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扩展降压治疗能获益的人群，当前主要聚焦在80岁以上高龄高血压患者和血压水平<140/90的心血管高危患者(心、脑血管病与糖尿病)。新动向(一)安慰剂纳催离缓释片±雅施达安慰剂HYVET:总死亡率总死亡率降低21%随访时间（年）百分率%纳催离缓释片±雅

施达1912193314921565814877379420202231从HYVET到临床实践■适用于收缩压160mmHg以上，一般状况尚好，生活能自理，认知功能无明显减退的高龄高血压患者。■降压速度应

该相对较平缓，避免体位性低血压。血压控制目标值150/80mmHg。RAS阻滞剂治疗心血管高危患者循证证据HOPE(Ramipril,2000)PROGRESS(Perindopril,2001)EUROPA(Perindopril,2003)ADVANCE(Perin/Indap,20

07)ONTARGET(Telmisartan,2008)HOPE139/793/3PROGRESS147/869/4EUROPA137/825/2ADVANCE145/815/3ONTARGET142/826/4基线血压血压↓RAS阻滞剂治疗心血管高危患者基线血压与血压下降幅度mmHg6080

100120140160BaselineTreatmentHTNTSD159.0159.094.091.0136.0127.279.074.8在心血管高危患者,强化血压控制。血压控制目标值<130/80

mmHg正在不断获得循证证据。新动向(二)SBPUKPDSADVPrisantLM.JClinPharmacol2004;44(4):423-430●因强化治疗总死亡率增加,08年2月7日宣布提前中止)●≤1001

20140160180Systolicbloodpressure(mmHg)1248Annualrate(%)Ischaemicstroke100120140160180Systolicbloodpressure(mmHg)0.010.020.040.080.160.32Haemorrhagi

cstrokeAdjustedrelativeofdoublingofserumcreatinineorESRD(±95%CI)UsualsystolicBP(mmHg)duringfollow-upProteinuria≥1g/dayProteinuria<1g/day10612<1

10110-119120-129130-139140-159>1604.805.408.401.701.20.702.224.811.60Reference1.2100806040200<120120-139140-15960100806040200<7070-79

80-8990Achievedsystolicbloodpressurelevels(mmHg)Achievedsystolicbloodpressurelevels(mmHg)Age-andsex-adjustedincidencerateCKD:Ptrend=0.

004Non-CKD:Ptrend<0.0001CKD:Ptrend=0.001Non-CKD:Ptrend<0.0001CKDNon-CKDIncidencerate(1000person-years)02040608010011010012013014015016017018

0190200210220Nadir,129.5mmHgSystolicBloodpressure,mmhgRelativeHazard,×3700204060801005060708090100110120Nadir,73.8mmHgDias

tolicBloodpressure,mmhgRelativeHazard,×2200冠心病患者血压控制水平与心血管危险AScientificStatementfromAHA,2007.4●冠心病患者需要积极控制血压，合理的血压控制目标值<130/80mmHg。（Ⅱa,B）●

应该相对缓慢降低血压，避免DBP<60mmHg。优化降压治疗方案，比较不同降压治疗药物和治疗方案在长期治疗过程中对血压控制、靶器官、不良反应、代谢以及终点事件等影响的差异。新动向(三)WeirMR,etal.SystolicBloodpressure,mmhgaboutthee

ffectsofblood-pressure-loweringtherapyinthisveryhigh-riskpopulation.DiastolicBP基线血压血压↓■ACEI/CCB联合特别有利于减少

冠心病事件(心肌梗死、不稳定性心绞痛、血运重建)。SystolicBloodpressure,mmhgTreatmentGroupsONTARGET:RenalDysfunctionDialysis&RelatedDeathTel+Ramvs.FabiaMJ

,etal.2005;366:895-906.SNSinhibitonAmJHypertens2007;20:807■降压速度应该相对较平缓，避免体位性低血压。TelmisartanValsartan320SNSinhibitonReduction

ofproteinuriaafteroneyearoftreatment:29%withMicardis80vs.Full-dosesingleagentCombination0-2-4-6-8-10-12-14-16-180-2-4-6-8-10-12-14SystolicBPDias

tolicBPARB动态血压监测研究系统综述24h平均下降值0-2-4-6-8-10-12-14-16-180-2-4-6-8-10-12-14SystolicBPDiastolicBPARB动态血压监测研究系统综述治疗后18-24h平均下降

值1009080706050403020100Patients(%)TreatmentGroupsN1156=78196907355646335320/CTZ320160/HCTZ1608080/12.5Placebo7.013.124.24.816

.732.63.133.351.417.932.848.425.856.474.622.535.754.245.267.184.82wk4wk8wk缬沙坦剂量对降压疗效的影响达标率和达标时间607080901005040

