降压治疗预防脑卒中的成本效益分析

目的:探讨预防脑卒中降压治疗药物选择的理想方案。方法:通过入选国内、外大样本,随机对照,有脑卒中为终点事件的高血压临床试验结果,结合中国原发性高血压的流行病学及转归特点,进行成本-效益的综合分析。结果:降压治疗高血压对预防各种心血管事件均有效,但以脑卒中效果最佳,且成本低,首选钙拮抗剂,其次为利尿剂,对减少心脏事件的效果以β-受体阻滞剂和血管紧张素转换酶抑制剂为佳。而中国高血压的流行病学特点为:低治疗率,低控制率,低知晓率,高发病率。预后主要是脑卒中约占77%。结论:对中国高血压防治的人群策略,首选廉价的利尿剂和钙拮抗剂,同时可提高治疗率;高血压治疗的方案应以预防脑卒中为主,应首选钙拮抗剂和利尿剂;个体治疗方案取决病人的临床评估,既存在的危险因素和对药物的耐受性来决定。昂贵的药未必是好药。     

降压治疗预防脑卒中的成本效益分析

目的：探讨预防脑卒中降压治疗药物选择的理想方案。方法：通过人选国内、外大样本，随机对照，有脑卒中为终点事件的高血压临床试验结果，结合中国原发性高血压的流行病学及转归特点，进行成本-效益的综合分析。结果：降压治疗高血压对预防各种心血管事件均有效，但以脑卒中效果最佳，且成本低，首选钙拮抗剂，其次为利尿剂，对减少心脏事件的效果以β-受体阻滞剂和血管紧张素转换酶抑制剂为佳。而中国高血压的流行病学特点为：低治疗率，低控制率，低知晓率，高发病率。预后主要是脑卒中约占77％。结论：对中国高血压防治的人群策略，首选廉价的利尿剂和钙拮抗剂，同时可提高治疗率；高血压治疗的方案应以预防脑卒中为主，应首选钙拮抗剂和利尿剂；个体治疗方案取决病人的临床评估，既存在的危险因素和对药物的耐受性来决定。昂贵的药未必是好药。     

对2004年降压治疗预防血管事件的大型随机试验的回顾分析

目的评估2004年结束的国际大规模多中心降压治疗预防血管事件的随机临床试验。方法研究人选标准为：大规模多中心降压治疗高血压的随机临床试验；长期试验且样本大于5000例；研究终点包括死亡、心梗、卒中及其他血管事件。结果2004年结束的国际大规模多中心降压治疗预防血管事件的随机临床试验主要有VALUE、ACTION、INVEST、PEACE等。全部试验均采用多中心随机对照方法。试验人选患者最少7665例，最多22599例。随访3—5年。试验受试对象均为有并有冠心病的高血压患者。试验分别选用ARB、β-blockers、ACEICCB。硝苯地平控释片显著减少新发心衰；减少心血管介入治疗、降低心血管死亡。ARB、ACEI显著减少新发糖尿病。结论大规模随机临床试验表明：降压治疗对高血压及脑血管病患者是有益的。ARB、β-blockers、ACEICCB减少高危高血压患者的血管事件，上述药物之间无显著性差异。     

高血压降压治疗达标率低的原因及干预效果分 析简

我国高血压患者数量居世界之首,但居民高血压知晓率、治疗率、治疗满意控制率（达标率）均很低。高血压是心、脑、肾等靶器官损害的主要原因,是一种可防可控的心血管危险因素。积极有效的降压治疗（降压达标）可以显著降低脑卒中、冠心病等致死致残性心血管事件的危险性。本次研究选取高血压降压治疗未达标者181例,进行分析和干预,现将结果报道如下。     

高血压病治疗中的利益—危险概念

近年来多个大型临床前瞻性试验结果提示:降压对降低卒中、左心衰、肾衰的发生率与死亡率有益,对冠心病却令人失望。从而使高血压治疗概念发生了很大的改观。过去认为高血压的治疗目标是充分降压,治疗效益与所用药物无关。然而,虽已明确降压治疗使脑卒中发病率、死亡率降低,但总死亡率、冠心病发病率、死亡率均无明显下降甚至上升。对这矛盾的现象解释认为:可能某些降压药物引起的脂质和糖代射紊乱等可抵消控制血压的潜在益处,甚至致病作用超过降压的防护作用。因此,高血压病治疗应根据病人临床资料合理选药联用,力求减少治疗危险,获得最大降压效益,即为利益—危险比例概念是高血压病治疗的关键。     

