【正文】 r e a te d a n d c o n tr o l l e dWong ND et al. Am J Cardiol. 2023。357:9723. Beckman JA et al. JAMA. 2023。m L et al. N Engl J Med. 2023。18:7518. N = 9791。47:191926. Goals for optimal health AACE. Endocr Pract. 2023。 de P et al. N Engl J Med. 2023。 ?Unadjusted Primary posite oute* (%) Followup (months) 60 50 40 30 20 10 0 Conventional Intensive 0 12 24 36 48 60 72 84 96 NNT = 5 Absolute risk reduction = 20% 53% RRR? P = N = 160 with type 2 diabetes and microalbuminuria Steno2: Intensive intervention improves vascular and neuropathic outes G230。360:190313. 120 140 160 180 Usual SBP (mm Hg) Usual DBP (mm Hg) 70 90 100 110 80 Systolic BP Diastolic BP Age at risk (y): 80–89 70–79 60–69 50–59 40–49 Age at risk (y): 80–89 70–79 60–69 50–59 40–49 256 128 64 32 16 8 4 2 1 0 256 128 64 32 16 8 4 2 1 0 IHD mortality (floating absolute risk)* *Plotted on a doubling scale BPLTTC: Comparison of more vs lessintensive BP lowering Events/participants by BPlowering strategy More intensive Less intensive Stroke 140/7494 261/13,394 CHD 274/7494 348/13,394 Major CV events 482/8034 719/13,948 Blood Pressure Lowering Treatment Trialists’ Collaboration. Lancet. 2023。165:14109. Dahl246。 bendroflumethiazide – mg* Primary oute: Nonfatal MI and fatal CHD Followup: years Randomized Doubleblind Dahl246。361:114958. Patients with risk factor (%) 0 10 20 30 40 50 60 70 80 90 100 Hypertension Aged ≥55 years Male Microalbuminuria/proteinuria Smoker Family history of CHD Plasma TC:HDLC ≥6 Type 2 diabetes ECG abnormalities LVH Prior cerebrovascular events Peripheral vascular disease ASCOTBPLA: BP reductions over time Blood pressure (mm Hg) Atenolol 50–100 mg 177。366:895906. Time (years) 0 BP Mean difference = , P 60 100 0 80 120 140 160 180 Mean difference = , P Diastolic BP Systolic BP ASCOTBPLA: Reduction in primary oute Proportion of events (%) 6 2 4 0 1 2 3 4 8 10 5 6 0 Time (years) 10% RRR HR (–) P = Atenolol 50–100 mg 177。366:895906. Nonfatal MI and fatal CHD ASCOTBPLA: Additional reductions with amlodipinebased regimen Dahl246。 perindopril 140 135 130 125 120 0 0 Time (years) mm Hg Brachial SBP Central aortic SBP CAFE Investigators. Circulation. 2023。113:121325. Beyond BP Reduction: Integrating RAAS Modulation in Vascular Protection HOPE Study Investigators. N Engl J Med. 2023. EUROPA Investigators. Lancet. 2023. PEACE Trial Investigators. N Engl J Med. 2023. Vascular protection: Focus on ACE inhibition Study ACE inhibitor Key inclusion criteria Primary oute HOPE N = 9297 ( years) Ramipril 10 mg Vascular disease* (80% had CAD) LVEF ≥40% No heart failure Age ≥55 years CV death, MI, stroke EUROPA N = 12,218 ( years) Perindopril 8 mg CHD No heart failure Age ≥18 years CV death, MI, cardiac arrest PEACE N = 8290 ( years) Trandolapril 4 mg CAD LVEF 40% Age ≥50 years CV death, MI, coronary revascularization *or diabetes + ≥1 CV risk factor LVEF = left ventricular ejection fraction HOPE Study Investigators. N Engl J Med. 2023. EUROPA Investigators. Lancet. 2023. PEACE Trial Investigators. N Engl J Med. 2023. HOPE, EUROPA, PEACE: Conitant CV therapies at baseline HOPE EUROPA PEACE Antiplatelet agents (%) 76 92 91 ?blockers (%) 40 62 60 Lipidlowering agents (%) 29 58 70 Calcium channel blockers (%) 47 31 36 Diuretics (%) 15 9 13 HOPE Study Investigators. N Engl J Med. 2023. EUROPA Investigators. Lancet. 2023. PEACE Trial Investigators. N Engl J Med. 2023. HOPE, EUROPA, PEACE: Primary outes HOPE Patients (%) Placebo 22% RR P 15 5 10 0 20 0 Ramipril 10 mg 2 4 1 3 Time (years) PEACE Placebo Trandolapril 4 mg 30 20 10 15 5 1 2 3 4 5 25 0 6 4% RR P = EUROPA 12 4 10 0 1 3 4 14 0 Placebo Perindopril 8 mg 8 6 2 5 2 20% RR P = RR = risk reduction HOPE, EUROPA, PEACE: Reduction in allcause mortality Events (%) ACEI Placebo HOPE EUROPA PEACE Total Favors ACEI Favors placebo Odds ratio (95% CI) Dagenais GR et al. Lancet. 2023。114:83854. CHD = MI and CV death Blood Pressure Lowering Treatment Trialists’ Collaboration metaanalysis N = 137,356。366:126778. Cholesterol Treatment Trialists’ Collaboration。361:114958. AngloScandinavian Cardiac Outes TrialLipid Lowering Arm ASCOTLLA: Design Dahl246。 perindopril 4–8 mg Atenolol 50–100 mg 177。 perindopril 4–8 mg Atenolol 50–100 mg 177。352:142535. Pedersen TR et al. JAMA. 2023。48:43845. Integrating Aggressive Medical Therapy in Diabetes Aggressive medical therapy in diabetes Adapted from Beckman JA et al. JAMA. 2023。355:2539. Daly CA et al. Eur Heart J. 2023。 HPS Collaborative Group. Lancet. 2023。364:68596. 15 10 5 0 Followup (years) 0 1 2 3 4 Cumulative hazard (%) Placebo 127 events Atorvastatin 10 mg 83 events CARDS: Statin reduces primary oute in diabetes Fatal/nonfatal MI, unstable angina, acute CHD death, resuscitated cardiac arrest, coronary revascularization, stroke Mean baseline LDLC 117 mg/dL 37% RRR (17%–52%) P = CARDS: Safety considerations Colhoun HM et al. Lancet. 2023。346:393403. Reduction in newonset diabetes (%) White (n = 1768) African American (n = 645) Hispanic (n = 508) American Indian (n = 171) Asian (n = 142) N = 3234 with IFG and IGT without diabetes Lifestyle vs placebo Metformin vs placebo Lifestyle vs metformin 0 20 40 60 80 HOPE, EUROPA