从最新指南看高血压患者的抗栓治疗2.ppt

中国进入慢性病时代 高血压是最常见的慢性病 中国目前高血压患者2亿，每年新发1000万 美国指南更新也将强调综合防治 高血压实质是血管性疾病 动脉粥样血栓形成 心血管疾病共同的病理过程 抗血小板药物分类及作用机理 阿司匹林的额外获益 Professor Peter Rothwell, John Radcliffe Hospital, Oxford, and University of Oxford, UK, noted that “previous guidelines have rightly cautioned that in healthy middle aged people the small risk of bleeding on aspirin partly offsets the benefit from prevention of strokes and heart attacks, but the reductions in deaths due to several common cancers will now alter this balance for many people.” 指南对阿司匹林使用人群的推荐 高血压合并不同危险因素的状况 总结 众多基础研究结果表明，血小板于血管壁的粘附、激活和聚集并释放多种细胞因子和炎症因子参与动脉粥样硬化的发生和发展及其事件的发生。首先，多种危险因素均能损伤血管内皮，血小板粘附于受损的血管内皮并释放血栓素A2 (TXA2)、血小板源生长因子（PDGF）、转化生长因子-B(TGF-B)和纤溶酶原激活物抑制物（PAI）等，进一步引起内皮损伤和平滑肌细胞的迁移和增殖，参与动脉粥样硬化的发生与发展。继之，动脉粥样硬化进程中斑块的不稳定是心、脑血管事件发生最重要的病理生理机制。新近研究表明，血小板通过释放细胞趋化因子（chemokine）诱导单核细胞、巨噬细胞和内皮细胞分泌肿瘤坏死因子和细胞趋化因子，同时这些因子又作用于血小板表面的各自受体促使血小板分泌更多的细胞趋化因子和炎症因子，从而参与不稳定斑块的形成，即血小板与炎症细胞间形成的恶性循环是不稳定斑块形成的重要机制之一。最后，由于斑块的不稳定进一步激活血小板形成白血栓并进而激活凝血系统形成大的红血栓而堵塞血管而导致临床上的急性心、脑血管事件的发生。血小板参与从动脉粥样硬化的形成到急性心、脑血管事件发生的全过程。因此，高血压病人的抗血小板治疗有其坚实的理论基础。 * * 看完机制，再从临床试验角度看看阿司匹林对高血压患者的益处 亚组分析显示阿司匹林使高血压亚组人群显著获益 按照血压划分显示阿司匹林使血压>140/90的人群获益 * HOT研究显示阿司匹林使高血压人群主要心血管事件显著降低15%，心肌梗死显著下降36%。 HOT:BACKGROUND: Despite treatment, there is often a higher incidence of cardiovascular complications in patients with hypertension than in normotensive individuals. Inadequate reduction of their blood pressure is a likely cause, but the optimum target blood pressure is not known. The impact of acetylsalicylic acid (aspirin) has never been investigated in patients with hypertension. We aimed to assess the optimum target diastolic blood pressure and the potential benefit of a low dose of acetylsalicylic acid in the treatment of hypertension. METHODS: 18790 patients, from 26 countries, aged 50-80 years (mean 61.5 years) with hypertension and diastolic blood pressure between 100 mm Hg and 115 mm Hg (mean 105 mm Hg) were randomly assigned a target diastolic blood pressure. 6264 patients were allocated to the