强化降压是否有益的Meta分析

Is aggressive antihypertension beneficial?a meta-analysis of randomized trials

目的评价当人群血压达到140/90mmHg（1mmHg=0.133kPa）以下时,继续降压是否有益。方法检索Pubmed、EMBASE数据库。入选试验满足条件：试验为随机对照试验,试验终点人群平均血压〈140/90mmHg,两组间终点血压差异有统计学意义。采用比值比（OR）和95%可信区间（95%CI）作为评价强化降压组和常规治疗组各种临床结局有无差异的指标。统计学分析应用RevMan 5.0软件。结果在检索到的文章中共有44个试验满足条件,总计193 772例患者。当血压降到140/90 mmHg以下时,继续降压可减少总病死率（OR=0.89,95%CI=0.85~0.94）、心血管病死率（OR=0.87,95%CI=0.80~0.94）、心血管事件发生率（OR=0.79,95%CI=0.70~0.89）、心肌梗死发生率（OR=0.89,95%CI=0.80~0.99）、非致死性心肌梗死发生率（OR=0.86,95%CI=0.79~0.94）、脑卒中发生率（OR=0.84,95%CI=0.79~0.89）,但同时增加了低血压发生率（OR=2.63,95%CI=1.87~3.71）、高钾血症发生率（OR=2.24,95%CI=1.49~3.38）,而致死性脑卒中发生率（OR=0.73,95%CI=0.52~1.03）、肾衰竭发生率（OR=2.01,95%CI=0.99~4.08）两组间差异无统计学意义。选择强化降压组血压〈130/80mmHg的试验进行亚组分析,强化降压和常规降压组间总病死率（OR=1.02,95%CI=0.89~1.17）、心血管病死率（OR=0.96,95%CI=0.70~1.30）、心肌梗死发生率（OR=0.97,95%CI=0.75~1.25）,差异无统计学意义,但强化降压可以减少脑卒中发生率（OR=0.63,95%CI=0.47~0.84）,心血管事件发生率（OR=0.87,95%CI=0.79~0.96）。结论无论人群基础血压高低,当血压降到140/90mmHg以下时,继续降压可以减少人群总病死率和心血管事件发生率,但同时增加了低血压等不良事件的发生率,而血压降到130/80 mmHg时,继续降压不能减少总病死率和心血管死亡、心肌梗死发生率,但仍可以减少脑卒中发生率。

Objective To evaluate the efficacy of aggressive antihypertensive treatment in patients when achieved blood pressure（BP）is less than 140/90 mmHg（1mmHg=0.133 kPa）.Methods We performed PUBMED,EMBASE searches for randomized antihypertensive clinical trials from 1996 to 2014,enrolled at least 100 patients with achieved BP ≤140/90 mmHg and a follow-up at least one year.Moreover,the trials all had statistic difference between aggressive antihypertensive treatment and standard antihypertensive treatment.Results We identified 44 randomized clinical trials involving 193 772 participants.Compared with standard antihypertensive treatment,participants who received aggressive antihypertensive treatment had similar outcome in fatal stroke（OR =0.73,95%CI =0.52-1.03）,renal failure（OR =2.01,95%CI =0.99-4.08）.Aggressive antihypertensive treatment decreased the risk of total mortality（OR =0.89,95%CI =0.85-0.94）,cardiovascular mortality（OR = 0.87,95%CI = 0.80-0.94）,cardiovascular events（OR =0.79,95%CI =0.70-0.89）,myocardial infarction（OR =0.89,95%CI =0.80-0.99）,stroke（OR =0.84,95%CI =0.79-0.89）,but increased the risk of hypotension（OR =2.63,95%CI =1.87-3.71）,hyperkalemia（OR =2.24,95%CI =1.49-3.38）.We performed a subgroup analysis of trails in which aggressive antihypertensive treatment in patients when achieved blood pressure（BP）is less than 130/80 mmHg.Compared with standard antihypertensive treatment,participants who received aggressive antihypertensive treatment had similar outcome in total mortality（OR =1.02,95%CI =0.89-1.17）,cardiovascular mortality（OR =0.96,95%CI =0.70-1.30）,myocardial infarction（OR =0.97,95%CI =0.75-1.25）.Aggressive antihypertensive treatment decreased the risk of stroke（OR =0.63,95%CI =0.47-0.84）,cardiovascular events（OR =0.87,95%CI =0.79-0.96）.ConclusionThe present evidence suggested that there are some benefit from aggressive antihypertensive treatment in patients when achieved BP is less than 140/90 mmHg,but the risk of serious adverse events increased.But there were hardly any benefit from aggressive antihypertensive treatment in patients when achieved BP is less than 130/80 mmHg,except the risk of stroke decreased.