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高血压与
糖尿病 Benefit of ACE Inhibitors in Diabetes: Important Findings of 5 Major Clinical Trials
UKPDS (1998)
Tight blood pressure control with captopril or atenolol compared to less tight control lowered the rates of stroke, any diabetes endpoint, microvascular outcomes, and death
Intensive compared to conventional glucose control lowered risk of any diabetes-related endpoint, microvascular endpoints and myocardial infarction
HOPE & MICRO-HOPE Substudy (2000)
Ramipril compared to placebo added to usual care reduces the occurrence of death, myocardial infarction, and stroke in both diabetics and nondiabetics
Ramipril decreased progression of proteinuria in diabetics
ABCD (1998)
Enalapril compared to nisoldipine provided comparable blood pressure control and better protection against myocardial infarction
ABCD, CAPPP, FACET and UKPDS meta-analysis (2000)
ACEIs compared to other agents significantly reduced the frequency of acute myocardial infarction, cardiovascular events, and all-cause mortality
UKPDS Impact of Tight* vs Less Tight? Blood Pressure Control on Diabetes-Related Endpoints
0.1
1
10
Favors tight control
Favors less tight control
*n=758 (mean achieved blood pressure of 144/82 mmHg)
?n=390 (mean achieved blood pressure of 154/87 mmHg)
Adapted from UKPDS Group. BMJ. 1998;317:703–713.
Reprinted with permission from the BMJ Publishing Group.
UKPDS Event Rates for Select Endpoints With Tight vs Less Tight Blood Pressure Control
Any diabetes-related endpoint
Diabetes-
related death
Stroke
Microvascular complications
Events per 1000 patient yrs
P=0.005
P=0.02
P=0.01
P=0.009
Less tight (n=390) mean achieved BP 154/87 mmHg
Tight (n=758) mean achieved BP 144/82 mmHg
UKPDS Group. BMJ. 1998;317:703–713.
UKPDS Relative Risk Reduction for Tight* vs Less Tight? Blood Pressure Control
*n=758 (mean achieved blood pressure of 144/82 mmHg)
?n=390 (mean achieved blood pressure of 154/87 mmHg)
UKPDS Group. BMJ. 1998;317:703–713.
UKPDS Outcomes by Treatment Group for Patients Randomized to Tight Blood Pressure Control*
UKPDS Group. BMJ. 1998;317:713–720.
*the differences between the treatment groups were not statistically significant
?for captopril compared to atenolol
UKPDS Kaplan-Meier Plots of Proportion of Patients with Any Diabetes-Related Endpoint
Patients with events (%)
Years from randomization
124 112
0
2
1
3
5
4
6
8
7
9
257 237
327 314
400 358
Captopril Atenolol
N.o of patients at risk:
Less tight blood pressure control
Captopril
Atenolol
P=0.43
UKPDS Group. BMJ. 1998;317:713–720.
Reprinted with permission from the BMJ Publishing Group.
UKPDS Kaplan-Meier Plots of Proportion of Patients Who Died of Disease Related to Diabetes
Patients with events (%)
Years from randomization
172 154
Less tight blood pressure control
Captopril
Atenolol
328 303
383 346
400 358
Captopril Atenolol
No. of patients at risk:
P=0.28
UKPDS Group. BMJ. 1998;317:713–720.
Reprinted with permission from the BMJ Publishing Group.
Favors
conventional
0.5
1
2
Favors
intensive
UKPDS Group. Lancet. 1998;352:837-853.
Reprinted with permission from Elsevier Science.
UKPDS Relative Risk Reduction for Intensive vs Less Intensive Glucose Control
Over 10 years, HbA1c was 7.0% (6.2-8.2) in the intensive group (n=2,729) compared with 7.9% (6.9-8.8) in the conventional group (n=1,138).
% relative risk reduction
P=0.03
P<0.01
P<0.01
P=0.05
P=0.02
UKPDS Group. Lancet. 1998;352:837-853.
UKPDS Relative Risk Reduction for Intensive vs Less Intensive Glucose Control
Over 10 years, HbA1c was 7.0% (6.2-8.2) in the intensive group (n=2,729) compared with 7.9% (6.9-8.8) in the conventional group (n=1,138).
UKPDS Findings on Tight Blood Pressure Control and Intensive Glucose Control
Tight vs less tight blood pressure control reduces risk of
Any diabetes-related endpoint 24% P=0.005
Microvascular complications 37% P=0.009
Stroke 44% P=0.01
An intensive compared to conventional glucose control policy reduces risk of
Any diabetes-related endpoint 12% P=0.03
Microvascular complications 25% P<0.01
Myocardial infarction 16% P=0.05
UKPDS Group. BMJ. 1998;317:703–712.
UKPDS Group. Lancet. 1998;352:837-853.
Tight control (using captopril or atenolol) mean achieved BP 144/82 mmHg (n=758)
Less tight control (avoiding ACEIs and ?-blockers) mean achieved BP 154/87 mmHg (n=390)
Over 10 years, HbA1c was 7.0% (6.2-8.2) in the intensive group treated
with sulfonylurea or insulin (n=2,729) compared with 7.9% (6.9-8.8)
in the conventional group (n=1,138) with diet modifications
Benefit of ACE Inhibitors in Diabetes: Important Findings of 5 Major Clinical Trials
UKPDS (1998)
Tight blood pressure control with captopril or atenolol compared to less tight&