1、 道理要讲,事实更重要ACEI vs ARB 走向PK台心衰试验 Consensus Solvd P 97:2202-22120ACEI安慰剂每1000人挽救的病例数*ACEI组比安慰剂组减少的死亡人数死亡例数239*39*104 *96*40003000200010000-1天 2-7天 8-30天 总计25 20 15 10 5 00 6 12 18 24 30 36 LosartanCaptoprilRelative risk 1.13(95% CI 0.991.28)Number at riskLosartan 2744 2504 2432 2390 2344 2301 1285Cap
2、topril 2733 2534 2463 2423 2374 2329 1309monthsAll-causemortality(%)OPTIMAAL: 主要终点（总死亡率）的Kaplan-Meier曲线p=0.069Lancet 360:752-760Resultsp=0.069 p=0.032p=0.722 p=0.587OPTIMAAL02468101214161820Rateof endpoint(%)Mortality MI CV death Strokecaptopril losartanOPTIMAAL: 讨论和结论 OPTIMAAL未能证明氯沙坦优于或不次于卡托普利；但倾向于
3、卡托普利更好 因此，在有并发症的急性心肌梗死后患者中， ACE抑制剂仍然应该是首选的治疗药物 氯沙坦停药率较低，耐受性优于ACE抑制剂 在不能耐受ACE抑制剂的患者中，氯沙坦的作用尚不确定，但可考虑使用Dickstein K, et al. Lancet 2002卡托普利00.050.10.150.20.250.30 6 12 18 24 30 36事件发生的概率VALLANT: ANI伴心衰患者治疗后的死亡率Pfeffer, McMurray, Velazquez, et al. N Engl J Med 2003;349缬沙坦 4909 4464 4272 4007 2648 1437 3
4、57月缬沙坦 vs.卡托普利: HR = 1.00; P = 0.982缬沙坦 +卡托普利vs.卡托普利: HR = 0.98; P = 0.726卡托普利 4909 4428 4241 4018 2635 1432 364缬沙坦 +卡托普利4885 4414 4265 3994 2648 1435 382缬沙坦 缬沙坦 +卡托普利 ACC/AHA: 心肌梗死后ACEI首选“仅在不能耐受ACEI时使用ARB”ACC/AHA, ST-Elevation MI (2004)Class I Recommendations:ACE inhibitors should be given to all p
5、atientsARBs should be given if intolerant to ACE inhibitorClass IIa Recommendations:ARBs may be used as an alternative to ACE inhibitors if there are clinical or radiographic signs of heart failure or LVEF 40%VBWGACEI outcome trials in CAD patients without HF: Totality of trial evidenceMIStrokeAll-c
6、ause deathEvent rate (%)Favors ACEIACEIRevascularizationFavors placeboPlacebo7.56.42.115.58.97.72.716.30.860.860.770.930.00040.00040.00040.0250.5 0.75 1.251Odds ratioPPepine CJ, Probstfield JL. Vasc Bio Clin Pract. CME Monograph; UF College of Medicine. 2004;6(3).HOPE, EUROPA, PEACE, QUIETVBWGO n g
7、o i n g m a j o r o u t c o m e s t r i a l s o f R A A S m o d u l a t i o nCV death, MI, stroke, hosp for heart failure5.5 Telmisartan80 mgPlacebo55 years, ACEI intolerant, with CAD, stroke, PAD, or diabetes + end-organ damage(N = 5776)TRANSCENDCV death, MI, stroke, hosp for heart failure5.5Ramipr
8、il10 mgTelmisartan80 mgRamipril10 mg + telmisartan 80 mg55 years with CAD, stroke, PAD, or diabetes + end-organ damage(N = 25,620)ONTARGET*Primary outcomeFollow-up (years)TreatmentPatientsONTARGET/TRANSCEND Investigators.Am Heart J.2004;148:52-61.*Ongoing TelmisartanAlone and in Combination with Ramipril Global Endpoint TrialTelmisartanRandomized Assessment Study in ACE Intolerant Subjects with Cardiovascular Disease
