Makani Harikrishna, Bangalore Sripal, Supariwala Azhar, Romero Jorge, Argulian Edgar, Messerli Franz H
Division of Cardiology, St Luke's Roosevelt Hospital, Columbia University College of Physicians and Surgeons, 1000, 10th Avenue, Suite 3B-30, New York, NY 10019, USA.
New York University School of Medicine, New York, NY, USA.
Eur Heart J. 2014 Jul;35(26):1732-42. doi: 10.1093/eurheartj/eht333. Epub 2013 Aug 21.
Angiotensin receptor blockers (ARBs) are available in different dosages and it is common clinical practice to uptitrate if blood pressure goal is not achieved with the initial dose. Data on the incremental antihypertensive efficacy with uptitration are scarce. It is also unclear if antihypertensive efficacy of losartan is comparable with other ARBs.
We systematically reviewed PubMed/EMBASE/Cochrane databases for all randomized clinical trials until December 2012 reporting 24 h ambulatory blood pressure (ABP) for most commonly available ARBs in patients with hypertension. Reduction in ABP with ARBs was evaluated at 25% of the maximum (max) dose, 50% of the max dose, and at the max dose. Comparison was made between 24 h BP-lowering effect of losartan 50 and 100 mg and other ARBs at 50% max dose and the max dose, respectively. Sixty-two studies enrolling 15 289 patients (mean age 56 years; 60% men) with a mean duration of 10 weeks were included in the analysis. Overall, the dose-response curve with ARBs was shallow with decrease of 10.3/6.7 (systolic/diastolic), 11.7/7.6, and 13.0/8.3 mmHg with 25% max dose, 50% max dose, and with the max dose of ARBs, respectively. Losartan in the dose of 50 mg lowered ABP less well than other ARBs at 50% max dose by 2.5 mmHg systolic (P < 0.0001) and 1.8 mmHg diastolic (P = 0.0003). Losartan 100 mg lowered ABP less well than other ARBs at max dose by 3.9 mm Hg systolic (P = 0.0002) and 2.2 mmHg diastolic (P = 0.002).
In this comprehensive analysis of the antihypertensive efficacy of ARBs by 24 h ABP, we observed a shallow dose-response curve, and uptitration marginally enhanced the antihypertensive efficacy. Blood pressure reduction with losartan at starting dose and at max dose was consistently inferior to the other ARBs.
血管紧张素受体阻滞剂（ARB）有不同剂量，若初始剂量未达到血压目标值，增加剂量是常见的临床做法。关于增加剂量后的降压疗效增量的数据很少。氯沙坦的降压疗效是否与其他ARB相当也不清楚。
我们系统检索了PubMed/EMBASE/Cochrane数据库，纳入截至2012年12月所有报告高血压患者中最常用ARB的24小时动态血压（ABP）的随机临床试验。在最大剂量的25%、50%以及最大剂量时评估ARB降低ABP的情况。分别比较氯沙坦50毫克和100毫克与其他ARB在最大剂量的50%和最大剂量时的24小时降压效果。分析纳入了62项研究，共15289例患者（平均年龄56岁；60%为男性），平均疗程10周。总体而言，ARB的剂量反应曲线较平缓，最大剂量的25%、50%以及最大剂量时收缩压/舒张压分别降低10.3/6.7、11.7/7.6和13.0/8.3 mmHg。50毫克剂量的氯沙坦在最大剂量的50%时降低ABP的效果比其他ARB差，收缩压低2.5 mmHg（P<0.0001），舒张压低1.8 mmHg（P = 0.0003）。100毫克氯沙坦在最大剂量时降低ABP的效果比其他ARB差，收缩压低3.9 mmHg（P = 0.0002），舒张压低2.2 mmHg（P = 0.002）。
在这项通过24小时ABP对ARB降压疗效的综合分析中，我们观察到剂量反应曲线较平缓，增加剂量仅略微增强了降压疗效。氯沙坦起始剂量和最大剂量时的血压降低效果始终低于其他ARB。
