Hypertension Unit, Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy.
IRCCS Neuromed, Pozzilli, IS, Italy.
Curr Hypertens Rep. 2019 Oct 10;21(11):85. doi: 10.1007/s11906-019-0991-2.
Essential hypertension is the main determinant of cardiovascular morbidity and mortality worldwide. During the last decades, several antihypertensive drug therapies have been introduced and tested in clinical trials, both as monotherapies and combination therapies. The current recommended therapeutic approaches effectively reduce the lifetime risk of experiencing major cardiovascular outcomes and disabling comorbidities, such as myocardial infarction, stroke, and congestive heart failure. On the basis of multiple proofs, antihypertensive therapy is currently recommended for improving event-free survival rate and quality of life in different clinical settings and conditions. At the same time, other cardiovascular drugs, including novel lipid-lowering, anti-platelet, and anti-coagulation agents, have been made available and also contribute to reduce the incidence of atherothrombotic diseases.
Beyond the beneficial aspects obtained by pharmacological treatment of major cardiovascular risk factors and comorbidities, including hypertension, several aspects remain to be defined. One major limitation linked to randomized, controlled clinical trials is represented by the relatively short duration of the studies, which usually ranges between 1 and 5 years. Whether antihypertensive therapy should be maintained for a longer time (after 5 years) and whether this is supported by sufficient evidence of a persisting benefit is supported by limited post-trial observations but mostly by findings derived from large clinical registries. The so-called legacy effect in the treatment of hypertension, in which patients who are treated with a given antihypertensive therapy may derive a long-term benefit after discontinuation of therapy, has been recently proposed on the basis of accumulating evidence and, in particular, on the availability of long-term post-trial observations in randomized controlled clinical trials. In this review, we discuss the evidence witnessing a legacy effect of antihypertensive therapy and whether this supports sufficiently lifetime drug treatment of hypertension.
原发性高血压是全球心血管发病率和死亡率的主要决定因素。在过去几十年中，已经引入并在临床试验中测试了几种降压药物治疗方法，包括单药治疗和联合治疗。目前推荐的治疗方法可有效降低发生主要心血管事件和致残性合并症（如心肌梗死、中风和充血性心力衰竭）的终生风险。基于多项证据，目前建议在不同的临床环境和条件下进行降压治疗，以提高无事件生存率和生活质量。同时，其他心血管药物，包括新型降脂、抗血小板和抗凝药物，也已上市，有助于降低动脉粥样硬化血栓疾病的发生率。
目的综述：除了通过药物治疗主要心血管危险因素和合并症（包括高血压）获得有益方面之外，还有几个方面需要确定。一个与随机对照临床试验相关的主要局限性是研究的持续时间相对较短，通常在 1 至 5 年之间。降压治疗是否应该更长时间（5 年后）维持，以及是否有足够的持续获益证据支持，这受到有限的试验后观察结果的支持，但主要是基于大型临床注册研究的结果。最近，在积累的证据的基础上，特别是在随机对照临床试验的长期试验后观察结果的基础上，提出了高血压治疗中的所谓“遗留效应”。在本文中，我们讨论了见证降压治疗遗留效应的证据，以及这是否足以支持高血压的终身药物治疗。
