在2017中国国际心力衰竭大会(CIHFC)暨中国医师协会心力衰竭专业委员会年会上，来自中国医学科学院阜外医院的张宇清教授为我们带来了“心力衰竭患者的血压管理问题”的精彩报告。
北京301医院CHF住院患者病因构成
Framingham研究分析了3400名男性和4199名女性，随着血压水平从低到高，心衰的的发生率增长了近一倍。
Donald M,circulation;2002,106(24)3068-72
HYVET:研究结果——血压
HYVET:研究结果——心血管终点
显著降低心力衰竭风险64%
SPRINT:随访期间的收缩压
主要终点及其组成事件发生率、风险比
高血压药物治疗的获益
Alberto Zanchetti, Costas Thomopoulos, Gianfranco Parati, Circ Res. 2015;116:1058-1073
降压治疗和心衰的关系
不同血压水平之间的差异
Alberto Zanchetti, Costas Thomopoulos, Gianfranco Parati, Circ Res. 2015;116:1058-1073
降压治疗的绝对风险降低与剩余风险
Alberto Zanchetti, Costas Thomopoulos, Gianfranco Parati, Circ Res. 2015;116:1058-1073
高血压合并与不合并靶器官损害时血压与冠脉血流和心血管事件的关系
Circulation. 1991;83:845–853.
Ann Intern Med. 2006;144:884–893
ONTARGET:血压达标率与事件的关系
Circulation. 2011;124:1727–1736
Hazard ratios for mortality associated with a 10 mm Hg increase in systolic blood pressure (SBP).
In the pooled heart failure studies, a 10 mm Hg increase in SBP implies a 13% decrease in mortality. Conversely, in the non-heart failure population, an increase in SBP is associated with a poorer prognosis.
C E Raphael et al. Heart 2009;95:56-62
Subgroup analyses of included studies.
C E Raphael et al. Heart 2009;95:56-62
J-curve between SBP & Heart failure
◆The effect of a higher SBP is most marked in populations with a lower starting SBP, with an 18% lower mortality in the lowest tertile (mean SBP 109) and a 10% decrease in the highest tertile (mean SBP 145) per 10 mm Hg higher SBP.
◆It is likely that the magnitude of effect associated with an increase in SBP continues to diminish such that a 10 mm Hg increase from 160 to 170 mm Hg would confer a much smaller decrease in mortality, if any.
◆Studies included in this analysis had a maximum SBP of 158 where there was a non-significant association between SBP and mortality. It may be that a level of blood pressure is reached beyond which a further increase confers an adverse prognosis, with a J-shaped relationship between SBP and mortality.
Arch Intern Med 2006;166:1892–8.
射血分数保留和减低的心衰患者生存趋势
HFPEF特征
◆左室腔不大；
◆向心性肥厚；心肌细胞直径较大，肌丝密度较高
◆LVEF正常；
Irbesartan in Patients with Heart Failure and Preserved Ejection Fraction
N Engl J Med 2008; 359:2456-2467
Between baseline and 6 months, blood pressure declined by a mean (±SD) of 3.8±18.0 mm Hg systolic and 2.1±10.5 mm Hg diastolic in the irbesartan group
N Engl J Med 2008; 359:2456-2467
慢性心衰的治疗药物
2014年中国心力衰竭治疗指南
2016年ESC急慢性心力衰竭指南
药物剂量：不同剂量咪哒普利对心衰患者运动耐量影响
心梗患者使用咪哒普利提高左室射血分数
抗高血压药物与LVH逆转
无症状性靶器官损害标志检测治疗引起改变的敏感性，发生改变需要的时间以及改变的预后价值
总结
◆对心力衰竭患者血压水平的关注更应注意低血压所导致的危害；
◆心力衰竭患者的血压控制目标目前缺乏随机化临床试验的证据；
◆对射血分数保留的心衰患者降压治疗获益有限；
◆RAS抑制剂治疗心力衰竭证据充分，需从心血管事件链的早期进行干预
