【翻译】利尿药和其他类型降压药相比治疗高血压效果有过之而无不及

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【翻译】利尿药和其他类型降压药相比治疗高血压效果有过之而无不及

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2008-02-03 21:09

Diuretics Appear Comparable to or Better Than Other Drugs for Treating Hypertension

Newswise — Use of calcium-channel blockers, alpha-blockers or angiotensin-converting enzyme (ACE) inhibitors appears to offer no advantages in improving clinical outcomes compared with use of diuretics when treating hypertension among individuals with metabolic syndrome, according to a report in the January 28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. This appears particularly true for black patients.
Patients with hypertension (high blood pressure) and metabolic syndrome are at high risk for the complications of cardiovascular disease, according to background information in the article. The metabolic syndrome was defined as hypertension plus at least two of the following factors: diabetes or pre-diabetes; a body mass index (BMI) of at least 30; high triglyceride levels; or low levels of high-density lipoprotein (“good” cholesterol). Because some medications for high blood pressure (including alpha-blockers, ACE inhibitors and calcium channel blockers) have a favorable metabolic profile—for instance, have more favorable short-term effects on blood glucose or blood cholesterol levels—they have been advocated over other drugs (beta-blockers and diuretics) for the treatment of patients with metabolic syndrome.
Jackson T. Wright Jr., M.D., Ph.D., of Case Western Reserve University and University Hospitals Case Medical Center, Cleveland, and colleagues analyzed data from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). A total of 42,418 participants with hypertension and at least one other risk factor for cardiovascular disease were randomly assigned to take a diuretic (chlorthalidone, 15,255 patients), a calcium channel blocker (amlodipine besylate, 9,048 patients), an alpha-blocker (doxazosin mesylate, 9,061 patients) or an ACE inhibitor (lisinopril, 9,054 patients). Each drug was used to start treatment and other drugs could be added if necessary to control blood pressure. Patients were followed for an average of 4.9 years for all drugs except the alpha-blocker; that arm of the trial was discontinued after an average 3.2 years of follow-up in light of increased rates of cardiovascular disease, including a near two-fold increased rates of heart failure, when compared with the diuretic arm. A total of 23,077 ALLHAT participants (54.4 percent) met criteria for metabolic syndrome.
“No differences were noted among the four treatment groups, regardless of race or metabolic syndrome status for the primary end point (non-fatal myocardial infarction [heart attack] and fatal coronary heart disease),” the authors write. Among patients with the metabolic syndrome (7,327 black and 15,750 white patients), the calcium channel blocker, ACE inhibitor and alpha-blocker had higher rates of heart failure compared with the diuretic; the ACE inhibitor and the alpha-blocker also had an increased risk of combined cardiovascular disease.
“The lack of benefit of the agents with the most favorable metabolic profile (i.e., ACE inhibitors and alpha-blockers) was especially marked in the black participants with metabolic syndrome,” the authors write. “The magnitude of the excess risk of end-stage renal [kidney] disease (70 percent), heart failure (49 percent) and stroke (37 percent) and the increased risk of combined cardiovascular disease and combined coronary heart disease strongly argue against the preference of ACE inhibitors over diuretics as the initial therapy in black patients with metabolic syndrome. Similar higher risk was noted for those randomized to the alpha-blocker vs. the diuretic.”
“These findings fail to provide support for the selection of alpha-blockers, ACE inhibitors, or calcium channel blockers over thiazide-type diuretics to prevent cardiovascular or renal outcomes in patients with metabolic syndrome, despite their more favorable metabolic profiles,” the authors conclude.
(Arch Intern Med. 2008;168[2]:207-217. Available pre-embargo to the media at www.jamamedia.org.)
Editor’s Note: This study was supported by a contract from the National Heart, Lung, and Blood Institute and by Pfizer Inc. (ALLHAT). Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail mediarelations@jama-archives.org.