他汀类降脂药能降低缺血性脑卒中患者再发卒中的风险

目的 观察他汀类药物在缺血性脑卒中二级预防中的作用.方法 将2006年以来在本院住院治疗的脑卒中/TIA患者60例随机分为他汀干预组和对照组.对照组仅接受康复治疗及危险因素治疗,干预组在对照组治疗基础上加用阿托伐他汀20 mg 1次/d治疗,观察3年内两组患者再发脑卒中/TIA,死亡以及其他心血管事件发生率.结果 干预组再发脑卒中/TIA,冠脉事件发生率低于对照组,而死亡率,脑出血发生率两组却无明显差异.结论 他汀类药物能有效预防脑卒中/TIA患者再发心脑血管事件的发生.     

他汀类降脂药能降低缺血性脑卒中患者再发卒中的风险

目的 观察他汀类药物在缺血性脑卒中二级预防中的作用.方法 将2006年以来在本院住院治疗的脑卒中/TIA患者60例随机分为他汀干预组和对照组.对照组仅接受康复治疗及危险因素治疗,干预组在对照组治疗基础上加用阿托伐他汀20 mg 1次/d治疗,观察3年内两组患者再发脑卒中/TIA,死亡以及其他心血管事件发生率.结果 干预组再发脑卒中/TIA,冠脉事件发生率低于对照组,而死亡率,脑出血发生率两组却无明显差异.结论 他汀类药物能有效预防脑卒中/TIA患者再发心脑血管事件的发生.     

抗高血压药物对冠心病的影响

近年来,多个大型临床前瞻性试验结果提示:降压治疗使脑卒中发病率、死亡率降低,但总死亡率、冠心病的发病率、死亡率均无明显下降,甚至上升。这可能与降压引起的代谢异常、左室肥厚、血液动力学变化等抵消了降压的益处,甚至致病作用超过降压的防护作用。本文重点讨论各种降压药对冠心病危险因素的影响。     

再发缺血性脑卒中患者对二级预防危险因素认知的调查分析

目的:了解再发缺血性脑卒中住院患者对二级预防危险因素知识、控制态度的情况,为保证健康教育质量,开展干预措施提供依据.方法:对80例我院神经内科住院的再发缺血性脑卒中患者,采用自行设计的卒中危险因素问卷进行调查.结果:再发缺血性脑卒中患者对危险因素掌握不足,缺血性脑卒中知识、态度、行为不一致,控制力较低.结论:再发缺血性脑卒中患者对二级预防的危险因素知晓率及控制率仍较低,需对再发缺血性脑卒中患者普及二级预防知识,提供规范的健康教育,开展有效脑卒中防治工作.     

高血压合并冠心病的防治要点

目前,高血压患者中约3%～5%合并冠心病,中国高血压患者的心血管病危险性比较高,本身属于重度危险者,即一个高血压相当于3项危险因素.我国已有大量研究资料显示,高血压对我国人群心血管病发病的影响远大于其他危险因素,是我国人群发生心血管病事件的首要危险因素,其独立致病的相对危险为3.4,人群归因危险百分比为35%.高血压是心脑血管病的第一危险因素.EUROPA、ACTION以及ASCOT等研究证实,降压达标可使冠心病发病率和死亡率显著下降20%左右,脑卒中下降30%以上.     

