Department of Medicine, NYC Health and Hospitals/Woodhull.
Department of Medicine, SUNY Downstate Medical Center, New York, New York.
J Hypertens. 2018 Jun;36(6):1247-1255. doi: 10.1097/HJH.0000000000001691.
Found in 36-41% of hypertension, elevated left ventricular mass (LVM) independently predicts cardiovascular events and total mortality. Conversely, drug-induced regression of LVM predicts improved outcomes. Previous studies have favored renin-angiotensin system inhibitors (RASIs) over other antihypertensives for reducing LVM but ignored differences among thiazide-type diuretics. From evidence regarding potency, cardiovascular events, and electrolytes, we hypothesized a priori that 'CHIP' diuretics [CHlorthalidone, Indapamide and Potassium-sparing Diuretic/hydrochlorothiazide (PSD/HCTZ)] would rival RASIs for reducing LVM.
Systematic review yielded 12 relevant double-blind randomized trials. CHIPs were more closely associated with reduced LVM than HCTZ (P = 0.004), indicating that RASIs must be compared with each diuretic separately. Publication bias favoring RASIs was corrected by cumulative analysis. For reducing LVM, HCTZ tended to be less effective than RASIs. However, the following surpassed RASIs: chlorthalidone Hedge's G: -0.37 (95% CI -0.72 to -0.02), P = 0.036; indapamide -0.20 (-0.39 to -0.01), P = 0.035; all CHIPs combined (with 61% of patients in one trial) -0.25 (-0.41to -0.09), P = 0.002. Statistical significance (P < 0.05) did not depend on any one trial. CHIPs reduction in LVM was 37% greater than that from RASIs. CHIPs superiority tended to increase with trial duration, from a negligible effect at 0.5 year to a maximal effect at 0.9-1.0 years: -0.26 (-0.43 to -0.09), P = 0.003. Fifty-eight percent of patients had information on echocardiographic components of LVM: relative to RASIs, CHIPs significantly reduced end-diastolic LV internal dimension (EDLVID): -0.18 (-0.36 to -0.00), P = 0.046. Strength of evidence favoring CHIPs over RASIs was at least moderate.
In these novel results in patients with hypertension, CHIPs surpassed RASIs for reducing LVM and EDLVID.
在 36-41%的高血压患者中，左心室质量（LVM）升高独立预测心血管事件和全因死亡率。相反，药物诱导的 LVM 消退可预测改善结局。先前的研究倾向于使用肾素-血管紧张素系统抑制剂（RASI）而非其他降压药来降低 LVM，但忽略了噻嗪类利尿剂之间的差异。根据关于效力、心血管事件和电解质的证据，我们假设，“CHIP”利尿剂[氯噻酮、吲达帕胺和保钾利尿剂/氢氯噻嗪（PSD/HCTZ）]将与 RASI 一样能降低 LVM。
系统评价产生了 12 项相关的双盲随机试验。CHIP 与 LVM 降低的相关性更密切（P=0.004），这表明必须单独比较 RASI 与每种利尿剂。通过累积分析纠正了有利于 RASI 的发表偏倚。在降低 LVM 方面，HCTZ 的效果似乎不如 RASI。然而，以下药物优于 RASI：氯噻酮 Hedge's G：-0.37（95%CI -0.72 至 -0.02），P=0.036；吲达帕胺-0.20（-0.39 至 -0.01），P=0.035；所有 CHIP 联合（一项试验中有 61%的患者）-0.25（-0.41 至 -0.09），P=0.002。统计学意义（P<0.05）不依赖于任何一项试验。CHIP 降低 LVM 的幅度比 RASI 高 37%。CHIP 的优势似乎随试验持续时间的增加而增加，从 0.5 年时的微不足道的效果增加到 0.9-1.0 年时的最大效果：-0.26（-0.43 至 -0.09），P=0.003。58%的患者有关于 LVM 超声心动图成分的信息：与 RASI 相比，CHIP 显著降低舒张末期左室内径（EDLVID）：-0.18（-0.36 至 -0.00），P=0.046。支持 CHIP 优于 RASI 的证据强度至少为中度。
在这些高血压患者的新结果中，CHIP 降低 LVM 和 EDLVID 的效果优于 RASI。
