The Relationship of Systolic and Diastolic Blood Pressure to ：收缩压和舒张的关系.ppt

The Relationship of Systolic and Diastolic Blood Pressure to Cardiovascular Disease Risk:Observational Data,Prevalence of Hypertension in the US,Percent hypertensive,18-29,Based on NHANES III(phase 1 and 2)Hypertension defined as blood pressure 140/90 mmHg or treatment,30-39,40-49,50-59,60-69,70-79,80+,Age,3%,9%,18%,38%,51%,66%,72%,JNC-VI.Arch Intern Med.1997;157:2413-2446.,Risk of hypertension(%),Residual lifetime risk of developing hypertension among people with blood pressure 140/90 mmHg,Years,Lifetime Risk of Developing Hypertension Beginning at Age 65,Men,Women,Vasan RS,et al.JAMA.2002;287:1003-1010.Copyright 2002,American Medical Association.,Mortality According to Blood Pressure in Men Age 50 to 69,Society of Actuaries.Blood Pressure Study,1939.,Ratio(%)of actual to expected mortality,Systolic blood pressure(mmHg),Diastolic blood pressure(mmHg),Age-adjusted annualincidence of CHD per 1000,Based on 30 year follow-up of Framingham Heart Study subjects free of coronary heart disease(CHD)at baseline,Systolic blood pressure(mmHg),Blood Pressure and Risk for Coronary Heart Disease in Men,Diastolic blood pressure(mmHg),Age 65-94,Age 35-64,Age 65-94,Age 35-64,Framingham Heart Study,30-year Follow-up.NHLBI,1987.,Relative risk of CHD mortality,He J,et at.Am Heart J.1999;138:211-219.Copyright 1999,Mosby Inc.,11271,Risk of CHD Death According to SBP and DBP in MRFIT,Decile,112-71-,118-76-,121-79-,125-81-,129-84-,132-86-,137-89-,142-92-,15198,(lowest 10%),(highest 10%),SBP(mmHg),DBP(mmHg),Systolic blood pressure(SBP)Diastolic blood pressure(DBP),CHD=coronary heart disease,Relative risk of stroke death,11271,Risk of Stroke Death According to SBP and DBP in MRFIT,Decile,112-71-,118-76-,121-79-,125-81-,129-84-,132-86-,137-89-,142-92-,15198,(lowest 10%),(highest 10%),SBP(mmHg),DBP(mmHg),Systolic blood pressure(SBP)Diastolic blood pressure(DBP),He J,et at.Am Heart J.1999;138:211-219.Copyright 1999,Mosby Inc.,Age-adjusted annual CVD event rate per 1000,Wilking SV et al.JAMA.1988;260:3451-3455.,Men,Women,Isolated Systolic Hypertension and CVD Risk in Framingham,ISH BP 160/95 mmHgBP 140/95 mmHg,82,43,33,2.4,18,2.5,CVD=cardiovascular disease ISH=isolated systolic hypertensionP0.001 for difference between both men and women with ISH and blood pressure(BP)140/95 mmHg,The Relationship of Hypertension Treatment to CVD Risk Reduction:Introduction,Incidence of cardiovascular disease,120,Hypertension Treatment Effect Mirrors Observational Data,140,160,180,200,220,Observational Data,Treatment Effect,Systolic blood pressure(mmHg),Landmark Clinical TrialsHypertension Treatment and Cardiovascular Disease Outcomes,1967 VA Cooperative Study on DBP 115-1291970 VA Cooperative Study on DBP 90-1141979 HDFP1980 Australian Trial,Oslo Trial1985 MRC I,EWPHE1991 SHEP,STOP-Hypertension 1992 MRC II in the elderly1997 Syst-Eur 2002 LIFE2002 ALLHAT,Relative Risk for Coronary Heart Disease,Odds ratios and95%confidence intervals,0,0.5,1,1.5,2,0.79(0.69 to 0.90),He J,et al.Am Heart J.1999;138:211-219.Copyright 1999,Mosby,Inc.,Active treatment better than placebo,Active treatment worse than placebo,Relative Risk for Stroke,0,0.5,1,1.5,2,0.63(0.55 to 0.72),Odds ratios and95%confidence intervals,Active treatment better than placebo,Active treatment worse than placebo,He J,et al.Am Heart J.1999;138:211-219.Copyright 1999,Mosby,Inc.,The Veterans Administration Cooperative Study on Antihypertensive Agents,The VA Cooperative Study,1967,VA Cooperative Study Group.JAMA.1967;202:1028-1034.,HCTZ=hydrochlorothiazide,-12,12,The VA Cooperative Study,1967:Change in Systolic and Diastolic Blood Pressure,Change in Systolic BP(mmHg),Percent of patients,Percent of patients,Change in Diastolic BP(mmHg),-76,-60,-44,-28,0,28,Decrease(-),(+)Increase,Active drugs,Placebo,Active drugs,Placebo,VA Cooperative Study Group.JAMA.1967;202:1028-1034.Copyright 1967,American