瑞典老年高血压试验(STOP-Hypertension)

标　　题　瑞典老年高血压试验中的发病率及病死率作　　者　ＤａｈｌｏｆＢ,ＬｉｎｄｈｏｌｍＬＨ,ＨａｎｓｓｏｎＬ,ｅｔａｌ.　　参考文献　Ｌａｎｃｅｔ,1991,338:1281～1285研究的疾病　高血压病。目　　的　是为了评估抗高血压药物治疗对70～84岁老年高血压患者的益处岁的高血压患者,基础血压≥180/90ｍｍＨｇ,或舒张压≥105ｍｍＨｇ。进入试验前12个月内有心肌梗死、脑卒中、体位性低血压及血压>230/120ｍｍＨｇ者已除外。随　　访　随访1～4年,平均25个月。治疗方案　患者被随机安排接受药物或安慰剂治疗,药物治疗任选下列四种方案…     

Cardiovascular Outcomes According to Systolic Blood Pressure in Patients With and Without Diabetes: An ACCOMPLISH Substudy

To evaluate the effects of achieved systolic blood pressure (SBP) during treatment on cardiovascular (CV) outcomes, the authors measured event rates of a composite primary endpoint (CV death or nonfatal myocardial infarction or stroke) at on‐treatment SBPs of ≥140 mm Hg and the 10 mm Hg intervals of <140 mm Hg, <130 mm Hg, and <120 mm Hg in 6459 patients with diabetes (mean age, 67) and 4246 patients without diabetes (mean age, 69) from the Avoiding Cardiovascular Events in Combination Therapy in Patients Living With Systolic Hypertension (ACCOMPLISH) trial. In the diabetic cohort, the primary endpoint was 49% lower (P<.001) at <140 mm Hg than at ≥140 mm Hg, and the separate components of this endpoint were also significantly reduced. Further SBP reductions did not improve outcomes, and at <120 mm Hg they were no longer different (except for stroke) from ≥140 mm Hg. In contrast, in the nondiabetic cohort, the primary endpoint event rate fell steadily (although not significantly) through the decreasing SBP categories until it was reduced by 45% (P=.0413) at <120 mm Hg. Total stroke rates for both the diabetic (−56%, P=.0120) and nondiabetic (−68%, P=.0067) cohorts were lowest at <120 mm Hg, and adverse renal events (serum creatinine increase ≥50%) were significantly lowest in the range of 130 mm Hg to 139 mm Hg for both cohorts. Diabetic patients (<140 mm Hg or <130 mm Hg) and nondiabetic patients (<120 mm Hg) may require different SBP targets for optimal CV protection, although stroke and renal considerations should also influence the selection of blood pressure targets.

There has been uncertainty regarding optimal blood pressure (BP) targets in patients with hypertension. For several years, guideline publications have recommended a systolic BP (SBP) of below 140 mm Hg for most patients,¹, ², ³ although one recent report asserted—for patients aged 60 years or older—that the available clinical trial evidence best supported a goal of below 150 mm Hg.⁴ Most information on BP targets has come from retrospective analyses of major clinical trials that were not originally designed to prospectively compare the effects of differing achieved SPB on cardiovascular (CV) outcomes. Still, these trials have been reasonably consistent in demonstrating that SBP values <140 mm Hg are associated with lower event rates than values ≥140 mm Hg.⁵, ⁶, ⁷, ⁸ Although interpretation of other hypertension trials⁹, ¹⁰ was thought to justify the less rigorous goal of <150 mm Hg in older people,⁴ this recommendation has been disputed.¹¹, ¹² Recently, two prospective trials have explored a more intensive target in predominantly older high‐risk hypertensive patients, comparing CV event rates in patients randomized to SBP targets of <140 mm Hg or <120 mm Hg. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial¹³ found that there was no greater overall CV benefit at <120 mm Hg than at <140 mm Hg, although stroke rates were significantly lower at the more intensive target.¹² However, the Systolic Prevention Intervention Trial (SPRINT),¹⁴ conducted in high‐risk patients without diabetes, did show lower overall fatal and nonfatal CV event rates in patients treated to <120 mm Hg.The Avoiding Cardiovascular Events Through Combination Therapy in Patients Living With Systolic Hypertension (ACCOMPLISH) trial¹⁵ was a major outcomes study designed to compare the effects on CV outcomes of differing classes of drugs in both diabetic and nondiabetic hypertensive patients at high CV risk.¹⁴ Using the ACCOMPLISH database, we have previously analyzed the effects of achieving differing levels of SBPs in the full cohort of patients.⁸ We found that, compared with ≥140 mm Hg, achieving <140 mm Hg produced clear CV outcomes benefits, but that there was no further benefit at lower SBP levels, including <120 mm Hg.In the present study, we have further analyzed CV outcomes according to achieved SBP categories, but studied patients with and without diabetes separately to enable a comparison of optimal treatment targets in these two patient groups.     

