ECRI Center for Clinical Evidence and Guidelines, Plymouth Meeting, Pennsylvania (K.E.D., K.T., A.H., B.R., L.H., J.F.).
Ann Intern Med. 2020 Dec 1;173(11):895-903. doi: 10.7326/M20-2037. Epub 2020 Sep 1.
Recent clinical trials suggest that treating patients with hypertension to lower blood pressure (BP) targets improves cardiovascular outcomes.
To summarize the effects of intensive (or targeted) systolic BP (SBP) and diastolic BP (DBP) lowering with pharmacologic treatment on cardiovascular outcomes and harms in adults with hypertension.
Multiple databases, including MEDLINE and EMBASE, were searched for relevant systematic reviews (SRs) published in English from 15 December 2013 through 25 March 2019, with updated targeted searches through 8 January 2020.
8 SRs of randomized controlled trials examining either a standardized SBP target of -10 mm Hg (1 SR) or BP lowering below a target threshold (7 SRs).
One investigator abstracted data, assessed study quality, and performed GRADE assessments; a second investigator checked abstractions and assessments.
The main outcome of interest was reduction in composite cardiovascular outcomes. High-strength evidence showed benefit of a 10-mm Hg reduction in SBP for cardiovascular outcomes among patients with hypertension in the general population, patients with chronic kidney disease, and patients with heart failure. Evidence on reducing SBP for cardiovascular outcomes in patients with a history of cardiovascular disease (moderate strength) or diabetes mellitus (high strength) to a lower SBP target was mixed. Low-strength evidence supported intensive lowering to a 10-mm Hg reduction in SBP for cardiovascular outcomes in patients with a history of stroke. All reported harms were considered, including general adverse events, serious adverse events, cognitive impairment, fractures, falls, syncope, hypotension, withdrawals due to adverse events, and acute kidney injury. Safety results were mixed or inconclusive.
This was a qualitative synthesis of new evidence with existing meta-analyses. Data were sparse for outcomes related to treating DBP to a lower target or for patients older than 60 years.
Overall, current clinical literature supports intensive BP lowering in patients with hypertension for improving cardiovascular outcomes. In most subpopulations, intensive lowering was favored over less-intensive lowering, but the data were less clear for patients with diabetes mellitus or cardiovascular disease.
U.S. Department of Veterans Affairs, Veterans Health Administration.
最近的临床试验表明，降低高血压患者的血压（BP）目标可以改善心血管结局。
总结用药物治疗降低收缩压（SBP）和舒张压（DBP）的强化（或靶向）目标对高血压成年人心血管结局和危害的影响。
从 2013 年 12 月 15 日到 2019 年 3 月 25 日，在多个数据库（包括 MEDLINE 和 EMBASE）中搜索了英语发表的相关系统评价（SR），并通过 2020 年 1 月 8 日的更新靶向搜索进行了补充。
8 项 SR 检查了标准化 SBP 目标值为-10mmHg（1 项 SR）或降压至低于目标阈值（7 项 SR）。
一名调查员提取数据、评估研究质量并进行 GRADE 评估；第二名调查员检查摘要和评估。
主要关注的结果是复合心血管结局的减少。高强度证据表明，在普通人群、慢性肾脏病患者和心力衰竭患者中，SBP 降低 10mmHg 对心血管结局有益。关于将有心血管疾病（中度强度）或糖尿病（高强度）病史的患者的 SBP 降低到更低目标值以改善心血管结局的证据存在差异。关于将有中风病史的患者的 SBP 降低 10mmHg 以改善心血管结局的证据强度较弱。报告的所有危害均被认为包括一般不良事件、严重不良事件、认知障碍、骨折、跌倒、晕厥、低血压、因不良事件退出、急性肾损伤。安全性结果喜忧参半或不确定。
这是对新证据和现有荟萃分析的定性综合。与将 DBP 降低到更低目标或治疗年龄大于 60 岁的患者相关的结局数据稀疏。
总的来说，目前的临床文献支持在高血压患者中进行强化降压以改善心血管结局。在大多数亚人群中，强化降压优于不太强化的降压，但对于糖尿病或心血管疾病患者的数据则不太明确。
美国退伍军人事务部，退伍军人健康管理局。
