潘生丁对于缺血性卒中的复发和其他血管病变的预防作用:随机对照试验中个体患者资料的荟萃分析

Background and Purpose - Results from randomized controlled trials of dipyridamole, given with or without aspirin, for secondary prevention after ischemic stroke or transient ischemic attack (TIA) have given conflicting results. We performed a meta- analysis using individual patient data from relevant randomized controlled trials. Methods - Randomized controlled trials involving dipyridamole in patients with previous ischemic stroke or TIA were sought from searches of the Cochrane Library, other electronic databases, references lists, earlier reviews, and contact with the manufacturer of dipyridamole. Individual patient data were merged from 5 of 7 relevant trials involving 11 459 patients. Results were adjusted for age, gender, qualifying event, and history of previous hypertension. Results- Recurrent stroke was reduced by dipyridamole as compared with control (OR, 0.82; 95% CI, 0.68 to 1.00), and by combined aspirin and dipyridamole versus aspirin alone (OR, 0.78; 95% CI, 0.65 to 0.93), dipyridamole alone (OR, 0.74; 95% CI, 0.60 to 0.90), or control (OR, 0.61; 95% CI, 0.51 to 0.71). The point estimates obtained for the comparisons of aspirin and dipyridamole versus control (OR, 0.63; significant) or versus aspirin (OR, 0.88; nonsignificant) were similar if the data from the largest trial, ESPS II (which provided 57% of data), were excluded. Similar findings were observed for nonfatal stroke. The combination of aspirin and dipyridamole also significantly reduced the composite outcome of nonfatal stroke, nonfatal myocardial infarction, and vascular death as compared with aspirin alone (OR, 0.84; 95% CI, 0.72 to 0.97), dipyridamole alone (OR, 0.76; 95% CI, 0.64 to 0.90), or control (OR, 0.66; 95% CI, 0.57 to 0.75). Vascular death was not altered in any group. Conclusions - Dipyridamole, given alone or with aspirin, reduces stroke recurrence in patients with previous ischemic cerebrovascular disease. The combination of aspirin and dipyridamole also reduces the composite of nonfatal stroke, nonfatal myocardial infarction, and vascular death as compared with aspirin alone.

一项短暂性脑缺血发作或轻度缺血性脑卒中后的远期存活率与血管事件风险的队列研究

Background: Determinants of survival and of risk of vascular events after tra nsient ischaemic attack (TIA) or minor ischaemic stroke are not well defined in the long term. We aimed to restudy these risks in a prospective cohort of patien ts after TIA or minor ischaemic stroke (Rankin grade≤ 3), after 10 years or mor e. Methods: We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial (recruitment in 1986- 89; arterial ca use of cerebral ischaemia). We included 24 hospitals in the Netherlands that rec ruited at least 50 patients. Primary outcomes were all- cause mortality and the composite event of death from all vascular causes, non- fatal stroke, and non - fatal myocardial infarction. We assessed cumulative risks by Kaplan- Meier a nalysis and prognostic factors with Cox univariate and multivariate analysis. Fi ndings: Follow- up was complete in 2447 (99% ) patients. After a mean follow- up of 10.1 years, 1489 (60% ) patients had died and 1336 (54% ) had had at le ast one vascular event. 10- year risk of death was 42.7% (95% CI 40.8- 44. 7). Age and sex- adjusted hazard ratios were 3.33 (2.97- 3.73) for age over 65 years, 2.10 (1.79- 2.48) for diabetes, 1.77 (1.45- 2.15) for claudication, 1. 94 (1.42- 2.65) for previous peripheral vascular surgery, and 1.50 (1.31- 1.71 ) for pathological Q waves on baseline electrocardiogram. 10- year risk of a vascular event was 44.1% (42.0- 46.1). After falling in the first 3 years, yearly risk of a vascular ev ent increased over time. Predictive factors for risk of vascular events were sim ilar to those for risk of death. Interpretation: Long- term secondary preventio n in patients with cerebral ischaemia still has room for further improvement.

稳定性心衰高血压患者可否用奥美沙坦?

