【文章內(nèi)容簡(jiǎn)介】 r 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。 bendroflumethiazide – mg/potassium Amlodipine 5–10 mg 177。 perindopril 4–8 mg Dahl246。f B et al. Lancet. 2023。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。 bendroflumethiazide – mg/potassium Amlodipine 5–10 mg 177。 perindopril 4–8 mg Dahl246。f B et al. Lancet. 2023。366:895906. Nonfatal MI and fatal CHD ASCOTBPLA: Additional reductions with amlodipinebased regimen Dahl246。f B et al. Lancet. 2023。366:895906. Secondary endpoints Nonfatal MI (excluding silent) + fatal CHD Total coronary endpoint Total CV events and procedures Allcause mortality CV mortality Fatal/nonfatal stroke Fatal/nonfatal HF Tertiary endpoints Development of diabetes Development of renal impairment Rate/1000 patientyears Amlodipinebased (n = 9639) Atenololbased (n = 9618) Amlodipine based better Atenolol based better Unadjusted hazard ratio P NS CAFE: Lower central aortic BP with newer vs older antihypertensive regimen Atenolol 177。 bendroflumethiazide Amlodipine 177。 perindopril 140 135 130 125 120 0 0 Time (years) mm Hg Brachial SBP Central aortic SBP CAFE Investigators. Circulation. 2023。113:121325. Similar effects on brachial BP CAFE: Summary ? Substantial and consistent differences in central aortic BP and hemodynamics with amlodipine 177。 perindopril vs atenolol 177。 bendroflumethiazide, despite similar brachial systolic BP effects ? Central aortic systolic BP and pulse pressure differences may explain ASCOTBPLA outes ? Central aortic pulse pressure may be a determinant of CV outes 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。368:5818. HOPE, EUROPA: Benefit consistent across ancillary therapy Adapted from Dagenais GR et al. Lancet. 2023。368:5818. Odds ratio (95% CI) Antiplatelets No antiplatelets Lipidlowering agents No lipidlowering agents ?blockers No ?blockers Revascularization No revascularization Subgroup Patients (n) 4year rates in placebo groups PInteraction 18,331 3184 9489 12,026 11,323 10,192 10,394 11,123 ACEI better ACEI worse CV death, nonfatal MI, or stroke HOPE, EUROPA, PEACE: Benefit of ACEIs across broad spectrum of risk Dagenais GR et al. Lancet. 2023。368:5818. Trial Patients (n) Annual rates in placebo groups OR (95% CI) P 5 20 40 5 30 15 35 Odds reduction (%) 25 10 0 PEACE 8290 7 (8 to 19) HOPE total 9297 25 (16 to 32) HOPE lower risk 3083 18 (4 to 35) HOPE med risk 3100 20 (3 to 33) HOPE high risk 3114 24 (12 to 34) EUROPA total 12,218 19 (8 to 28) EUROPA lower risk 3976 19 (5 to 38) EUROPA med risk 3975 28 (11 to 41) EUROPA high risk 3975 10 (4 to 22) AIRE 1986 24 (7 to 38) TRACE 1749 25 (9 to 33) SOLVDP 4228 15 (2 to 27) SOLVDT 2569 23 (10 to 33) SAVE 2231 20 (4 to 33) CV death,* nonfatal MI or stroke ACEI worse ACEI better *Or total mortality in AIRE, TRACE, SOLVD, SAVE trials ACEIs vs ARBs: Comparative effect on stroke, HF, and CHD Turnbull F. 15th European Meeting on Hypertension. 2023. Adapted by Strauss MH, Hall AS. Circulation. 2023。114:83854. CHD = MI and CV death Blood Pressur