血压管理在预防中风中的作用：对93项随机对照试验的系统评价和网状Meta分析

Role of Blood Pressure Management in Stroke Prevention: A Systematic Review and Network Meta-Analysis of 93 Randomized Controlled Trials.

作者信息

Zhong Xiao-Ling, Dong Yi, Xu Wei, Huang Yu-Yuan, Wang Hui-Fu, Zhang Tian-Song, Sun Li, Tan Lan, Dong Qiang, Yu Jin-Tai

机构信息

Department of Neurology, Qingdao Central Hospital, Qingdao University, Qingdao, China.

Department of Neurology and Institute of Neurology, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China.

出版信息

J Stroke. 2021 Jan;23(1):1-11. doi: 10.5853/jos.2020.02698. Epub 2021 Jan 31.

BACKGROUND AND PURPOSE

The present study aimed to compare the efficacy and tolerability of different blood pressure (BP)-lowering strategies.

METHODS

Randomized controlled trials that compared various antihypertensive treatments and stroke outcomes were included. Eligible trials were categorized into three scenarios: single or combination antihypertensive agents against placebos; single or combination agents against other agents; and different BP-lowering targets. The primary efficacy outcome was the risk reduction pertaining to strokes. The tolerability outcome was the withdrawal of drugs, owing to drug-related side effects (PROSPERO registration number CRD42018118454 [20/12/2018]).

RESULTS

The present study included 93 trials (average follow-up duration, 3.3 years). In the pairwise analysis, angiotensin-converting enzyme inhibitors (ACEis) and beta-blockers (BBs) were inferior to calcium channel blockers (CCBs) (odds ratio [OR], 1.123; 95% confidence interval [CI], 1.008 to 1.252) (OR, 1.261; 95% CI, 1.116 to 1.425) for stroke prevention, BB was inferior to angiotensin II receptor blockers (ARB) (OR, 1.361; 95% CI, 1.142 to 1.622), and diuretics were superior to ACEi (OR, 0.871; 95% CI, 0.771 to 0.984). The combination of ACEi+CCB was superior to ACEi+diuretic (OR, 0.892; 95% CI, 0.823 to 0.966). The network meta-analysis confirmed that diuretics were superior to BB (OR, 1.34; 95% CI, 1.11 to 1.58), ACEi+diuretic (OR, 1.47; 95% CI, 1.02 to 2.08), BB+CCB (OR, 2.05; 95% CI, 1.05 to 3.79), and renin inhibitors (OR, 1.87; 95% CI, 1.25 to 2.75) for stroke prevention. Regarding the tolerability profile, the pairwise analysis revealed that ACEi was inferior to CCB and less tolerable, compared to the other treatments.

CONCLUSIONS

Monotherapy using diuretics, CCB, or ARB, and their combinations could be employed as first-line treatments for stroke prevention in terms of efficacy and tolerability.

背景与目的

本研究旨在比较不同降压策略的疗效和耐受性。

方法

纳入比较各种抗高血压治疗与卒中结局的随机对照试验。符合条件的试验分为三种情况：单一或联合抗高血压药物与安慰剂对照；单一或联合药物与其他药物对照；以及不同的降压目标。主要疗效结局是卒中相关风险降低。耐受性结局是因药物相关副作用而停药（国际前瞻性系统评价注册库注册号CRD42018118454 [2018年12月20日]）。

结果

本研究纳入93项试验（平均随访时间3.3年）。在成对分析中，血管紧张素转换酶抑制剂（ACEI）和β受体阻滞剂（BB）在预防卒中方面不如钙通道阻滞剂（CCB）（比值比[OR]，1.123；95%置信区间[CI]，1.008至1.252）（OR，1.261；95%CI，1.116至1.425），BB不如血管紧张素II受体阻滞剂（ARB）（OR，1.361；95%CI，1.142至1.622），利尿剂优于ACEI（OR，0.871；95%CI，0.771至0.984）。ACEI+CCB组合优于ACEI+利尿剂（OR，0.892；95%CI，0.823至0.966）。网状Meta分析证实，利尿剂在预防卒中方面优于BB（OR，1.34；95%CI，1.11至1.58）、ACEI+利尿剂（OR，1.47；95%CI，1.02至2.08）、BB+CCB（OR，2.05；95%CI，1.05至3.79）和肾素抑制剂（OR，1.87；95%CI，1.25至2.75）。关于耐受性情况，成对分析显示，与其他治疗相比，ACEI不如CCB且耐受性较差。