Alderman M H, Madhavan S, Cohen H
Department of Epidemiology and Social Medicine, Albert Einstein College of Medicine, Bronx, New York 10461, USA.
Am J Hypertens. 1996 May;9(5):413-8. doi: 10.1016/0895-7061(95)00438-6.
This study was designed to evaluate the impact of the protocol-driven antihypertensive therapy on outcomes guided by the Joint National Committee (JNC) on Detection, Evaluation, and Treatment of high blood pressure. In a systematic hypertension control program for union employees conducted in New York City, untreated patients who began treatment on monotherapy guided by JNC recommendations during three representative periods: I-pre-JNC IV (1986-1987); II-post-JNC IV (1990-1991); and III (JNC V)-period of application of what were later published as JNC-V guidelines (1992) were observed during 1 year of treatment. A total of 550 presumably untreated patients were prescribed either diuretics, beta-blockers, calcium channel blockers, or angiotensin converting enzyme inhibitors. There were 231 in period I, 213 in II, and 106 in III. The patient composition over time became more predominantly female and Hispanic (I to III: 28% to 34%, and 35% to 45%, respectively). The main outcome measures were type of drug first prescribed and the outcomes at the end of 1 year-changes in blood pressure, clinical chemistry measures and therapy, and clinic attendance are dropout rate. The pattern of first drug prescription changed from 85% to 90% of patients given diuretics or beta-blockers in I to 90% begun on calcium channel blockers or angiotensin converting enzyme inhibitors in II and finally, to an even distribution of drugs in III. Blood pressure response was similar across the three periods, 135/89 mm Hg (I), 138/89 (II), and 140/89 (III). Proportion of patients remaining on their initial drug in each period was fairly similar (60%, 67%, and 69%). Scheduled clinic visits fell significantly from 7.4 visits in I, 6.9 in II, and 6.4 in III (I upsilon III P = .004). Dropouts diminished significantly from 17% in I, to 10% in II, and 9% in III (I upsilon II or III P = .045). Modest positive changes in cholesterol and fasting blood sugar level occurred over time. In this general community setting, dramatic shifts in the choice of initial drug based upon application of JNC guidelines had little discernable impact on short term patient outcomes.
本研究旨在评估按照美国国家联合委员会（JNC）关于高血压的检测、评估和治疗的方案驱动的抗高血压治疗对治疗结果的影响。在纽约市针对工会员工开展的一项系统性高血压控制项目中，观察了在三个代表性时期开始接受单药治疗的未治疗患者，这三个时期分别为：I期——JNC IV之前（1986 - 1987年）；II期——JNC IV之后（1990 - 1991年）；III期（JNC V）——应用后来作为JNC - V指南发表的时期（1992年），治疗期为1年。总共550名推测未接受治疗的患者被处方使用利尿剂、β受体阻滞剂、钙通道阻滞剂或血管紧张素转换酶抑制剂。I期有231名患者，II期有213名，III期有106名。随着时间推移，患者构成中女性和西班牙裔占比越来越高（I期到III期：分别从28%增至34%和从35%增至45%）。主要结局指标为首次处方药物的类型以及1年末的结局——血压变化、临床化学指标和治疗情况，以及门诊就诊率和失访率。首次药物处方模式从I期85%至90%的患者使用利尿剂或β受体阻滞剂，变为II期90%的患者开始使用钙通道阻滞剂或血管紧张素转换酶抑制剂，最终在III期各种药物分布均匀。三个时期的血压反应相似，分别为135/89 mmHg（I期）、138/89（II期）和140/89（III期）。每个时期继续使用初始药物的患者比例相当相似（分别为60%、67%和69%）。预定门诊就诊次数从I期的7.4次显著降至II期的6.9次和III期的6.4次（I期对比III期，P = .004）。失访率从I期的17%显著降至II期的10%和III期的9%（I期对比II期或III期，P = .045）。随着时间推移，胆固醇和空腹血糖水平有适度的正向变化。在这个普通社区环境中，基于JNC指南应用而导致的初始药物选择的显著变化对短期患者结局几乎没有明显影响。
