1.47), 1.20 (1.01-1.41), and 1.82 (1.51-2.19) in nonblack participants for amlodipine, lisinopril, and doxazosin comparisons with chlorthalidone, respectively. Higher rates for combined cardiovascular disease were observed with lisinopril-chlorthalidone (RRs, 1.24 [1.09-1.40] and 1.10 [1.02-1.19], respectively) and doxazosin-chlorthalidone comparisons (RRs, 1.37 [1.19-1.58] and 1.18 [1.08-1.30], respectively) in black and nonblack participants with MetS. Higher rates of stroke were seen in black participants only (RR, 1.37 [1.07-1.76] for the lisinopril-chlorthalidone comparison, and RR, 1.49 [1.09-2.03] for the doxazosin-chlorthalidone comparison). Black patients with MetS also had higher rates of end-stage renal disease (RR, 1.70 [1.13-2.55]) with lisinopril compared with chlorthalidone.
The ALLHAT findings fail to support the preference for calcium channel blockers, alpha-blockers, or angiotensin-converting enzyme inhibitors compared with thiazide-type diuretics in patients with the MetS, despite their more favorable metabolic profiles. This was particularly true for black participants.
对于患有代谢/心脏代谢综合征（MetS）的高血压患者，提倡使用具有良好代谢效应的抗高血压药物进行一线治疗。我们比较了使用噻嗪类利尿剂（氯噻酮）、钙通道阻滞剂（苯磺酸氨氯地平）、α受体阻滞剂（甲磺酸多沙唑嗪）或血管紧张素转换酶抑制剂（赖诺普利）治疗的伴有和不伴有MetS的高血压个体按种族划分的治疗结果。
对“抗高血压和降脂治疗预防心脏病发作试验”（ALLHAT）进行亚组分析，这是一项针对42418名参与者的随机、双盲高血压治疗试验。我们将MetS定义为高血压加上以下至少两项：空腹血清葡萄糖水平至少100mg/dL、体重指数（按千克体重除以身高米的平方计算）至少30、空腹甘油三酯水平至少150mg/dL，以及男性高密度脂蛋白胆固醇水平低于40mg/dL或女性低于50mg/dL。
在所有治疗比较中，患有MetS的患者心力衰竭发生率均显著更高。在黑人参与者中，与氯噻酮相比，氨氯地平、赖诺普利和多沙唑嗪的相对风险（RR）分别为1.50（95%置信区间，1.18 - 1.90）、1.49（1.17 - 1.90）和1.88（1.42 - 2.47）；在非黑人参与者中，相应的RR分别为1.25（1.06 - 1.47）、1.20（1.01 - 1.41）和1.82（1.51 - 2.19）。在患有MetS的黑人和非黑人参与者中，赖诺普利 - 氯噻酮（RR分别为1.24[1.09 - 1.40]和1.10[1.02 - 1.19]）以及多沙唑嗪 - 氯噻酮比较（RR分别为1.37[1.19 - 1.58]和1.18[1.08 - 1.30]）时，心血管疾病合并发生率更高。仅在黑人参与者中观察到中风发生率更高（赖诺普利 - 氯噻酮比较的RR为1.37[1.07 - 1.76]，多沙唑嗪 - 氯噻酮比较的RR为1.49[1.09 - 2.03]）。与氯噻酮相比，患有MetS的黑人患者使用赖诺普利时终末期肾病发生率也更高（RR为1.70[1.13 - 2.55]）。
ALLHAT研究结果不支持在患有MetS的患者中，相较于噻嗪类利尿剂，更倾向于使用钙通道阻滞剂、α受体阻滞剂或血管紧张素转换酶抑制剂，尽管它们具有更有利的代谢特征。对于黑人参与者尤其如此。
