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.

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.