Yusuf S, Lessem J, Jha P, Lonn E
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
J Hypertens Suppl. 1993 Jun;11(4):S61-73.
To summarize the risk factors associated with coronary heart disease and strokes and to evaluate measures used in the prevention and treatment of these diseases.
A review of the results of randomly allocated clinical trials of treatment for both primary and secondary prevention of coronary heart disease and strokes.
Reductions in elevated blood pressure and cholesterol and cessation of cigarette smoking have clearly been shown to reduce the incidence of coronary heart disease. A reduction in blood pressure has also been shown to reduce the risk of strokes. In addition to other classical risk factors, such as abnormal serum lipids, diabetes and a genetic predisposition, recent studies have shown that elevated levels of fibrinogen and other clotting factors, elevated levels of renin and decreased levels of anti-oxidant vitamins such as E, C and beta-carotene can predict coronary heart disease and strokes. Thrombolytic therapy, aspirin and beta-blockers have been shown to reduce mortality in patients with myocardial infarction, and the latter two agents reduce mortality, re-infarction and strokes with long-term use. Treatment with intravenous magnesium and nitrates has shown promise but larger trials are required to confirm the results. Both aspirin and heparin have proven value in reducing the incidence of myocardial infarction and death in unstable angina. Following an acute myocardial infarction, long-term therapy with aspirin, beta-blockers, lipid-lowering agents and oral anticoagulants has been shown to reduce mortality and re-infarction. In patients with large infarcts associated with a low ejection fraction or heart failure, the use of angiotensin converting enzyme (ACE) inhibitors reduces mortality, hospitalization for heart failure and re-infarction. The use of diuretics to lower blood pressure reduces strokes. In contrast, calcium antagonists do not appear to consistently reduce mortality or prevent vascular events when used for primary or secondary prevention of either myocardial infarction or strokes.
Myocardial infarction and strokes can be prevented by refraining from smoking and maintaining appropriate blood pressure levels and a favourable balance of lipids. Following a myocardial infarction, further drug treatment should include aspirin, thrombolytic therapy (in acute myocardial infarction), beta-blockers, ACE inhibitors (in patients with a low ejection fraction) and perhaps anticoagulants.
总结与冠心病和中风相关的危险因素，并评估用于预防和治疗这些疾病的措施。
回顾冠心病和中风一级及二级预防治疗的随机分配临床试验结果。
血压升高和胆固醇降低以及戒烟已被明确证明可降低冠心病的发病率。血压降低也已被证明可降低中风风险。除了其他经典危险因素，如血脂异常、糖尿病和遗传易感性外，最近的研究表明，纤维蛋白原和其他凝血因子水平升高、肾素水平升高以及抗氧化维生素如E、C和β-胡萝卜素水平降低可预测冠心病和中风。溶栓治疗、阿司匹林和β受体阻滞剂已被证明可降低心肌梗死患者的死亡率，后两种药物长期使用可降低死亡率、再梗死率和中风发生率。静脉注射镁和硝酸盐治疗已显示出前景，但需要更大规模的试验来证实结果。阿司匹林和肝素在降低不稳定型心绞痛的心肌梗死发病率和死亡率方面已被证明具有价值。急性心肌梗死后，长期使用阿司匹林、β受体阻滞剂、降脂药物和口服抗凝剂已被证明可降低死亡率和再梗死率。对于伴有低射血分数或心力衰竭的大面积梗死患者，使用血管紧张素转换酶（ACE）抑制剂可降低死亡率、因心力衰竭住院率和再梗死率。使用利尿剂降低血压可减少中风。相比之下，钙拮抗剂在用于心肌梗死或中风一级或二级预防时，似乎并不能持续降低死亡率或预防血管事件。
通过戒烟、维持适当的血压水平和良好的血脂平衡可预防心肌梗死和中风。心肌梗死后，进一步的药物治疗应包括阿司匹林、溶栓治疗（急性心肌梗死时）、β受体阻滞剂、ACE抑制剂（射血分数低的患者），或许还包括抗凝剂。
