SPRINT 试验后最佳收缩压目标：来自随机试验网络荟萃分析的见解
Optimal Systolic Blood Pressure Target After SPRINT: Insights from a Network Meta-Analysis of Randomized Trials.
作者信息
Bangalore Sripal, Toklu Bora, Gianos Eugenia, Schwartzbard Arthur, Weintraub Howard, Ogedegbe Gbenga, Messerli Franz H
机构信息
Division of Cardiology, New York University School of Medicine, New York, NY.
Division of Cardiology, Mount Sinai Beth Israel Medical Center, New York, NY.
出版信息
Am J Med. 2017 Jun;130(6):707-719.e8. doi: 10.1016/j.amjmed.2017.01.004. Epub 2017 Jan 19.
BACKGROUND
The optimal on-treatment blood pressure (BP) target has been a matter of debate. The recent SPRINT trial showed significant benefits of a BP target of <120 mm Hg, albeit with an increase in serious adverse effects related to low BP.
METHODS
PubMed, EMBASE, and CENTRAL were searched for randomized trials comparing treating with different BP targets. Trial arms were grouped into 5 systolic BP target categories: 1) <160 mm Hg, 2) <150 mm Hg, 3) <140 mm Hg, 4) <130 mm Hg, and 5) <120 mm Hg. Efficacy outcomes of stroke, myocardial infarction, death, cardiovascular death, heart failure, and safety outcomes of serious adverse effects were evaluated using a network meta-analysis.
RESULTS
Seventeen trials that enrolled 55,163 patients with 204,103 patient-years of follow-up were included. There was a significant decrease in stroke (rate ratio [RR] 0.54; 95% confidence interval [CI], 0.29-1.00) and myocardial infarction (RR 0.68; 95% CI, 0.47-1.00) with systolic BP <120 mm Hg (vs <160 mm Hg). Sensitivity analysis using achieved systolic BP showed a 72%, 97%, and 227% increase in stroke with systolic BP of <140 mm Hg, <150 mm Hg, and <160 mm, respectively, when compared with systolic BP <120 mm Hg. There was no difference in death, cardiovascular death, or heart failure when comparing any of the BP targets. However, the point estimate favored lower BP targets (<120 mm Hg, <130 mm Hg) when compared with higher BP targets (<140 mm Hg or <150 mm Hg). BP targets of <120 mm Hg and <130 mm Hg ranked #1 and #2, respectively, as the most efficacious target. There was a significant increase in serious adverse effects with systolic BP <120 mm Hg vs <150 mm Hg (RR 1.83; 95% CI, 1.05-3.20) or vs <140 mm Hg (RR 2.12; 95% CI, 1.46-3.08). BP targets of <140 mm Hg and <150 mm Hg ranked #1 and #2, respectively, as the safest target for the outcome of serious adverse effects. Cluster plots for combined efficacy and safety showed that a systolic BP target of <130 mm Hg had optimal balance between efficacy and safety.
CONCLUSIONS
In patients with hypertension, a on-treatment systolic BP target of <130 mm Hg achieved optimal balance between efficacy and safety.
背景
治疗期间的最佳血压（BP）目标一直存在争议。近期的收缩压干预试验（SPRINT）表明，血压目标<120 mmHg有显著益处，尽管与低血压相关的严重不良反应有所增加。
方法
检索PubMed、EMBASE和CENTRAL以查找比较不同血压目标治疗的随机试验。试验组分为5个收缩压目标类别：1）<160 mmHg，2）<150 mmHg，3）<140 mmHg，4）<130 mmHg，5）<120 mmHg。使用网状Meta分析评估中风、心肌梗死、死亡、心血管死亡、心力衰竭的疗效结局以及严重不良反应的安全性结局。
结果
纳入了17项试验，共55163例患者，随访204103患者年。收缩压<120 mmHg（对比<160 mmHg）时，中风（率比[RR] 0.54；95%置信区间[CI]，0.29 - 1.00）和心肌梗死（RR 0.68；95% CI，0.47 - 1.00）显著减少。使用实际收缩压进行的敏感性分析显示，与收缩压<120 mmHg相比，收缩压<140 mmHg、<150 mmHg和<160 mmHg时中风分别增加72%、97%和227%。比较任何血压目标时，死亡、心血管死亡或心力衰竭无差异。然而与较高血压目标（<140 mmHg或<150 mmHg）相比，点估计值更倾向于较低血压目标（<120 mmHg，<130 mmHg）。收缩压<120 mmHg和<130 mmHg分别位列最有效目标的第1和第2位。收缩压<120 mmHg对比<150 mmHg（RR 1.83；95% CI，1.05 - 3.20）或对比<140 mmHg（RR 2.12；95% CI，1.46 - 3.08）时，严重不良反应显著增加。收缩压<140 mmHg和<150 mmHg分别位列严重不良反应结局最安全目标的第1和第2位。综合疗效和安全性的聚类图显示，收缩压目标<130 mmHg在疗效和安全性之间达到了最佳平衡。
结论
在高血压患者中，治疗期间收缩压目标<130 mmHg在疗效和安全性之间达到了最佳平衡。
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