30201000714212835424956DurationofTreatment(days)PatientsAchievingGoal(%)Valsartan320/HCTZValsartan160/HCTZValsartan320V

alsartan/HCTZ80/125Valsartan160Valsartan80Placebo缬沙坦不同剂量对降压疗效的影响ComparativeLongtermEfficacyofTwoAT1ReceptorBlock

ers(Telmisartanvs.Losartan)onProteinuriainPatientswithType-2DiabetesandOvertNephropathyandHypertensionJhypertens.2005

;23:445-453.CombinationUptitrationNICECombiStudy00.02-0.02-0.04-0.06-0.08-0.10-0.12两组间P＝0.002JMIC－B:长效硝苯地平与ACEI延缓冠状动脉粥硬化进展的比较

长效硝苯地平ACEI治疗持续3年治疗后冠脉管腔最小直径变化（mm）0.02±0.27mmP＝0.543－0.12±0.27mmP<0.001*localdefinitionTel+Ramvs.Ram在心血管高危患者

，常同时存在以肾小动脉硬化和缺血性损害为特点的CKD。糖尿病性和非糖尿病性肾病与慢性缺血性肾脏病在病理生理、诊断和治疗方面应当有所切割。DiastolicBPJMIC－B:长效硝苯地平与ACEIACCOMPLISH:心血管复合终点KennethJamerson,etal.MildBPe

levationRAS阻滞剂治疗心血管高危患者Ram+TelvRam基线血压血压↓Low-dosesingleagentJMIC－B:长效硝苯地平与ACEIUptitrationValsartan320Valsartan320ASCOT-BPLA:终点事件发生率Patients(

%)JHypertens2007;25:1105–87Nadir,129.延缓冠状动脉粥硬化进展的比较TreatmentGroupsPROGRESS147/869/4：ARBs多效性的差异Uricacidexc

retionPPARgammaSNSinhibitonAnti-infl/AntiplateletAT1-blockadeAT2-stimulationTelmisartan,EXP3179Eprosart

anEXP3179Class-EffectBalancevaries→MagnitudevariesDependingondoseLosartan降压药物多效性的临床意义●降压药物多效性的协同作用有利于降压治疗中多种心血管危险因素的综合控制，有助于保护靶器官和干预

病理生理环节，从而在特定情况下可能转化为更大程度地降低心血管危险。●降压药物多效性将成为临床优化选择降压药物的重要依据和靓点。（氨氯地平+/-培哚普利Vs.阿替洛尔+/-苄氟噻嗪）*P<0.05降低百分比(%)-35-30-25-20-1

5-10-50*******非致死心梗和冠心病死亡心血管死亡总死亡总冠脉事件致死/非致死性卒中总心血管事件和介入新发糖尿病肾损害ASCOT-BPLA:终点事件发生率累计事件发生率（%）HR(95%CI):0.8

0(0.72,0.90)(天)P=0.0002ACEI/HCTZCCB/ACEI650526ACCOMPLISH:心血管复合终点20%ACCOMPLISH:意义■对特定人群选择优化的降压治疗方案提供了循证证据。■ACEI/CCB联合特别

有利于减少冠心病事件(心肌梗死、不稳定性心绞痛、血运重建)。在优化的基础上，简化降压治疗模式,寻找强效、快捷、平稳和安全的联合治疗方案和途径。新动向(三)降压治疗模式的历史演进序贯治疗(阶梯治疗(联合治疗(ChoosebetweenLow-dose2-drugcombinationLow-

dosesingleagentNotatBPgoalFulldoseofsingleagentSwitchtodifferentagentatlowdoseFulldoseof2-drugcombinationAddathirddrugatlow

doseNotatBPgoal2–3drugcombinationatfulldoseFulldosesof2–3-drugcombinationFull-dosesingleagentMarkedBPelevationHigh/ve

ryhighCVriskLowerBPtargetMildBPelevationLow/moderateCVriskConventionalBPtargetTALENTstudySTudyEvALuatingtheEffi

cacyofNifedipineGITS-TelmisartaninBloodPressureControlACCOMPLISH:心血管复合终点abouttheeffectsofblood-pressure-loweringtherapyinthisveryh

igh-riskpopulation.Fulldoseof2-drugcombination2005;366:895-906.■ACEI/CCB联合特别有利于减少冠心病事件(心肌梗死、不稳定性心绞痛、血运重建)。AD

VANCE(Perin/Indap,2007)AmJHypertens2007;20:807Valsartan1602005;366:895-906.LateBreakerpresentationatACC2008.PrisantLM.Valsartan320Shi

nodaE,etal.UsualsystolicBP(mmHg)duringfollow-up15thESHmeeting,Milan,Italy,June17-21,2005Age-andsex-adjustedin

cidenceratePROGRESS147/869/4PrisantLM.（氨氯地平+/-培哚普利Vs.在心血管高危患者,强化血压控制。10090807060504030201000369121518212427Mo

nthsafterstartoftherapy21%17%PercentageofpatientsfullyadherentFixed-dosecombinationCoadministrationof2

pills