冠心病患者的心肌梗死和中风与收缩压和舒张压变化的关系。

Systolic and diastolic blood pressure changes in relation with myocardial infarction and stroke in patients with coronary artery disease.

机构信息

From the Department of Medicine, Hospital of Assisi, Assisi, Italy (P.V.); Department of Medicine (G.R.) and Department of Cardiology and Cardiovascular Pathophysiology (F.A.), University Hospital of Perugia, Perugia, Italy; Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University 'Federico II', Naples, Italy (B.T.); Department of Health Sciences, University of Milano-Bicocca and IRCCS Istituto Auxologico Italiano, Milano, Italy (G.M.); Department of Clinical Epidemiology and Biostatistics and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (J.P., P.G., K.T., S.Y.); and Department of Cardiovascular Medicine, John Radcliffe Hospital, Oxford, United Kingdom (P.S.).

出版信息

Hypertension. 2015 Jan;65(1):108-14. doi: 10.1161/HYPERTENSIONAHA.114.04310. Epub 2014 Oct 20.

DOI:10.1161/HYPERTENSIONAHA.114.04310

PMID:25331850

Abstract

UNLABELLED

Excessively high and low achieved blood pressure (BP) may be associated with a bad outcome in patients with coronary artery disease, the J curve phenomenon. The effect of BP changes from baseline in relation with the subsequent risk of stroke and myocardial infarction (MI) is unknown. Of the 25 620 patients randomized in the Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study, we selected 19 102 patients with coronary artery disease at baseline. BP at entry was 141/82 mm Hg, and its average decrease during follow-up was 7/6 mm Hg. BP entered the analysis as time-varying variable modeled with restricted cubic splines. After adjustment for several potential determinants of reverse causality, a change in BP from baseline by -34/-21 mm Hg (10th percentile) was associated with a lesser risk of stroke without any significant increase in the risk of MI. A rise in systolic/diastolic BP from baseline by 20/10 mm Hg (90th percentile) was associated with an increased risk of stroke, whereas the risk of MI increased with systolic BP and not with diastolic BP. In conclusion, in patients with coronary artery disease and initially free from congestive heart failure, a BP reduction from baseline over the examined BP range had little effect on the risk of MI and predicted a lower risk of stroke. An increase in systolic BP from baseline increased the risk of stroke and MI. The relationships of BP with risk were much steeper for stroke than for MI. A treatment-induced BP reduction over the explored range seems to be safe in patients with coronary artery disease.

CLINICAL TRIAL REGISTRATION URL

http://www.clinicaltrials.gov. Unique identifier: NCT00153101.

摘要

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在患有冠状动脉疾病的患者中，血压（BP）过高或过低可能与不良预后相关，即 J 曲线现象。BP 从基线的变化与随后发生中风和心肌梗死（MI）的风险之间的关系尚不清楚。在 Ongoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial（ONTARGET）研究中，我们从 25620 名随机患者中选择了 19102 名基线时患有冠状动脉疾病的患者。入院时的 BP 为 141/82mmHg，随访期间平均下降 7/6mmHg。BP 作为时变变量进入分析，采用限制立方样条建模。在调整了几个潜在的逆因果关系决定因素后，与基线相比，BP 下降-34/-21mmHg（第 10 百分位数）与中风风险降低相关，而 MI 风险没有显著增加。与基线相比，收缩压/舒张压升高 20/10mmHg（第 90 百分位数）与中风风险增加相关，而 MI 风险随收缩压增加而增加，与舒张压无关。总之，在基线时无充血性心力衰竭的冠状动脉疾病患者中，BP 从基线的降低在检查的 BP 范围内对 MI 风险几乎没有影响，并且预测中风风险较低。收缩压从基线的升高增加了中风和 MI 的风险。BP 与风险的关系对于中风比 MI 更为陡峭。在冠状动脉疾病患者中，在探索的 BP 范围内进行降压治疗似乎是安全的。