常连选-高血压患者的诊断及降压策略.ppt

卒中患者的降压策略 常连选 淇县朝歌镇卫生院 内科执业医师 学士学位 To lower or not lower BP in acute stroke An old debate! Arch Neurology 1985;42:999-1002 Blood pressure management in acute stroke remains controversial to date Expert Rev. Neurother 2010;10(2),225-241 Blood perssure lowering is recommended after the acute phase, including in patients with normal blood pressure (ClassⅠ ,Lever A) ESO Guidelines ischaemic Stroke 2008 有关卒中后血压管理的几个关键问题 何时启动降压治疗？ 降低到什么程度？ 如何选择药物？ 对于正在服药的高血压病人，是否应该继续用药？ 脑卒中患者急性期降压的临床研究 BEST(1988) INWEST(1988) FIST(1996) VENUS(2001) ACCESS(2003) ATACH(2008) INTERACT(2008) CHHIPS(2009) 降压治疗在卒中二级预防的证据 PATS(1995) （Post-stroke antihypertensive treat study） HOPE(2000) (Heart Outcomes Prevention evaluation) PROGRESS(2004) (Perindopril Protection against Recurrent Stroke study) MOSE(2005) (Morbidity and Mortality after Stroke, and Eprosartan compared with Nitrendipine for Secondary Prevention study) TRANSCEND(2008) (Telmisartan Randomised Assessment Study) PROFESS(2008) (Prevention Regimen for Effectively Avoiding Second Strokes) 何时启动降压治疗 Is it dangerous to lower blood preasure early after stroke? EXPRESS(The Early use of Existing Preventive Strategies for Stroke) PhaseⅠ(n=634) April 2002-Sept 2004 Median delay to first prescription: 20 days PhaseⅡ (n=644) Oct2004-March 2007 Median delay to first prescription: 1 days Lancet 2007;370: 1432-1442 Acute blood pressure lowering therapy Ischemic Stroke or ICH 何时启动？ 发病后当天启动降压治疗似乎没有不利的影响 缺乏RCT证实 早期启动有助于提高依从性，更好达标 降压治疗可能是危险的 血流动力性卒中或TIA 严重卒中 进食不足 严重血管狭窄 高肾素血管紧张素活性（ACEI、ARB） Timing of lowering BP in acute phase 急性期降压目标值 对于脑出血，积极降压的安全性已有大量证据证实 脑梗死患者明显降低血压对预后有不利影响 降血压与急性卒中-meta分析 对26个脑卒中RCT的药物临床研究分析： n=4146例，平均69岁，基础BP157/89mmHg 结论： 血压对于急性缺血性卒中的作用是：“U型” 最佳血压点在150/80mmHg Lemoardl-Bee，Blood pressure in Acute Stroke Collaboration (BASC), University of Nottingham,UR 急性期降压目标