Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
Department of Non-Communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
BMJ. 2020 Nov 18;371:m4080. doi: 10.1136/bmj.m4080.
To study whether treatment recommendations based on age and ethnicity according to United Kingdom (UK) clinical guidelines for hypertension translate to blood pressure reductions in current routine clinical care.
Observational cohort study.
UK primary care, from 1 January 2007 to 31 December 2017.
New users of angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB), calcium channel blockers (CCB), and thiazides.
Change in systolic blood pressure in new users of ACEI/ARB versus CCB, stratified by age (< ≥55) and ethnicity (black non-black), from baseline to 12, 26, and 52 week follow-up. Secondary analyses included comparisons of new users of CCB with those of thiazides. A negative outcome (herpes zoster) was used to detect residual confounding and a series of positive outcomes (expected drug effects) was used to determine whether the study design could identify expected associations.
During one year of follow-up, 87 440 new users of ACEI/ARB, 67 274 new users of CCB, and 22 040 new users of thiazides were included (median 4 (interquartile range 2-6) blood pressure measurements per user). For non-black people who did not have diabetes and who were younger than 55, CCB use was associated with a larger reduction in systolic blood pressure of 1.69 mm Hg (99% confidence interval -2.52 to -0.86) relative to ACEI/ARB use at 12 weeks, and a reduction of 0.40 mm Hg (-0.98 to 0.18) in those aged 55 and older. In subgroup analyses using six finer age categories of non-black people who did not have diabetes, CCB use versus ACEI/ARB use was associated with a larger reduction in systolic blood pressure only in people aged 75 and older. Among people who did not have diabetes, systolic blood pressure decreased more with CCB use than with ACEI/ARB use in black people (reduction difference 2.15 mm Hg (-6.17 to 1.87)); the corresponding reduction difference was 0.98 mm Hg (-1.49 to -0.47) in non-black people.
Similar reductions in blood pressure were found to be associated with new use of CCB as with new use of ACEI/ARB in non-black people who did not have diabetes, both in those who were aged younger than 55 and those aged 55 and older. For black people without diabetes, CCB new use was associated with numerically greater reductions in blood pressure than ACEI/ARB compared with non-black people without diabetes, but the confidence intervals were overlapping for the two groups. These results suggest that the current UK algorithmic approach to first line antihypertensive treatment might not lead to greater reductions in blood pressure. Specific indications could be considered in treatment recommendations.
研究根据英国（UK）高血压临床指南中的年龄和种族制定的治疗建议是否能转化为当前常规临床护理中的血压降低。
观察性队列研究。
2007 年 1 月 1 日至 2017 年 12 月 31 日期间，英国初级保健。
新使用血管紧张素转换酶抑制剂/血管紧张素受体阻滞剂（ACEI/ARB）、钙通道阻滞剂（CCB）和噻嗪类药物的患者。
新使用 ACEI/ARB 与 CCB 的患者的收缩压变化，按年龄（< ≥55）和种族（黑人 非黑人）分层，从基线到 12、26 和 52 周随访。次要分析包括比较新使用 CCB 与噻嗪类药物的患者。使用疱疹单纯性病毒感染（单纯疱疹）作为负性结局（不良反应）来检测残余混杂因素，使用一系列阳性结局（预期药物效果）来确定研究设计是否能够识别预期的关联。
在一年的随访期间，共纳入了 87440 名新使用 ACEI/ARB、67274 名新使用 CCB 和 22040 名新使用噻嗪类药物的患者（每名患者中位数有 4 次（四分位间距 2-6）血压测量）。对于没有糖尿病且年龄小于 55 岁的非黑人患者，与 ACEI/ARB 相比，CCB 的使用与收缩压的更大降低相关，在 12 周时为 1.69mmHg（99%置信区间-2.52 至-0.86），在年龄 55 岁及以上的患者中为 0.40mmHg（-0.98 至 0.18）。在没有糖尿病的非黑人患者中，使用 6 个更精细的年龄类别进行亚组分析，与 ACEI/ARB 相比，仅在年龄 75 岁及以上的患者中，CCB 的使用与收缩压的更大降低相关。在没有糖尿病的人群中，与 ACEI/ARB 相比，CCB 的使用与黑人患者的收缩压降低更多（降低差异 2.15mmHg（-6.17 至 1.87））；非黑人患者的相应降低差异为 0.98mmHg（-1.49 至-0.47）。
在没有糖尿病的非黑人患者中，与 ACEI/ARB 相比，CCB 的新使用与收缩压的相似降低相关，无论患者年龄小于 55 岁还是 55 岁及以上。对于没有糖尿病的黑人患者，与非黑人患者相比，CCB 的新使用与 ACEI/ARB 相比，血压降低的数值更大，但两组的置信区间重叠。这些结果表明，目前英国的一线抗高血压治疗算法方法可能不会导致血压的更大降低。在治疗建议中可以考虑特定的适应症。