Preventable stroke and stroke prevention

Stroke is a major cause of death and disability in the world. The main causes of stroke are atherothromboembolism and cardiogenic embolism. The main causal and treatable risk factors for atherothromboembolic ischemic stroke are increasing blood pressure (BP), increasing cholesterol, cigarette smoking and diabetes; and the main risk factors for cardiogenic ischemic stroke are atrial fibrillation (AF) and ischemic heart disease. Strategies to reduce the incidence of stroke include prevention of first-ever and recurrent stroke, and treatment of patients with acute stroke to reduce death and disability. The two main strategies of stroke prevention are the 'population' (or 'mass') approach and the 'high risk' approach. The 'population' approach aims to reduce stroke by lowering the prevalence and mean level of causal risk factors in the community, by means of public education and government legislation. The 'high risk' approach aims to reduce stroke by identifying individuals at high risk of stroke, and lowering their risk by means of optimal medical therapies. Level 1 evidence from randomized controlled trials indicates that effective treatments for high risk patients include control of causal risk factors (lowering BP, lowering blood cholesterol), antithrombotic therapy (antiplatelet therapy with aspirin, clopidogrel, or the combination of aspirin and dipyridamole for patients in sinus rhythm, and anticoagulation with warfarin or ximelagatran for patients in AF) and, where appropriate, carotid revascularization for patients with severe carotid stenosis.     

卒中后不同降压方案的有效性及安全性:系统评价及meta分析

目的 评价不同降压方案在卒中二级预防中的有效性及安全性.方法 检索Pubmed、Embase、Cochrane图书馆、万方、中国知网、重庆维普、中国生物医学文献数据库(CBM)等中英文数据库,检索时间为数据库起始时间至2020年6月1日.纳入标准:比较降压治疗组与对照组(安慰剂或空白对照)或比较强化降压组与标准降压组(...     

培哚普利治疗对防治高血压合并脑卒中患者并发症的临床试验

目的 探讨培哚普利降压治疗对预防高血压合并脑卒中患者并发症的研究。方法 对155例既往有脑卒中病史的轻中度高血压病患者随机分组,进行三年的培哚普利及安慰剂的双盲对照临床试验,观察三年的治疗组及安慰剂组的血压、心脑血管并发症的发生率及病死率,在研究结束时给予连续3日动态血压监测(ambulatory blood pressuremonitoring,ABPM)。结果 与安慰剂组比较,治疗组3日动态血压监测示血压控制满意,三年心脑血管并发症的发生率和死亡率(分别为6.85％和2.74％)明显低于安慰剂组(17.10％和9.21％)。结论 培哚普利降压有效、平稳、持久,持续降压治疗对预防高血压合并脑卒中患者心脑血管并发症具有重要作用。     

Acetylsalicylic acid + extended-release dipyridamole combination therapy for secondary stroke prevention

BACKGROUND: Approximately 25% of strokes are recurrent. Antiplatelet therapy is indicated for the prevention of recurrent stroke in patients with a history of noncardioembolic minor stroke or transient ischemic attack (TIA). Although clinicians may choose acetylsalicylic acid (ASA) as first-line therapy for secondary prevention, clinical guidelines and evidence from trials suggest that ASA may not be the most effective strategy. OBJECTIVE: The purpose of this review was to discuss results from clinical trials that have compared the efficacy of ASA monotherapy versus ASA + extendedrelease dipyridamole in secondary stroke prevention. METHODS: Relevant randomized experimental and clinical studies in patients with a history of minor stroke or TIA of noncardioembolic etiology were identified using a search of the US National Library of Medicine database, with no limits on publication dates. The primary search terms used were secondary stroke prevention, antiplatelet therapy, acetylsalicylic acid, ASA, aspirin, aspirin + extended-release dipyridamole, and combination therapy. RESULTS: Early trials of dipyridamole monotherapy or ASA + dipyridamole involved small numbers of patients and found no significant treatment differences. Two major trials that compared ASA monotherapy, dipyridamole monotherapy, and ASA + dipyridamole were identified: the Second European Stroke Prevention Study (ESPS-2) and the European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT). Efficacy measurements in ESPS-2 found that stroke relative risk reductions were 18% (P = 0.013), 16% (P = 0.039), and 37% (P < 0.001), respectively, compared with placebo for a relative risk reduction of 23.1% (P = 0.006) favoring the combination over ASA monotherapy. In ESPRIT, patients who received ASA + dipyridamole had a 20% relative risk reduction versus ASA monotherapy for the composite end point of death from all vascular causes, nonfatal stroke, nonfatal myocardial infarction, or major bleeding complications. In ESPS-2, headache was 5% more common with dual therapy compared with ASA monotherapy. ESPRIT found that combination treatment was not associated with a higher complication rate than ASA monotherapy, but that the rate of withdrawal due to adverse events was higher in the group that received the combination. CONCLUSION: Based on the results from these 2 large, randomized trials, ASA + dipyridamole was more effective than ASA monotherapy as first-line therapy for secondary stroke prevention in these patients with a history of minor stroke or TIA of noncardioembolic etiology.     

