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急性脑出血患者的强化降压治疗
Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage


Adnan I. Qureshi ... 心脑血管疾病 其他 • 2016.09.15

强化降压在脑出血急性期是否还有一席之地?


田成林

解放军总医院神经内科

 

脑出血后血压升高是一种常见现象。升高的血压增加血肿扩大的风险,加重脑水肿,并与不良预后相关1,2。在脑出血急性期,控制显著升高的血压是临床常规治疗措施,但降压的最佳目标值并不明确。INTERACT2研究证实,强化降压(收缩压<140 mmHg)在脑出血急性期是安全的。尽管总的死亡率和残疾率没有降低,但通过对功能预后(改良Rankin评分)的分类分析显示,强化降压组的功能恢复优于标准降压组3。据此,美国心脏病学会和卒中学会修订了自发脑出血处理指南中的相关内容,推荐对收缩压在150~220 mmHg(Ⅱa类推荐;B级证据)及超过220 mmHg(Ⅱb类推荐;C级证据)的急性脑出血患者进行强化降压4。但曙光乍现之后,强化降压的前景再次黯淡。2016年9月15日《新英格兰医学杂志》发表了ATACH-2研究的结果。该研究的中期分析显示,与标准降压组(收缩压控制在140~179 mmHg)相比,在发病后4.5小时内将收缩压降至110~139 mmHg以下并维持24小时,没有降低发病后3个月的死亡率和残疾率,并且显著增加7天内肾脏负性事件的风险,研究也因此而提前终止5

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摘要


背景

治疗脑内出血患者急性反应性高血压时,指导选择收缩压目标值水平的资料有限。

 

方法

为了检验强化降低收缩压是否优于标准降压,我们将符合脑出血(出血量<60 cm3)且格拉斯哥昏迷量表(Glasgow Coma Scale,GCS)评分≥5分(评分3~15分,评分越低表示状态越差)的患者随机分配至收缩压目标值为110~139 mmHg组(强化治疗组),或目标值为140~179 mmHg组(标准治疗组),症状发作后4.5小时内静脉给予尼卡地平降压治疗。主要结局是随机分组3个月后的死亡或致残(改良Rankin量表评分4~6分,量表范围从0分[无症状]到6分[死亡]),结局由不知晓治疗分组的研究者确定。

 

结果

基线平均收缩压(±标准差)为(200±27.0)mmHg的1,000名参与者中,500名被分配至强化治疗组,500名被分配至标准治疗组。患者平均年龄61.9岁,56.2%为亚裔。由于预设的中期分析显示无效而停止对患者的招募。在强化治疗组中,38.7%(186/481)的患者出现死亡或致残的主要结局,在标准治疗组中为37.7%(181/480)(相对风险1.04;95%可信区间为0.85~1.27;分析根据年龄、初始GCS积分、有无脑室内出血进行了校正)。在强化治疗组中,1.6%的患者在随机分组后的72小时内发生了现场研究者认为与治疗相关的严重不良事件,标准治疗组为1.2%。与标准治疗组相比,随机分组后7日内,强化治疗组的肾功能不良事件显著增加(9.0%对4.0%,P=0.002)。

 

结论

与以140~179 mmHg为收缩压目标值的标准降压相比,给予颅内出血患者以110~139 mmHg为目标值的治疗未能降低死亡和致残率(由美国国家神经病和卒中研究所[National Institute of Neurological Disorders and Stroke]和美国国家心脑血管中心[National Cerebral and Cardiovascular Center]资助;ATACH-2临床试验在ClinicalTrials.gov注册号为NCT01176565)。





作者信息

Adnan I. Qureshi, M.D., Yuko Y. Palesch, Ph.D., William G. Barsan, M.D., Daniel F. Hanley, M.D., Chung Y. Hsu, M.D., Renee L. Martin, Ph.D., Claudia S. Moy, Ph.D., Robert Silbergleit, M.D., Thorsten Steiner, M.D., Jose I. Suarez, M.D., Kazunori Toyoda, M.D., Ph.D., Yongjun Wang, M.D., Haruko Yamamoto, M.D., Ph.D., and Byung-Woo Yoon, M.D., Ph.D., for the ATACH-2 Trial Investigators and the Neurological Emergency Treatment Trials Network*
Address reprint requests to Dr. Qureshi at the Zeenat Qureshi Stroke Research Center, University of Minnesota, 925 Delaware St. SE, Minneapolis, MN 55455, or at qureshai@gmail.com. *A complete list of the investigators and sites participating in the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial is provided in the Supplementary Appendix, available at NEJM.org.

 

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