Medical Association.,-12,12,-76,-60,-44,-28,0,28,Decrease(-),(+)Increase,The VA Cooperative Study,1967:Assessable Morbid/Fatal Events,VA Cooperative Study Group.JAMA.1967;202:1028-1034.,*P0.001 active drug therapy vs placebo,The VA Cooperative Study,1967:Conclusions,The actively treated group experienced a reduction in multiple hypertension-related endpoints21 morbid/fatal events on placebo1 morbid/fatal event on active therapy,VA Cooperative Study Group.JAMA.1967;202:1028-1034.,The VA Cooperative Study,1970,VA Cooperative Study Group.JAMA.1970;213:1143-1152.,The VA Cooperative Study,1970:Assessable Morbid/Fatal Events,VA Cooperative Study Group.JAMA.1970;213:1143-1152.,*P0.001 active drug therapy vs placebo,The VA Cooperative Study,1970:Conclusions,Active treatment reduced fatal and nonfatal endpointsA subsequent analysis revealed that benefits were statistically significant only for those with baseline diastolic blood pressure 105-114 mmHg,VA Cooperative Study Group.Circulation.1972;45(5):991-1004.VA Cooperative Study Group.JAMA.1970;213:1143-1152.,The European Working Party on High Blood Pressure in the Elderly,1985,The European Working Party on High Blood Pressure in the Elderly,1985,Amery A,et al.Lancet.1985;1:1349-1354.,Survival free of event(%),Year of follow-up,EWPHE Cardiovascular Mortality On-Treatment Analysis,Active(n=416),Placebo(n=424),P=0.023,Amery A,et al.Lancet.1985;1:1349-1354.Reprinted with permission from Elsevier Science.,EWPHE=European Working Party on High Blood Pressure in the Elderly,EWPHEConclusions,Active treatment reduced cardiovascular(CV)mortality,largely due to a reduction in cardiac mortalityOlder patients(60 yrs old)with combined systolic and diastolic hypertension who received active therapy experienced 29 fewer CV events and 14 fewer CV deaths per 1,000 patient-years of treatment,Amery A,et al.Lancet.1985;1:1349-1354.,EWPHE=European Working Party on High Blood Pressure in the Elderly,The Hypertension Detection and Follow-up Program,1979,The Hypertension Detection and Follow-up Program,1979,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,Cumulative mortality(%),0,1,3,6,Year of follow-up,HDFP Mortality RatesEntire Cohort,2,4,5,Referred Care,Stepped Care,HDFP=Hypertension Detection and Follow-up Program,*P0.01,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,(n=5,456),(n=5,485),*,0,1,3,6,2,4,5,Cumulative mortality(%),HDFP Mortality RatesDiastolic BP 90104 mmHg,Referred Care,Stepped Care,HDFP=Hypertension Detection and Follow-up Program,Year of follow-up,*P0.01,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,(n=3,822),(n=3,903),*,BP=blood pressure,HDFPConclusions,Overall,stepped care(SC)compared to referred care(RC)reduced total mortality by 17%(6.4 vs.7.7%;P0.01)In patients with baseline diastolic blood pressure 90104 mmHg(n=7,725),mortality was reduced by 20%with SC vs.RC(5.9%vs.7.4%;P0.01)Aggressive treatment of SC patients with the lowest baseline diastolic blood pressures(9094 and 9599 mmHg)reduced mortality,HDFP=Hypertension Detection and Follow-up Program,HDFP Cooperative Group.JAMA.1979;242:2562-2571.,The Systolic Hypertension in the Elderly Program,1991,The Systolic Hypertension in the Elderly Program,1991,SHEP Research Group.JAMA.1991;265:3255-3264.,BP=blood pressure,Change in BP(mmHg),Years,SHEPChange in Blood Pressure,Placebo(n=2,371),Active Rx(n=2,365),Years,Systolic BP,Diastolic BP,SHEP Research Group.JAMA.1991;265:3255-3264.Copyright 1991,American Medical Association.,BP=blood pressure,SHEP=Systolic Hypertension in the Elderly Program,Placebo(n=2,371),Active Rx(n=2,365),Blood pressure(mmHg),0,12,36,60,Months of follow-up,SHEPAverage Blood Pressure During Follow-up,24,48,0,SHEP=Systolic Hypertension in the Elderly Program,SHEP Research Group.JAMA.1991;265:3255-3264.Copyright 1991,American Medical Association.,Cumulative stroke rate per 100 persons,0,12,36,60,Months of follow-up,SHEPCumulative Stroke