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2008-02-03 21:10

翻译后：
利尿药和其他类型降压药相比治疗高血压效果有过之而无不及
科技信息——根据1月28日《内科学文献》（Archives of Internal Medicine，美国医学协会杂志之一）的报道，在高血压合并代谢综合征人群，钙通道阻滞剂、α-阻滞剂或血管紧张素转换酶抑制剂跟利尿剂相比，就提高临床预后上没有显示出优势。就黑种人群而言，这一点更明确。
根据文章的背景资料，有高血压（血压升高）和代谢综合征的患者并发心血管疾病的风险更高。其中代谢综合征定义为高血压（我认为还是指血压高）合并以下危险因素至少两个：糖尿病或糖尿病前期，体重指数》30，甘油三酯水平升高，或高密度脂蛋白水平降低（“好”胆固醇）。鉴于一些降压药（包括α-阻滞剂，血管紧张素转换酶抑滞剂＆钙通道阻滞剂）对代谢的积极作用——比如，对血糖、血脂水平有更多良好的短期效应——所以，对于合并代谢综合征的病人，他们比其它药物（β受体阻滞剂＆利尿剂）更提倡用。
克利夫兰西储大学＆西储大学医学中心的Jackson T. Wright Jr., M.D., Ph.D.及其同仁们分析了来自“ALLHAT”试验（预防心脏病发作的降压降脂干预治疗试验）的数据。总共有42,418 参与者，他们都有高血压合并至少一项心血管疾病危险因素，被随机分配到利尿剂治疗组（氯噻酮，15,255 名患者）、钙通道阻滞剂治疗组（阿罗地平磺酸盐，9,048 名患者）、α-阻滞剂治疗组（甲磺酸喹唑嗪，9,061 名患者）或血管紧张素转换酶抑制剂治疗组（赖诺普利，9,054 名患者）。每种药物均作为初始治疗药物，血压控制不良时可加用其他药物联合降压（other drugs could be added if necessary to control blood pressure）。除α-阻滞剂治疗组，每组平均随访4.9年；鉴于和利尿剂治疗组比较，α-阻滞剂治疗组心血管疾病发病率(？不知道合适否)增加，包括心力衰竭发病率增加近两倍，平均随访3.2年后就终止了。ALLHAT试验共23,077名参与者（54.4％）符合“代谢综合征”标准。
“不考虑种族或代谢综合征具体情况，主要终点（非致命性心肌梗塞[心脏病发作]＆致命性冠心病）上四个治疗组没有区别，”作者写道。在合并代谢综合征人群（黑种人7327名＆白种人15750名）中，钙通道阻滞剂、血管紧张素转换酶抑制剂＆α-阻滞剂治疗组较利尿剂治疗组有更高的心衰发病率； α-阻滞剂治疗组、血管紧张素转换酶抑制剂治疗组也有并发心血管疾病的危险性增高。
“ACEI＆α-阻滞剂类降压药被认为对代谢有最大的裨益，就合并代谢综合征的黑种人而言，他们缺乏益处，这个结果非常醒目”作者写道。“对于合并代谢综合征的黑种人，衡量一下过分的风险：终末期肾病（70％）、心衰（49％）＆中风（37％）、还有并发心血管疾病＆冠心病的风险增加，这些都强烈的反对舍利尿剂不用而偏爱ACEI类作为初始治疗药物。于利尿剂治疗组比较，α-阻滞剂同样更高危。”“这些结果不能证明对合并代谢综合征的病人预防心血管疾病或肾脏保护，选择α-阻滞剂、血管紧张素转换酶抑制剂或钙通道阻滞剂取代噻嗪类利尿剂是明智的，虽然他们对代谢有更多的裨益”，作者总结。
(Arch Intern Med. 2008;168[2]:207-217. Available pre-embargo to the media at www.jamamedia.org.)
编辑按: This study was supported by a contract from the National Heart, Lung, and Blood Institute and by Pfizer Inc. (ALLHAT). Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.
For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail mediarelations@jama-archives.org

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