Satisfaction with current migraine therapy: experience from 3 centers in US and Sweden

OBJECTIVE: To assess the level of satisfaction and determinants of satisfaction or dissatisfaction of patients presenting in tertiary care, in regard to their usual care (UC) for the acute treatment of migraine. DESIGN/METHODS: Patients seen in 3 headache centers were assessed by means of 21 attributes related to their UC. Questions covered satisfaction with efficacy (including onset of relief, degree of relief, consistency of action, ease of use), tolerability (lack of side effects overall, CNS side effects, other side effects), and willingness to continue using the same medication and to change to another medication. All questions were answered on a 5-point scale (where 1 was strongly agree, 2 was agree, 3 was neutral, 4 was disagree, and 5 was strongly disagree). RESULTS: We assessed 183 subjects (74.8% women, mean age = 39.3 years). UC consisted, as a single drug or combination, of: triptan conventional tablets--62%; triptan disintegrating tablets--8%; sumatriptan nasal spray 9%; sumatriptan injection, 9%; nontriptans--19.6%. Most (54%) had no benefit within the first hour of treatment. The maximum benefit took more than 1 hour to be reached in 69%, and more than 2 hours in 36%. After the maximum benefit had been reached, pain worsened in 61%. Although 58% were satisfied with the degree of relief, 37% were dissatisfied with the speed of effect, 50% with the recurrence of pain, and 42% with the need for a second dose. Most were satisfied with the tolerability (56%). Finally, most (79.7%) said they were willing to try another acute medication. CONCLUSIONS: An important subset of patients, including a large subgroup of patients using triptans, is dissatisfied with their UC. Clinical trials assessing patients' preference should be conducted to complement the information from clinical trials.     

Renal outcomes in hypertensive Black patients at high cardiovascular risk

The ACCOMPLISH trial (Avoiding Cardiovascular events through Combination therapy in Patients Living with Systolic Hypertension) was a 3-year multicenter, event-driven trial involving patients with high cardiovascular risk who were randomized in a double-blinded manner to benazepril plus either hydrochlorothiazide or amlodipine and titrated in parallel to reach recommended blood pressure goals. Of the 8125 participants in the United States, 1414 were of self-described Black ethnicity. The composite kidney disease end point, defined as a doubling in serum creatinine, end-stage renal disease, or death was not different between Black and non-Black patients, although the Blacks were significantly more likely to develop a greater than 50% increase in serum creatinine to a level above 2.6 mg/dl. We found important early differences in the estimated glomerular filtration rate (eGFR) due to acute hemodynamic effects, indicating that benazepril plus amlodipine was more effective in stabilizing eGFR compared to benazepril plus hydrochlorothiazide in non-Blacks. There was no difference in the mean eGFR loss in Blacks between therapies. Thus, benazepril coupled to amlodipine was a more effective antihypertensive treatment than when coupled to hydrochlorothiazide in non-Black patients to reduced kidney disease progression. Blacks have a modestly higher increased risk for more advanced increases in serum creatinine than non-Blacks.     