Rate,24,48,72,P=0.0003,Placebo(n=2,371),Active Rx(n=2,365),SHEP=Systolic Hypertension in the Elderly Program,SHEP Research Group.JAMA.1991;265:3255-3264.Copyright 1991,American Medical Association.,Relative risk(95%CI),Stroke,CHD,Active Therapy vs.Placebo,CHF,Death,0.63,0.46,0.68,0.87,CVD,0.75,SHEPCardiovascular Disease Endpoints,SHEP Research Group.JAMA.1991;265:3255-3264.,SHEP=Systolic Hypertension in the Elderly Program,CHD=coronary heart disease;CHF=congestive heart failure;CVD=cardiovascular disease,SHEPConclusions,SHEP was the first clinical trial to demonstrate that reduction of blood pressure in patients with isolated systolic hypertension reduced cardiovascular(CV)mortalityThe relative risk of stroke was reduced by 36%with therapy compared to placebo(P=0.0003)The 5-year absolute benefits were a reduction in 30 strokes and 55 major CV disease events per 1,000 persons,SHEP Research Group.JAMA.1991;265:3255-3264.,SHEP=Systolic Hypertension in the Elderly Program,The Systolic Hypertension in Europe(Syst-Eur)Trial,1997,The Systolic Hypertension in Europe Trial,1997,Staessen JA,et al.Lancet.1997;350:757-764.,Systolic BP(mmHg),Syst-Eur Mean Sitting Systolic Blood Pressure,0,Placebo(n=2,297),Active treatment(n=2,398),1,2,3,4,Years since randomization,Staessen JA,et al.Lancet.1997;350:757-764.Reprinted with permission from Elsevier Science.,Syst-Eur=Systolic Hypertension in Europe Trial,P0.001,Syst-Eur Mean Sitting Diastolic Blood Pressure,0,1,2,3,4,Diastolic BP(mmHg),Placebo(n=2,297),Active treatment(n=2,398),P0.001,Years since randomization,Staessen JA,et al.Lancet.1997;350:757-764.Reprinted with permission from Elsevier Science.,Syst-Eur=Systolic Hypertension in Europe Trial,Events per 100 patients,Syst-Eur Primary EndpointFatal and Nonfatal Stroke,Placebo(n=2,297),Active treatment(n=2,398),P=0.003,Years since randomization,Staessen JA,et al.Lancet.1997;350:757-764.Reprinted with permission from Elsevier Science.,Syst-Eur=Systolic Hypertension in Europe Trial,Percentage relative risk reduction(95%CI),Stroke,MI,Active therapy vs.placebo,CHF,Death,42%P=0.003,29%,31%P0.001,14%,All CVD,30%,Syst-EurCardiovascular Disease Endpoints,Staessen JA,et al.Lancet.1997;350:757-764.,MI=myocardial infarction;CHF=congestive heart failure;CVD=cardiovascular disease,Syst-Eur=Systolic Hypertension in Europe Trial,Syst-Eur Conclusions,Older men and women with isolated systolic hypertension who received active treatment with a dihydropyridine calcium channel blocker experienced fewer strokes and cardiovascular disease(CVD)events than those receiving placebo.Treatment of 1,000 patients for 5 years with this type of regimen could prevent 29 strokes or 53 major CVD endpoints.,Staessen JA,et al.Lancet.1997;350:757-764.,Syst-Eur=Systolic Hypertension in Europe Trial,The Australian National Blood Pressure(ANBP)Study,1980,The Australian National Blood Pressure Study,1980,The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study Mean Diastolic Blood Pressure,Diastolic blood pressure(mmHg),The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study Incidence of Trial Endpoints(TEP)*,*Rates per 1,000 person-years exposure to risk.P0.05 P0.025,The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study Intention-to-Treat Trial Endpoints,The Australian Study Committee.Lancet.1980;1:1261-1267.,The Australian Study On-Treatment Trial Endpoints(TEP),Number of trial endpoints,Days in trial,2000,1600,1200,600,400,All TEPP0.01,All Fatal TEPP0.05,Active(n=1,721),Placebo(n=1,706),The Australian Study Committee.Lancet.1980;1:1261-1267.Reprinted with permission from Elsevier Science.,The Australian Study Conclusions,The actively treated compared to placebo group experienced 30 fewer trial endpoints endpoints(P0.05)There was a significant reduction in mortality in the actively treated group,mostly due to a reduction in death from cardiovascular disease(P0.025),The Australian Study Committee.Lancet.1980;1:1261-1267.,