高血压合并冠状动脉疾病患者的脉压与心血管事件风险：一项国际维拉帕米缓释片 - 群多普利研究（INVEST）分析
Pulse pressure and risk of cardiovascular outcomes in patients with hypertension and coronary artery disease: an INternational VErapamil SR-trandolapril STudy (INVEST) analysis.
作者信息
Bangalore Sripal, Messerli Franz H, Franklin Stanley S, Mancia Giuseppe, Champion Annette, Pepine Carl J
机构信息
Division of Cardiology, Department of Medicine, Columbia University College of Physicians and Surgeons, St. Luke's-Roosevelt Hospital Center, 1000 Tenth Avenue, Suite 3B-30, New York, NY 10025, USA.
出版信息
Eur Heart J. 2009 Jun;30(11):1395-401. doi: 10.1093/eurheartj/ehp109. Epub 2009 Apr 7.
AIM
The purpose of this study was to assess the relationship between pulse pressure (PP) and cardiovascular outcomes in a large, elderly, coronary artery disease (CAD) population with hypertension, and compare the predictive power of PP with other blood pressure measures.
METHODS AND RESULTS
In INternational VErapamil-trandolapril STudy, 22,576 CAD patients with hypertension (mean age 66 years) were randomized to verapamil-SR or atenolol-based strategies and followed for 2.7 years (mean). Primary outcome (PO) was time to first occurrence of death (all-cause), non-fatal myocardial infarction (MI), or non-fatal stroke. Mean follow-up PP was summarized by 5 mmHg subgroups for association with incidence of PO. Stepwise Cox proportional hazards models were used to estimate adjusted relative hazard ratios (HR) for the risk of PO with follow-up PP as a continuous variable, with linear and quadratic terms. Similar models were constructed for follow-up systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressures (MAP). A -2 log-likelihood statistic was used to assess the predictive power of PP compared with SBP, DBP, and MAP. For follow-up PP, the incidence and adjusted HR for the PO formed a J- or U-shaped curve. After adjusting for baseline covariates, both linear and quadratic terms for PP were significant (P < 0.0001 for both), with a nadir of 54 mmHg (bootstrapping 95% CI 42-60 mmHg). Similar quadratic relationships were found between PP and all-cause mortality or MI; the relationship between PP and stroke was linear. Pulse pressure was a predictor of PO even after including SBP (P = 0.007 linear term) or DBP (P < 0.0001 for both linear and quadratic terms) or MAP (P < 0.01 for both liner and quadratic terms) in the model. Using -2 log-likelihood differences, SBP (-2 log-likelihood difference 77.1 vs. 7.3 for PP), DBP (-2 log-likelihood difference 138.5 vs. 44.6 for PP), and MAP (-2 log-likelihood difference 125.0 vs. 13.4 for PP) were stronger predictors of PO than PP.
CONCLUSION
In CAD patients with hypertension, PP (on anti-hypertensive treatment) is a weaker predictor of cardiovascular outcomes than SBP, DBP, or MAP.
目的
本研究旨在评估在患有高血压的大型老年冠状动脉疾病（CAD）人群中脉压（PP）与心血管结局之间的关系，并比较PP与其他血压指标的预测能力。
方法与结果
在国际维拉帕米 - 群多普利研究中，22576例患有高血压的CAD患者（平均年龄66岁）被随机分为维拉帕米缓释制剂组或阿替洛尔治疗组，并随访2.7年（平均）。主要结局（PO）为首次发生死亡（全因）、非致死性心肌梗死（MI）或非致死性卒中的时间。平均随访PP按5 mmHg亚组进行汇总，以分析与PO发生率的关联。采用逐步Cox比例风险模型，将随访PP作为连续变量，通过线性和二次项来估计PO风险的调整相对风险比（HR）。对随访收缩压（SBP）、舒张压（DBP）和平均动脉压（MAP）构建类似模型。使用-2对数似然统计量评估PP与SBP、DBP和MAP相比的预测能力。对于随访PP，PO的发生率和调整后的HR形成J形或U形曲线。在调整基线协变量后，PP的线性和二次项均具有显著性（两者P均<0.0001），最低点为54 mmHg（自抽样95% CI 42 - 60 mmHg）。在PP与全因死亡率或MI之间发现了类似的二次关系；PP与卒中之间的关系为线性。即使在模型中纳入SBP（线性项P = 0.007）或DBP（线性和二次项P均<0.0001）或MAP（线性和二次项P均<0.01）后，脉压仍是PO的预测指标。使用-2对数似然差异，SBP（-2对数似然差异77.1对比PP的7.3）、DBP（-2对数似然差异138.5对比PP的44.6）和MAP（-2对数似然差异125.0对比PP的13.4）对PO的预测能力比PP更强。
结论
在患有高血压的CAD患者中，PP（在抗高血压治疗中）对心血管结局的预测能力比SBP、DBP或MAP弱。
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