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收缩压降至120毫米汞柱以下是否优于140毫米汞柱，尤其是糖尿病患者和既往卒中患者，存在不确定性。 2024年6月27日，中国医学科学院/北京协和医学院/阜外医院李静作为通讯作者在Lancet（IF 98）在线发表题为“Lowering systolic blood pressure to less than 120 mm Hg versus less than 140 mm Hg in patients with high cardiovascular risk with and without diabetes or previous stroke: an open-label, blinded-outcome, randomised trial”的研究论文，该研究进行了一项有或无糖尿病或既往卒中的心血管高危患者收缩压降至120 mm Hg以下，而非140 mm Hg以下的开放标签、盲法结局、随机试验。 研究结果表明，对于心血管高危高血压患者，无论是否患有糖尿病或卒中史，与收缩压低于140 mm Hg的治疗策略相比，收缩压低于120 mm Hg的治疗策略可以预防主要血管事件，并有轻微的额外风险。
Lowering blood pressure is one of the most effective treatments to prevent cardiovascular events, reducing systolic blood pressure to 140 mm Hg is the accepted standard antihypertensive treatment. There is uncertainty as to whether systolic blood pressure below 120 mmHg is a better target than below 140 mmHg, due to limited and conflicting evidence from randomised controlled trials. SPRINT was the only trial to demonstrate that systolic blood pressure below 120 mm Hg was more effective than standard care in reducing cardiovascular high risk and without the risk of major vascular events in patients with diabetes or stroke, and the ACCORD trial compared two systolic blood pressure targets in patients with diabetes and the RESPECT trial compared systolic blood pressure targets in patients with a history of stroke, both with non-significant results. Even in participants with baseline systolic blood pressure below 120 mm Hg, blood pressure reduced the risk of major cardiovascular events. This beneficial effect was weaker in participants with diabetes than in those without diabetes. However, in both analyses, the proportion of participants with baseline systolic blood pressure below 120 mm Hg was very small. In addition, there is little data on the harms of lowering systolic blood pressure below 120 mm Hg. Given the uncertain benefits and potential harms described above, most current clinical guidelines do not recommend lowering systolic blood pressure below 120 mm Hg.
两个治疗组在试验过程中的收缩压（Credit: Lancet）
Here, the investigators report the results of the Effect of Intensive Antihypertensive Therapy on Reducing the Risk of Vascular Event (ESPRIT) trial, which compared the efficacy and safety of intensive antihypertensive therapy for systolic blood pressure below 120 mm Hg in more than 3 years of standard care in more than 11,000 patients at high cardiovascular risk, with or without diabetes mellitus or previous stroke. Throughout the follow-up period (except for the first 3 months of titration), the mean systolic blood pressure was 119.1 mm Hg (SD 11∙1) in the intensive treatment group and 134.8 mm Hg (10∙5) in the standard treatment group. At a median follow-up of 3.4 years, the primary outcome event occurred in 547 (9.7%) participants in the intensive treatment group and 623 (11.1%) participants in the standard care group (hazard ratio [HR] 0.88, 95% CI 0.78-0.99; p = 0∙028). There was no heterogeneity in the effects of diabetic status, duration of diabetes, or history of stroke. The frequency of severe syncope adverse events in the intensive treatment group (24 of 5624 [0∙4%]) was higher than that in the standard treatment group (8 of 5631 [0∙1%]); Hr 3∙00，95% CI 1∙35-6∙68)。 There were no significant differences between the two groups for serious adverse events such as hypotension, electrolyte abnormalities, traumatic falls, and acute kidney injury. Overall, systolic blood pressure below 120 mm Hg prevents major vascular events and death in patients with cardiovascular hypertension at high risk compared with systolic blood pressure less than 140 mm Hg, with a slight risk of disproportionality, regardless of diabetes or a history of stroke. The results of this study provide new evidence on the benefits and harms of treatment with a systolic blood pressure of less than 120 mm Hg.
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https://doi.org/10.1016/S0140-6736(24)01028-6
Editor-in-charge|Explore Jun
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文章来源|“ iNature”
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