近日，英国伦敦卫生与热带医学院教授Emily Herrett及其研究组，分析了四种降压治疗策略对心血管疾病的适用性和后续风险。 这一研究成果于2019年8月24日发表在国际顶尖医学期刊《柳叶刀》上。

研究组使用英国临床实践研究数据链，对30-79岁无心血管疾病的高血压初级治疗患者进行回顾性队列研究。他们评估并比较了四种不同的治疗策略，以确定哪种治疗更合适，分别为2011年英国国家卫生与临床优化研究所（NICE）指南、2019年NICE指南建议、单独血压（阈值≥140/90毫米汞柱）和仅预测10年心血管风险（QRISK2评分≥10%）。

2011年1月1日至2016年3月31日，研究组对1222670例患者中位随访了4.3年。271963名（22.2%）患者符合2011年NICE指南，327429名（26.8%）患者符合2019年NICE指南建议，481859名（39.4%）患者符合单独血压≥140/90毫米汞柱，357840名（29.3%）患者符合QRISK2≥10%。

随访期间，32183例患者被诊断出心血管疾病，总发生率为每1000人年7.1例。符合2011年NICE指南治疗的患者心血管事件发生率为每1000人年15.2例，2019年NICE指南建议为14.9例，单独血压阈值为11.4例，单独QRISK2阈值为16.9例。

按英国人口比例计算，研究组估计2011年NICE指南将避免233152起心血管事件发生（28名患者需要治疗10年才能避免一起事件），2019年NICE指南建议将避免270233起（29名患者），单独血压阈值将避免301523起（38名患者），QRISK2阈值将避免322921起（27名患者）。

综上，基于心血管风险的策略（QRISK2评分≥10%）可比2011年NICE指南多预防三分之一以上的心血管疾病事件，比2019年NICE指南建议多预防五分之一以上的心血管事件，且在避免每起事件的治疗次数上疗效类似。

研究人员表示，世界范围内的降压治疗建议仍主要以血压阈值为指导，尽管有强有力的证据表明降压对不同血压谱的患者都有益处。

附：英文原文

Title: Eligibility and subsequent burden of cardiovascular disease of four strategies for blood pressure-lowering treatment: a retrospective cohort study

Author: Emily Herrett, PhD;Sarah Gadd, MSc;Prof Rod Jackson, PhD;Prof Krishnan Bhaskaran, PhD;Elizabeth Williamson, PhD;Prof Tjeerd van Staa, PhD;Reecha Sofat, MRCP;Prof Adam Timmis, FRCP;Prof Liam Smeeth, FRCGP

Issue&Volume: VOLUME 394, ISSUE 10199, P663-671, AUGUST 24, 2019

Summary: 

Background

Worldwide treatment recommendations for lowering blood pressure continue to be guided predominantly by blood pressure thresholds, despite strong evidence that the benefits of blood pressure reduction are observed in patients across the blood pressure spectrum. In this study, we aimed to investigate the implications of alternative strategies for offering blood pressure treatment, using the UK as an illustrative example.

Methods

We did a retrospective cohort study in primary care patients aged 30–79 years without cardiovascular disease, using data from the UK's Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality. We assessed and compared four different strategies to determine eligibility for treatment: using 2011 UK National Institute for Health and Care Excellence (NICE) guideline, or proposed 2019 NICE guideline, or blood pressure alone (threshold ≥140/90 mm Hg), or predicted 10-year cardiovascular risk alone (QRISK2 score ≥10%). Patients were followed up until the earliest occurrence of a cardiovascular disease diagnosis, death, or end of follow-up period (March 31, 2016). For each strategy, we estimated the proportion of patients eligible for treatment and number of cardiovascular events that could be prevented with treatment. We then estimated eligibility and number of events that would occur during 10 years in the UK general population.

Findings

Between Jan 1, 2011, and March 31, 2016, 1?222?670 patients in the cohort were followed up for a median of 4·3 years (IQR 2·5–5·2). 271?963 (22·2%) patients were eligible for treatment under the 2011 NICE guideline, 327?429 (26·8%) under the proposed 2019 NICE guideline, 481?859 (39·4%) on the basis of a blood pressure threshold of 140/90 mm Hg or higher, and 357?840 (29·3%) on the basis of a QRISK2 threshold of 10% or higher. During follow-up, 32?183 patients were diagnosed with cardiovascular disease (overall rate 7·1 per 1000 person-years, 95% CI 7·0–7·2). Cardiovascular event rates in patients eligible for each strategy were 15·2 per 1000 person-years (95% CI 15·0–15·5) under the 2011 NICE guideline, 14·9 (14·7–15·1) under the proposed 2019 NICE guideline, 11·4 (11·3–11·6) with blood pressure threshold alone, and 16·9 (16·7–17·1) with QRISK2 threshold alone. Scaled to the UK population, we estimated that 233?152 events would be avoided under the 2011 NICE guideline (28 patients needed to treat for 10 years to avoid one event), 270?233 under the 2019 NICE guideline (29 patients), 301?523 using a blood pressure threshold (38 patients), and 322?921 using QRISK2 threshold (27 patients).

Interpretation

A cardiovascular risk-based strategy (QRISK2 ≥10%) could prevent over a third more cardiovascular disease events than the 2011 NICE guideline and a fifth more than the 2019 NICE guideline, with similar efficiency regarding number treated per event avoided.

DOI: https://doi.org/10.1016/S0140-6736(19)31359-5

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31359-5/fulltext