降压治疗对老年人卒中获益时间的荟萃分析。
Time to benefit for stroke reduction after blood pressure treatment in older adults: A meta-analysis.
机构信息
College of Medicine, California Northstate University, Elk Grove, California, USA.
Medical Student Training in Aging Research (MSTAR) Program, Division of Geriatrics, School of Medicine, University of California, San Francisco, California, USA.
出版信息
J Am Geriatr Soc. 2022 May;70(5):1558-1568. doi: 10.1111/jgs.17684. Epub 2022 Feb 9.
BACKGROUND
Hypertension treatment in older adults can decrease mortality, cardiovascular events, including heart failure, cognitive impairment, and stroke risk, but may also lead to harms such as syncope and falls. Guidelines recommend targeting preventive interventions with immediate harms and delayed benefits to patients whose life expectancy exceeds the intervention's time to benefit (TTB). Our objective was to estimate a meta-analyzed TTB for stroke prevention after initiation of more intensive hypertension treatment in adults aged ≥65 years.
METHODS
Studies were identified from two Cochrane systematic reviews and a search of MEDLINE and Google Scholar for subsequent publications until August 31, 2021. We abstracted data from randomized controlled trials comparing standard (untreated, placebo, or less intensive treatment) to more intensive treatment groups in older adults (mean age ≥ 65 years). We fit Weibull survival curves and used a random-effects model to estimate the pooled annual absolute risk reduction (ARR) between control and intervention groups. We applied Markov chain Monte Carlo methods to determine the time to ARR thresholds (0.002, 0.005, and 0.01) for a first stroke.
RESULTS
Nine trials (n = 38,779) were identified. The mean age ranged from 66 to 84 years and study follow-up times ranged from 2.0 to 5.8 years. We determined that 1.7 (95%CI: 1.0-2.9) years were required to prevent 1 stroke for 200 persons (ARR = 0.005) receiving more intensive hypertensive treatment. Heterogeneity was found across studies, with those focusing on tighter systolic blood pressure control (SBP < 150 mmHg) showing longer TTB. For example, in the SPRINT study (baseline SBP = 140 mmHg, achieved SBP = 121 mmHg), the TTB to avoid 1 stroke for 200 patients treated was 5.9 years (95%CI: 2.2-13.0).
CONCLUSIONS
More intensive hypertension treatment in 200 older adults prevents 1 stroke after 1.7 years. Given the heterogeneity across studies, the TTB estimates from individual studies may be more relevant for clinical decision-making than our summary estimate.
背景
在老年人中进行高血压治疗可以降低死亡率、心血管事件发生率，包括心力衰竭、认知障碍和中风风险，但也可能导致晕厥和跌倒等危害。指南建议针对预期寿命超过干预获益时间（TTB）的患者，针对即时危害和延迟获益进行预防性干预。我们的目的是估计在 2021 年 8 月 31 日之前，对≥65 岁成年人进行更强化的高血压治疗后，预防中风的荟萃分析 TTB。
方法
从两项 Cochrane 系统评价和 MEDLINE 和 Google Scholar 的搜索中确定研究，以寻找随后的出版物。我们从比较标准（未治疗、安慰剂或较不强化治疗）与老年人（平均年龄≥65 岁）更强化治疗组的随机对照试验中提取数据。我们拟合了威布尔生存曲线，并使用随机效应模型估计对照组和干预组之间的年度绝对风险降低（ARR）的汇总值。我们应用马尔可夫链蒙特卡罗方法来确定第一次中风的 ARR 阈值（0.002、0.005 和 0.01）的时间。
结果
确定了 9 项试验（n=38779）。平均年龄范围为 66 至 84 岁，研究随访时间范围为 2.0 至 5.8 年。我们确定，为了预防 200 名接受更强化降压治疗的患者发生 1 次中风，需要 1.7 年（95%CI：1.0-2.9）。研究之间存在异质性，其中关注更严格的收缩压控制（SBP<150mmHg）的研究显示 TTB 更长。例如，在 SPRINT 研究中（基线 SBP=140mmHg，达到的 SBP=121mmHg），为 200 名患者治疗以避免 1 次中风的 TTB 为 5.9 年（95%CI：2.2-13.0）。
结论
在 200 名老年人中进行更强化的高血压治疗可在 1.7 年后预防 1 次中风。鉴于研究之间存在异质性，个体研究的 TTB 估计值可能比我们的汇总估计值更能为临床决策提供参考。
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