Metabolic Syndrome, Independent of Its Components, Is a Risk Factor for Stroke and Death But Not for Coronary Heart Disease Among Hypertensive Patients in the ASCOT-BPLA

OBJECTIVE

To evaluate whether in hypertensive patients the risk of cardiovascular disease is greater in association with the metabolic syndrome (MetS) or the sum of its individual components.

RESEARCH DESIGN AND METHODS

Cox regression analysis models were developed to assess the influence of age, sex, ethnicity, and the individual components of MetS on risk associated with the MetS (using several definitions) of coronary outcomes, stroke, and all-cause mortality.

RESULTS

MetS was significantly associated with coronary outcomes, stroke, and all-cause mortality after adjusting for age, sex, and ethnicity. However, when the model was further adjusted for the individual components, MetS was associated with significantly increased risk of stroke (hazard ratio 1.34 [95% CI 1.07–1.68]) and all-cause mortality (1.35 [1.16–1.58]) but not coronary outcomes (fatal coronary heart disease plus nonfatal myocardial infarction 1.16 [0.95–1.43] and total coronary events 1.06 [0.91–1.24]).

CONCLUSIONS

MetS, independent of its individual components, is associated with increased risk of stroke and all-cause mortality but not coronary outcomes.Studies in the recent past evaluating the usefulness of the metabolic syndrome (MetS) have provided equivocal results (1–4). The database from the blood pressure–lowering arm of the Anglo-Scandinavian Cardiac Outcomes Trial-Blood Pressure Lowering Arm (ASCOT-BPLA) (5) provides an excellent opportunity to evaluate whether in hypertensive patients the risk of cardiovascular (CV) disease and death is greater in association with the MetS or the sum of its individual components.     

Rofecoxib in the acute treatment of migraine: a randomized controlled clinical trial

OBJECTIVE: To investigate the efficacy, tolerability, and safety of rofecoxib and ibuprofen for acute migraine treatment. BACKGROUND: Rofecoxib was effective and well tolerated in a previous study of treatment of a single migraine attack. We sought to replicate these findings for a single attack and also study the clinical profile of rofecoxib in the acute treatment of multiple migraine attacks. Ibuprofen was included as a reference nonselective NSAID. METHODS: Adult migraineurs (n = 783) treated one migraine attack with either rofecoxib (25 or 50 mg), ibuprofen 400 mg, or placebo in a randomized, double-blind study. Patients could elect to enroll in a 3-month double-blind extension phase. RESULTS: In the single-attack phase, headache relief at 2 hours postdose was reported by 59.4%, 62.2%, and 57.7% of patients who took rofecoxib 25 mg, rofecoxib 50 mg, and ibuprofen 400 mg, respectively, versus 30.5% for placebo (all P < .001 vs placebo). The active drugs were statistically superior to placebo on a variety of additional measures. In the extension phase, the mean percentage of patients' attacks with headache relief at 2 hours postdose was 61.8% for rofecoxib 25 mg, 65.4% for rofecoxib 50 mg, and 59.3% for ibuprofen 400 mg. The mean percentage of patients' attacks with 24-hour sustained headache relief was greater for rofecoxib 50 mg (52.0%) than for rofecoxib 25 mg (47.8%, P < .050) or ibuprofen (39.0%, P < .010). In the single-attack phase, the adverse event rate was higher for rofecoxib 50 mg (37.8%) than placebo (27.8%, P < .050); rates were similar to placebo for rofecoxib 25 mg (32.0%, n.s.) and ibuprofen 400 mg (28.1%, n.s.). In the extension phase, treatment groups had similar adverse event rates. CONCLUSIONS: Rofecoxib 25 and 50 mg and ibuprofen 400 mg were effective and generally well tolerated in the acute treatment of migraine.