AHA 2014年会的一项报告表明,在伴有稳定性心衰的高血压患者中,在血管紧张素转换酶抑制剂（ACEI）和/或β阻滞剂基础上添加血管紧张素受体拮抗剂（ARB）奥美沙坦未能改善其临床转归。此项研究共纳入1 147例伴有症状性心衰的高血压患者,并且受试者均接受ACEI和/或β阻滞剂治疗。将患者随机分入对照组或奥美沙坦组,并进行3--6年的随访。患者平均男性65岁,男性为75%,并且大多数为NYHA Ⅱ级。主要终点由全因死亡、非致命性心梗、非致命性卒中和心衰住院组成。

高血压治疗期间左心室质量改变的预后价值

Context: Increased baseline left ventricular(LV) mass predicts cardiovascular( CV) complications of hypertension, but the relation between lower LV mass and ou tcome during treatment for hypertension is uncertain. Objective: To determine wh ether reduction of LV mass during antihypertensive treatment modifies risk of ma jor CV events independent of blood pressure change. Design, Setting, and Partici pants: Prospective cohort substudy of the Losartan Intervention For Endpoint Red uction in Hypertension(LIFE) randomized clinical trial, conducted from 1995 to 2 001. A total of 941 prospectively identified patients aged 55 to 80 years with e ssential hypertension and electrocardiographic LV hypertrophy had LV mass measur ed by echocardiography at enrollment in the LIFE trial and thereafter were follo wed up annually for a mean(SD) of 4.8(1.0) years for CV events. Main Outcome Mea sures: Composite end point of CV death, fatal or nonfatal myocardial infarction, and fatal or nonfatal stroke. Results: The composite end point occurred in 104 patients(11%). The multivariable Cox regression model showed a strong associati on between lower intreatment LV mass index and reduced rate of the composite C V end point(hazard ratio[HR], 0.78 per 1SD(25.3) decrease in LV mass index; 95 %confidence interval[CI], 0.65-0.94; P=.009) over and above that predicted by reduction in blood pressure. There were parallel associations between lower in treatment LV mass index and lower CV mortality (HR, 0.62; 95%CI, 0.47-0.82; P= .001), stroke (HR, 0.76; 95%CI, 0.60-0.96; P=.02), myocardial infarction (HR, 0.85; 95%CI, 0.62-1.17, P=.33), and allcause mortality (HR, 0.72; 95%CI, 0. 59-0.88, P=.002), independent of systolic blood pressure and assigned treatment . Results were confirmed in analyses adjusting for additional CV risk factors, e lectrocardiographic changes, or when only considering events after the first yea r of study treatment. Conclusion: In patients with essential hypertension and ba seline electrocardiographic LV hypertrophy, lower LV mass during antihypertensiv e treatment is associated with lower rates of clinical end points, additional to effects of blood pressure lowering and treatment modality.

老年人认知和预后研究(SCOPE):随机分组后未接受附加治疗患者的结局

Objective: To assess clinical outcomes in the Study on Cognition and Prognosis in the Elderly(SCOPE) in patients who did not receive add-on antihypertensive therapy after randomization, i.e. in patients that best reflect the original intention of a placebo-controlled trial. Design: Post-hoc analysis of a prospective, randomized, controlled trial. Settings and participants: Five hundred and twenty-seven centres in 15 countries participated in SCOPE. Patients aged 70-89 years, with systolic blood pressure 160-179 mmHg and/or diastolic blood pressure 90-99 mmHg, and preserved cognitive function were eligible. Out of 4937 patients in SCOPE, 2098 did not receive add-on therapy. Intervention: The number of patients who received candesartan 8-16 mg once daily was 1253, and 845 received placebo. Mean follow-up was 3.7 and 3.5 years, respectively. Main outcome measures: Primary: major cardiovascular events(cardiovascular mortality, non-fatal stroke or non-fatal myocardial infarction). Secondary: total mortality, cardiovascular mortality, fatal and non-fatal myocardial infarction, fatal and non-fatal stroke, cognitive function, and dementia. Results: The treatment groupswere generally well balanced for baseline characteristics. Blood pressure fell by 21.8/11.0 mmHg in the candesartan group and by 17.2/ 8.4mmHgin the placebo group. There were significant relative risk reductions with candesartan in major cardiovascular events(32%,P=0.013), cardiovascular mortality(29%,P=0.049), and total mortality(27%, P =0.018). There were no significant differences between the treatment groups in cognitive outcomes. Both treatments were generally well tolerated. Conclusions: Treatment of elderly patients with mild hypertension is beneficial and supports current recommendations. Candesartan appears an appropriate therapy in such patients, in view of its favourable tolerability profile and ability to reduce major cardiovascular events.