舒张压、亚临床心肌损伤与心脏事件：对血压控制的启示
Diastolic Blood Pressure, Subclinical Myocardial Damage, and Cardiac Events: Implications for Blood Pressure Control.
作者信息
McEvoy John W, Chen Yuan, Rawlings Andreea, Hoogeveen Ron C, Ballantyne Christie M, Blumenthal Roger S, Coresh Josef, Selvin Elizabeth
机构信息
Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Ciccarone Center for the Prevention of Heart Disease, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.
Department of Epidemiology and the Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
出版信息
J Am Coll Cardiol. 2016 Oct 18;68(16):1713-1722. doi: 10.1016/j.jacc.2016.07.754. Epub 2016 Aug 30.
BACKGROUND
The optimal systolic blood pressure (SBP) treatment goal is in question, with SPRINT (Systolic Blood Pressure Intervention Trial) suggesting benefit for 120 mm Hg. However, achieving an SBP this low may reduce diastolic blood pressure (DBP) to levels that could compromise myocardial perfusion.
OBJECTIVES
This study sought to examine the independent association of DBP with myocardial damage (using high-sensitivity cardiac troponin-T [hs-cTnT]) and with coronary heart disease (CHD), stroke, or death over 21 years.
METHODS
The authors studied 11,565 adults from the ARIC (Atherosclerosis Risk In Communities) cohort, analyzing DBP and hs-cTnT associations as well as prospective associations between DBP and events.
RESULTS
Mean baseline age was 57 years, 57% of patients were female, and 25% were black. Compared with persons who had DBP between 80 to 89 mm Hg at baseline (ARIC visit 2), the adjusted odds ratio of having hs-cTnT ≥14 ng/l at that visit was 2.2 and 1.5 in those with DBP <60 mm Hg and 60 to 69 mm Hg, respectively. Low DBP at baseline was also independently associated with progressive myocardial damage on the basis of estimated annual change in hs-cTnT over the 6 years between ARIC visits 2 and 4. In addition, compared with a DBP of 80 to 89 mm Hg, a DBP <60 mm Hg was associated with incident CHD and mortality, but not with stroke. The DBP and incident CHD association was strongest with baseline hs-cTnT ≥14 ng/l (p value for interaction <0.001). Associations of low DBP with prevalent hs-cTnT and incident CHD were most pronounced among patients with baseline SBP ≥120 mm Hg.
CONCLUSIONS
Particularly among adults with an SBP ≥120 mm Hg, and thus elevated pulse pressure, low DBP was associated with subclinical myocardial damage and CHD events. When titrating treatment to SBP <140 mm Hg, it may be prudent to ensure that DBP levels do not fall below 70 mm Hg, and particularly not below 60 mm Hg.
背景
最佳收缩压（SBP）治疗目标存在争议，收缩压干预试验（SPRINT）表明收缩压降至120mmHg有益。然而，将收缩压降得如此之低可能会使舒张压（DBP）降至可能损害心肌灌注的水平。
目的
本研究旨在探讨舒张压与心肌损伤（使用高敏心肌肌钙蛋白T[hs-cTnT]）以及21年间冠心病（CHD）、中风或死亡之间的独立关联。
方法
作者研究了社区动脉粥样硬化风险（ARIC）队列中的11565名成年人，分析了舒张压与hs-cTnT的关联以及舒张压与事件之间的前瞻性关联。
结果
平均基线年龄为57岁，57%的患者为女性，25%为黑人。与基线时舒张压在80至89mmHg之间的人（ARIC第2次访视）相比，在该访视时hs-cTnT≥14ng/l的校正比值比在舒张压<60mmHg和60至69mmHg的人群中分别为2.2和1.5。根据ARIC第2次和第4次访视之间6年期间hs-cTnT的估计年度变化，基线时舒张压较低也与进行性心肌损伤独立相关。此外，与舒张压80至89mmHg相比，舒张压<60mmHg与冠心病事件和死亡率相关，但与中风无关。舒张压与冠心病事件的关联在基线hs-cTnT≥14ng/l时最强（交互作用p值<0.001）。舒张压低与hs-cTnT升高和冠心病事件的关联在基线收缩压≥120mmHg的患者中最为明显。
结论
特别是在收缩压≥120mmHg的成年人中，因此脉压升高，舒张压低与亚临床心肌损伤和冠心病事件相关。在将治疗目标调整为收缩压<140mmHg时，谨慎的做法可能是确保舒张压水平不低于70mmHg，特别是不低于60mmHg。
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