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社区综合干预降低高血压患者的心血管风险
作者:小柯机器人 发布时间:2019/9/3 17:20:22

加拿大麦克马斯特大学Jon-David Schwalm与合作者进行了一项大型试验,探讨通过社区为基础的综合干预来降低高血压患者心血管风险的效果。研究论文9月2日在线发表于《柳叶刀》。

HOPE4是一项开放的、基于社区的、随机分组的对照试验,在哥伦比亚和马来西亚30个社区招募了1371名新发或控制不佳的高血压患者。727名被随机分配到对照组进行常规护理,644名被分配到干预组。

干预措施包括非医务工作者通过电脑评估心血管疾病风险和咨询治疗方案,推荐免费降压药和他汀类药物并由医生进行监督,家人朋友对其支持以提高药物依从性并保持健康生活方式。采用弗雷明翰风险评分对两组患者10年心血管疾病的风险进行评估。

30个社区均随访了12个月。对照组的10年心血管疾病风险降低了6.40%,干预组降低了11.17%,差异为-4.78%。干预组患者的收缩压平均降低了11.45 mmHg,低密度脂蛋白平均降低了0.41 mmol/L,差异显著。干预组中有69%的患者血压控制低于140 mmHg,显著高于对照组(30%)。干预组中未发生任何安全问题。

综上,由非医务工作者主导的包括初级保健师和当地家庭成员的综合护理模式可大大改善血压控制,并降低心血管疾病风险。

研究人员介绍,高血压是全球心血管疾病的主要原因。尽管已证明控压有好处,但高血压的控制仍不尽人意。

附:英文原文

Title: A community-based comprehensive intervention to reduce cardiovascular risk in hypertension (HOPE 4): a cluster-randomised controlled trial

Author: Jon-David Schwalm, MD,Tara McCready, PhD,Prof Patricio Lopez-Jaramillo, PhD,Prof Khalid Yusoff, MBBS,Prof Amir Attaran, DPhil,Pablo Lamelas, MSc,Paul A Camacho, MD,Fadhlina Majid, BSc,Prof Shrikant I Bangdiwala, PhD,Prof Lehana Thabane, PhD,Shofiqul Islam, PhD,Prof Martin McKee, DSc,Prof Salim Yusuf, DPhil

Issue&Volume: September 2, 2019

Summary:

Background

Hypertension is the leading cause of cardiovascular disease globally. Despite proven benefits, hypertension control is poor. We hypothesised that a comprehensive approach to lowering blood pressure and other risk factors, informed by detailed analysis of local barriers, would be superior to usual care in individuals with poorly controlled or newly diagnosed hypertension. We tested whether a model of care involving non-physician health workers (NPHWs), primary care physicians, family, and the provision of effective medications, could substantially reduce cardiovascular disease risk.

Methods

HOPE 4 was an open, community-based, cluster-randomised controlled trial involving 1371 individuals with new or poorly controlled hypertension from 30 communities (defined as townships) in Colombia and Malaysia. 16 communities were randomly assigned to control (usual care, n=727), and 14 (n=644) to the intervention. After community screening, the intervention included treatment of cardiovascular disease risk factors by NPHWs using tablet computer-based simplified management algorithms and counselling programmes; free antihypertensive and statin medications recommended by NPHWs but supervised by physicians; and support from a family member or friend (treatment supporter) to improve adherence to medications and healthy behaviours. The primary outcome was the change in Framingham Risk Score 10-year cardiovascular disease risk estimate at 12 months between intervention and control participants. The HOPE 4 trial is registered at ClinicalTrials.gov, NCT01826019.

Findings

All communities completed 12-month follow-up (data on 97% of living participants, n=1299). The reduction in Framingham Risk Score for 10-year cardiovascular disease risk was −6·40% (95% CI 8·00 to −4·80) in the control group and −11·17% (−12·88 to −9·47) in the intervention group, with a difference of change of −4·78% (95% CI −7·11 to −2·44, p<0·0001). There was an absolute 11·45 mm Hg (95% CI −14·94 to −7·97) greater reduction in systolic blood pressure, and a 0·41 mmol/L (95% CI −0·60 to −0·23) reduction in LDL with the intervention group (both p<0·0001). Change in blood pressure control status (<140 mm Hg) was 69% in the intervention group versus 30% in the control group (p<0·0001). There were no safety concerns with the intervention.

Interpretation

A comprehensive model of care led by NPHWs, involving primary care physicians and family that was informed by local context, substantially improved blood pressure control and cardiovascular disease risk. This strategy is effective, pragmatic, and has the potential to substantially reduce cardiovascular disease compared with current strategies that are typically physician based.

期刊信息

LANCET:《柳叶刀》,创刊于1823年。隶属于爱思唯尔出版社,最新IF:59.102
官方网址:http://www.thelancet.com/
投稿链接:http://ees.elsevier.com/thelancet