ỨC CHẾ MEN CHUYỂN và CHẸN THỤ THỂ ANGIOTENSINE TRONG điều TRỊ TĂNG HUYẾT áp ở BỆNH NHÂN có BỆNH ĐỘNG MẠCH VÀNH

ỨC CHẾ MEN CHUYỂN VÀ CHẸN
THỤ THỂ ANGIOTENSINE
TRONG ĐIỀU TRỊ TĂNG HA Ở
BN CÓ BỆNH ĐM VÀNH
PGS.TS Trương Quang Bình

ĐH Y Dược - TPHCM
Angiotensinogen
Angiotensin I
Angiotensin II
Adrenalin
release
Inflammatory
responses
Na
+
, H
2
O
reabsorption
ACE inhibition
Renin inhibition
Selective AT
1
-
receptor
blockade
Vasopressin
release
Aldosterone
production

AT
1
AT
2
ACE
Renin
Bradykinin
degradation
The Renin-Angiotensin System
Alternative pathways
AT
3
AT
4
?
ACE-inhibitors in high risk patients ≥55
years of age: HOPE trial
- 9,297 patients

- Documented CAD
or DM + 1 RF

- No history of
CHF or
LV dysfunction
The HOPE investigators. N Engl J Med 2000;342:145-153.
CV death, AMI or stroke
RRR 28% (14-30)
EUROPA: results
Perindopril 8mg

Placebo
ans
0
2
4
6
8
10
12
14
0
1
2 3 4 5
CV death, AMI or resuscitated cardiac arrest
Annual event rate (placebo) : 2.4 %
RRR: 20% [95% CI : 9 - 29]
p = 0.0003
Lancet 2003; 362: 782-88
• 12 218 patients
with stable CAD
• no CHF
Review the clinical hypetensive trials

Bertrand Michel (2010)
• Morbidity-mortality trials
conducted from 2000 to June 2010
• Trials including mainly hypertensive patients
• All-cause mortality: a prespecified end point or
reported in the principal study publication
Michel E. BERTRAND, MD, FRCP (London), FESC, FACC, FAHA

Lille University Heart Hospital, Lille, France


21 trials: all-cause mortality reduction?
Study
All-cause mortality HR P
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
RENAAL
IDNT
ALLHAT
LIFE

INVEST
ANBP-2
SCOPE
VALUE
JMIC-B
ASCOT-BPLA
MOSES
JIKEI HEART
ONTARGET
PRoFESS
ACCOMPLISH
TRANSCEND
HYVET
ADVANCE
KYOTO HEART
HIJ-CREATE
1.03 (0.83-1.29)
1.04 (0.77-1.40)
1.00 (0.94-1.08)
0.88 (0.77-1.01)
0.98 (0.89-1. 08)
0.92 (0.76-1.12)
0.96 (0.81-1.14)
1.03 (0.94-1.13)
0.74 (0.35-1.58)
0.90 (0.81-0.99)
1.08 (0.74-1.57)
1.04 (0.61-1.76)
1.02 (0.93-1.11)
1.02 (0.92-1.13)

0.90 (0.75-1.07)
1.05 (0.91-1.22)
0.79 (0.65-0.95)
0.86 (0.75-0.98)
0.68 (0.40-1.17)
1.17 (0.83-1.66)
0.88
0.57
0.90
0.07
0.72
0.27
NS
0.45
0.40
0.03
0.72
0.75
NS
0.55
0.08
0.49
0.02
0.03
0.33
0.36
Active treatment better Control better
n = 194.621
HR: 0.97

95% CI: 0.94-1.00, P = 0.031
Study
All-cause mortality HR P
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
RENAAL
IDNT
ALLHAT
LIFE
INVEST
ANBP-2

SCOPE
VALUE
JMIC-B
ASCOT-BPLA
MOSES
JIKEI Heart
ONTARGET
PRoFESS
ACCOMPLISH
TRANSCEND
HYVET
ADVANCE
KYOTO HEART
HIJ-CREATE
NAVIGATOR
1.03 (0.83-1.29)
1.04 (0.77-1.40)
1.00 (0.94-1.08)
0.88 (0.77-1.01)
0.98 (0.89-1. 08)
0.92 (0.76-1.12)
0.96 (0.81-1.14)
1.03 (0.94-1.13)
0.74 (0.35-1.58)
0.90 (0.81-0.99)
1.08 (0.74-1.57)
1.04 (0.61-1.76)
1.02 (0.93-1.11)
1.02 (0.92-1.13)
0.90 (0.75-1.07)

1.05 (0.91-1.22)
0.79 (0.65-0.95)
0.86 (0.75-0.98)
0.68 (0.40-1.17)
1.17 (0.83-1.66)
0.90 (0.77-1.05)
0.88
0.57
0.90
0.07
0.72
0.27
NS
0.45
0.40
0.03
0.72
0.75
NS
0.55
0.08
0.49
0.02
0.03
0.33
0.36
NS
Individually, significant reduction in all-cause
mortality has been demonstrated in 3 trials only