Institut National de la Santé et de la Recherche Médicale, Centre d'Investigations Cliniques-9501, CHU Nancy, Vandoeuvre lès Nancy, France.
Hypertension. 2012 Aug;60(2):339-46. doi: 10.1161/HYPERTENSIONAHA.111.190397. Epub 2012 Jul 9.
Optimal blood pressure (BP) targets are still controversial in end-stage renal disease. Recent data have highlighted shortcomings of the usual BP hypothesis in other patient populations and emphasized the importance of visit-to-visit variability of BP in predicting cardiovascular events. The Fosinopril in Dialysis Study failed to demonstrate the efficacy of 2-year angiotensin-converting enzyme inhibition with fosinopril versus placebo in 397 hemodialysis patients with left ventricular hypertrophy but provided an opportunity to assess the influence of BP variability on cardiovascular events. The primary end point was the occurrence of a composite of cardiovascular death, nonfatal myocardial infarction, unstable angina, stroke, revascularization, hospitalization for heart failure, and resuscitated cardiac arrest. The variations in BP throughout the 17 visits were assessed by within-patient overall variability of systolic, diastolic, and pulse pressures between adjacent readings, by within-patient overall variability of systolic/diastolic/pulse pressures, and the residual of the linear fit. Compared with our previous predictive model of cardiovascular events occurrence based on stroke, peripheral arterial disease, coronary artery disease, diabetes mellitus, left ventricular mass, and age (which exhibited similar coefficients herein), the percentage of explained variance improved by 30.1% (R(2)=0.141-0.183) when adding the coefficient of variation of within-patient overall variability of systolic BP. Usual BP parameters were neither cardiovascular events predictors nor correlated to BP variability. Visit-to-visit BP variability was extremely high in hemodialysis patients compared with other populations and a major determinant of cardiovascular events. Such assessments should be prioritized for testing prevention strategies in end-stage renal disease.
在终末期肾病患者中，最佳血压（BP）目标仍存在争议。最近的数据突显了通常的 BP 假说在其他患者群体中的不足，并强调了 BP 随访间变异性在预测心血管事件中的重要性。福辛普利透析研究未能证明在 397 例左心室肥厚的血液透析患者中，2 年血管紧张素转换酶抑制剂福辛普利与安慰剂相比的疗效，但提供了评估 BP 变异性对心血管事件影响的机会。主要终点是心血管死亡、非致死性心肌梗死、不稳定型心绞痛、卒、血运重建、心力衰竭住院和复苏性心脏骤停的复合发生。通过相邻读数之间的收缩压、舒张压和脉压的患者内总体变异性、收缩压/舒张压/脉压的患者内总体变异性以及线性拟合的残差来评估 17 次随访期间的 BP 变化。与我们之前基于卒、外周动脉疾病、冠心病、糖尿病、左心室质量和年龄的心血管事件发生预测模型相比（在此处表现出相似的系数），当添加收缩压患者内总体变异性变异系数时，解释方差的百分比提高了 30.1%（R²=0.141-0.183）。与 BP 变异性相关的常用 BP 参数既不是心血管事件的预测因子，也与 BP 变异性不相关。与其他人群相比，血液透析患者的随访间 BP 变异性极高，是心血管事件的主要决定因素。此类评估应优先用于测试终末期肾病的预防策略。