Age and gender bias in statin trials

Cardiovascular disease is strongly age-related, and is the leading cause of death in older people. Several well-publicized trials have recently reported that statin drugs (HMG CoA reductase inhibitors) are effective in lowering cholesterol and in reducing the risk of myocardial infarction and stroke. In order to determine whether the results of these trials are relevant to our ageing population, we examined the representation of older people and women in randomized controlled trials of statin drugs. A systematic search of the medical literature from 1990 to 1999 was done to identify randomized placebo-controlled trials of statin drugs which evaluated clinical end-points-myocardial infarction, stroke or death. We identified 19 trials: 15 secondary prevention and four primary prevention. The mean age, age range and gender of the participants in these trials were determined. In the secondary prevention trials, the total number of patients randomized was 31683, with a combined mean age of 58.1 years. No trial enrolled people beyond the age of 75 years, and only 23% of the trial population was female. The four primary prevention trials randomized a combined total of 14 557 subjects with a mean age of 56.9 years. Only 10% of study participants were female. Statin drug trials have suffered from age and gender bias, having been mainly conducted in middle-aged male populations. The extrapolation of evidence from these trials to older people and women needs further evaluation.     

Antihypertensive therapy in patients with stroke

Most patients with acute ischemic stroke do not need antihypertensive therapy, because the rapid lowering of blood pressure (BP) may reduce cerebral blood flow due to impaired cerebral autoregulation. In patients with severe hypertension, or associated with other complications (hemorrhagic transformation, myocardial infarction, renal failure or dissection of the aorta), antihypertensive therapy should be done cautiously. In chronic phase, the optimal BP level for the prevention of stroke recurrence remains unclear. The presence of the J-curve phenomenon is still controversial. The several large scale trials are now in progress to determine the optimal BP level for the secondary prevention in stroke patients.     

Effect of homocysteine interventions on the risk of cardiocerebrovascular events: a meta‐analysis of randomised controlled trials

Aims: To evaluate the effects of homocysteine lowering intervention on the risk of cardiocerebrovascular events and all‐cause mortality in randomised controlled trials among people with preexisting cardiocerebrovascular or renal disease. Methods: Studies were retrieved by searching MEDLINE and OVID (from January 1966 to December 2008) using the following keywords: homocysteine, hyperhomocysteinaemia, cardiovascular disease, coronary disease, cerebrovascular disease, B vitamins, folic acid, randomised controlled trial. References of all retrieved articles were also searched. Randomised controlled trials which compared folic acid or plus B vitamins supplementation with either placebo or usual care were evaluated with cardiocerebrovascular disease events or all‐cause mortality reported as an end‐point. Data on study design, characteristics of participants, changes in homocysteine levels, and cardiocerebrovascular events and all‐cause mortality were independently abstracted by two investigators using a standardised protocol. Results: Seventeen trials involving 39,107 patients with preexisting cardiocerebrovascular or renal disease were included. Results of meta‐analyses showed that no significant differences were identified between the intervention group and the control group. The overall relative risks (95% confidence intervals) of outcomes for patients treated with folic acid or plus B vitamins supplementation compared with controls were 1.01 (0.97–1.05) for cardiovascular events, 1.01 (0.94–1.07) for coronary heart disease, 0.94 (0.85–1.04) for stroke and 1.00 (0.95–1.05) for all‐cause mortality. In the exclusion of low‐quality trials and seven trials in grain fortification countries respectively, sensitivity analyses did not change the overall results. Conclusion: There is no sufficient evidence to show that homocysteine lowering intervention can reduce the risk of cardiocerebrovascular diseases or all‐cause mortality among people with preexisting vascular disease. Folic acid supplementation should not be recommended for the secondary prevention of cardiocerebrovascular diseases. More evidence from large‐scale randomised controlled trials is needed to confirm this.     

