Psaty B M, Smith N L, Siscovick D S, Koepsell T D, Weiss N S, Heckbert S R, Lemaitre R N, Wagner E H, Furberg C D
Cardiovascular Health Research Unit, Seattle, WA 98101, USA.
JAMA. 1997 Mar 5;277(9):739-45.
To review the scientific evidence concerning the safety and efficacy of various antihypertensive therapies used as first-line agents and evaluated in terms of major disease end points.
MEDLINE searches and previous meta-analyses for 1980 to 1995.
We selected long-term studies that assessed major disease end points as an outcome. For the meta-analysis, we chose placebo-controlled randomized trials. For randomized trials using surrogate end points such as blood pressure, we selected the largest studies that evaluated multiple drugs. Where clinical trial evidence was lacking, we relied on information from observational studies.
Diuretics and beta-blockers have been evaluated in 18 long-term randomized trials. Compared with placebo, beta-blocker therapy was effective in preventing stroke (relative risk [RR], 0.71; 95% confidence interval [CI], 0.59-0.86) and congestive heart failure (RR, 0.58; 95% CI, 0.40-0.84). The findings were similar for high-dose diuretic therapy (for stroke, RR, 0.49; 95% CI, 0.39-0.62; and for congestive heart failure, RR, 0.17; 95% CI, 0.07-0.41). Low-dose diuretic therapy prevented not only stroke (RR, 0.66; 95% CI, 0.55-0.78) and congestive heart failure (RR, 0.58; 95% CI, 0.44-0.76) but also coronary disease (RR, 0.72; 95% CI, 0.61-0.85) and total mortality (RR, 0.90; 95% CI, 0.81-0.99). Although calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors reduce blood pressure in hypertensive patients, the clinical trial evidence in terms of health outcomes is meager. For several short-acting dihydropyridine calcium channel blockers, the available evidence suggests the possibility of harm. Whether the long-acting formulations and the nondihydropyridine calcium channel blockers are safe and prevent major cardiovascular events in patients with hypertension remains untested and therefore unknown.
Until the results of large long-term clinical trials evaluating the effects of calcium channel blockers and ACE inhibitors on cardiovascular disease incidence are completed, the available scientific evidence provides strong support for the current national guidelines, which recommend diuretics and beta-blockers as firstline agents and low-dose therapy for all antihypertensive agents.
回顾关于各种用作一线药物并根据主要疾病终点进行评估的降压疗法的安全性和有效性的科学证据。
1980年至1995年的MEDLINE检索及先前的荟萃分析。
我们选择评估主要疾病终点作为结果的长期研究。对于荟萃分析，我们选择安慰剂对照的随机试验。对于使用诸如血压等替代终点的随机试验，我们选择评估多种药物的最大规模研究。在缺乏临床试验证据的情况下，我们依赖观察性研究的信息。
利尿剂和β受体阻滞剂已在18项长期随机试验中进行了评估。与安慰剂相比，β受体阻滞剂治疗在预防中风（相对危险度[RR]，0.71；95%置信区间[CI]，0.59 - 0.86）和充血性心力衰竭（RR，0.58；95% CI，0.40 - 0.84）方面有效。高剂量利尿剂治疗的结果相似（中风，RR，0.49；95% CI，0.39 - 0.62；充血性心力衰竭，RR，0.17；95% CI，0.07 - 0.41）。低剂量利尿剂治疗不仅预防了中风（RR，0.66；95% CI，0.55 - 0.78）和充血性心力衰竭（RR，0.58；95% CI，0.44 - 0.76），还预防了冠心病（RR，0.72；95% CI，0.61 - 0.85）和总死亡率（RR，0.90；95% CI，0.81 - 0.99）。尽管钙通道阻滞剂和血管紧张素转换酶（ACE）抑制剂可降低高血压患者的血压，但关于健康结局的临床试验证据较少。对于几种短效二氢吡啶类钙通道阻滞剂，现有证据提示可能存在危害。长效制剂和非二氢吡啶类钙通道阻滞剂对高血压患者是否安全并预防主要心血管事件仍未得到验证，因此尚不清楚。
在评估钙通道阻滞剂和ACE抑制剂对心血管疾病发病率影响的大型长期临床试验结果完成之前，现有科学证据为当前国家指南提供了有力支持，该指南推荐利尿剂和β受体阻滞剂作为一线药物，并对所有降压药物采用低剂量治疗。