Rhythm or rate control in atrial fibrillation: insights from the randomized controlled trials

Pharmacologic treatment remains the mainstay of therapy in patients with atrial fibrillation for the maintenance of normal sinus rhythm. Initial therapy of atrial fibrillation is often directed toward the maintenance of sinus rhythm by means of cardioversion and the use of antiarrhythmic drugs. Heart rate control is often only pursued when rhythm control fails. Four randomized controlled trials have carefully evaluated the yield of these two treatment strategies as the initial approach to patients with paroxysmal or persistent atrial fibrillation. In essence, all four trials demonstrated that an initial strategy of rate control is equally effective compared to the rhythm control approach in terms of clinically important outcome measures including mortality, stroke prevention, or quality of life. Accordingly, rate control can be considered as an initial approach to therapy in patients with paroxysmal or persistent atrial fibrillation. The four randomized trials clearly demonstrate that continuous anticoagulation is mandatory in all patients with atrial fibrillation and risk factors for stroke, irrespective of the initial therapeutic approach of rhythm or rate control.     

Candesartan cilexetil in the management of blood pressure for acute and recurrent stroke in Japan: the Challenge-Stroke study

The Challenge-Stroke study was conducted in Japanese patients initiated on candesartan cilexetil therapy within 3 months of suffering a stroke to investigate the clinical use of candesartan and its efficacy/safety in this therapeutic setting. A total of 869 patients formed the safety analysis set. In total, 79.6% of patients with brain hemorrhage (BH) and 60.2% with brain infarction (BI) began candesartan before post-stroke day 3 and 7, respectively. Baseline average blood pressure (BP) was 152.0/83.2 mmHg in the BH group and 165.2/89.8 mmHg in the BI group; this was reduced to 125.8/75.4 mmHg and 136.3/78.1 mmHg, respectively, at 1 year. The incidence of adverse drug reactions was 6.7 and 8.0%, respectively. There were 12 recurrent strokes in the BH group and 11 in the BI group after 1 year. The risk of recurrent stroke was significantly higher for BH patients with a final systolic BP ≥150 mmHg than for those with a final systolic BP <130 mmHg (hazard ratio: 6.807; p = 0.004). Aggressive antihypertensive therapy is currently employed in Japanese patients with acute stroke. Candesartan was safe and effective for BP control in acute stroke patients. Strict BP management may be useful for secondary prevention of stroke after BH.     

Current approaches to the treatment of hypertension in older persons

Hypertension is a major risk factor for cardiovascular disease and is present in 69% of patients with a first myocardial infarction, in 77% of patients with a first stroke, in 74% of patients with chronic heart failure, and in 60% of patients with peripheral arterial disease. Double-blind, randomized, placebo-controlled trials have demonstrated that antihypertensive drug therapy reduces cardiovascular events in patients aged 65 to 79 years. In the Hypertension in the Very Elderly Trial, patients aged ≥ 80 years who were treated with antihypertensive drug therapy had, at 1.8-year follow-up, a 30% reduction in fatal or nonfatal stroke (P = 0.06), a 39% reduction in fatal stroke (P = 0.05), a 21% reduction in all-cause mortality (P = 0.02), a 23% reduction in cardiovascular death (P = 0.06), and a 64% reduction in heart failure (P < 0.001). Although the optimal blood pressure (BP) treatment goal in the elderly has not been determined, existing epidemiologic and clinical trial data suggest that a reasonable therapeutic BP goal should be < 140/90 mm Hg in persons aged < 80 years and a systolic BP of 140 to 145 mm Hg if tolerated in persons aged ≥ 80 years. Nonpharmacologic lifestyle measures should be encouraged both to prevent development of hypertension and as adjunctive therapy in persons with hypertension. Diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, and calcium channel blockers have all shown benefit in reducing cardiovascular events in randomized trials. The choice of specific drugs depends on efficacy, tolerability, presence of specific comorbidities, and cost. Adverse effects from treatment, such as electrolyte disturbances, renal dysfunction, and excessive orthostatic BP reduction, should be avoided.