近期高血压指南颠覆了既往指南推荐的高危患者血压靶标，尤其是那些伴心血管疾病、肾脏疾病或188bet在线平台网址 的患者推荐较低的血压靶标。这一变化是否意味着强化降压治疗策略与严重心血管和肾病事件风险减少得更多有关?

        11月6日在线发表于《柳叶刀》(Lancet)杂志的一项有关降压治疗的系统综述荟萃分析表明，与标准降压治疗方案相比，强化降压治疗可使血管获益更多。在高危患者中，强化降压治疗可带来更多的获益，包括那些收缩压低于140/90 mmHg的患者。强化降压治疗对高危患者的净绝对获益显著。

        研究者们检索了MEDLINE、Embase和Cochrane Library数据库，纳入1950年1月1日~2015年11月3日随访时间至少6个月且对比强化降压与标准降压的随机对照试验。没有任何年龄或语言限制。荟萃分析了血压降低的严重心血管事件(包括心肌梗死、卒中、心力衰竭或心血管死亡，单独或复合事件)、非心血管和全因死亡、终末期肾病和不良事件以及蛋白尿和188bet在线平台网址 患者视网膜病变进展的相对风险。

        结果显示，共纳入19项试验、44989例患者。在平均3.8年随访中共记录2496例严重心血管事件。

        强化降压组平均血压为133/76 mmHg，标准降压组为140/81 mmHg。与标准降压相比，强化降压能降低约14%的严重心血管事件风险、13%心肌梗死风险、22%卒中风险、10%蛋白尿风险、19%视网膜病变进展风险。但强化降压对心衰、心血管死亡、总死亡或终末期肾脏病无明确的影响。所有患者群体均一致地显示出强化降压可降低严重心血管事件，即使是收缩压低于140 mmHg的患者也有明显获益。在入组时有血管疾病、肾脏疾病或188bet在线平台网址 的患者绝对获益最大。在针对高危患者的试验中，强化降压的绝对获益更大。

        仅有6项试验报告了与降压治疗相关的严重不良事件，其中强化降压组发生率为1.2%/年，标准降压组为0.9%/年(相对危险度RR为1.35)。强化降压组严重低血压的发生率较高(RR 2.68，P=0.015)，但绝对剩余较小(0·3%vs0·1%/人-年)。

        参考文献：XinfangXie,et al. Published Online Lancet:07 November 2015

Effects of intensive blood pressure lowering on cardiovascular and renal outcomes: updated systematic review and meta-analysis
Xinfang Xie, MD
,
Emily Atkins, BHlthSc
,
Prof Jicheng Lv, MD 
,
Alexander Bennett, BMedSc
,
Prof Bruce Neal, MBChB
,
Prof Toshiharu Ninomiya, PhD
,
Prof Mark Woodward, PhD
,
Prof Stephen MacMahon, PhD
,
Fiona Turnbull, PhD
,
ProfGraham S Hillis, MBChB
,
Prof John Chalmers, MBBS
,
Prof Jonathan Mant, MD
,
Abdul Salam, MPharm
,
Prof Kazem Rahimi, PhD
,
Prof Vlado Perkovic, MBBS
,
Prof Anthony Rodgers, MBChB 
Published Online: 07 November 2015
Publication History
Published Online:07 November 2015
Summary
Background
Recent hypertension guidelines have reversed previous recommendations for lower blood pressure targets in high-risk patients, such as those with cardiovascular disease, renal disease, or diabetes. This change represents uncertainty about whether more intensive blood pressure-lowering strategies are associated with greater reductions in risk of major cardiovascular and renal events. We aimed to assess the efficacy and safety of intensive blood pressure-lowering strategies.
Methods
For this updated systematic review and meta-analysis, we systematically searched MEDLINE, Embase, and the Cochrane Library for trials published between Jan 1, 1950, and Nov 3, 2015. We included randomised controlled trials with at least 6 months' follow-up that randomly assigned participants to more intensive versus less intensive blood pressure-lowering treatment, with different blood pressure targets or different blood pressure changes from baseline. We did not use any age or language restrictions. We did a meta-analysis of blood pressure reductions on relative risk (RR) of major cardiovascular events (myocardial infarction, stroke, heart failure, or cardiovascular death, separately and combined),and non-vascular and all-cause mortality, end-stage kidney disease, and adverse events, as well as albuminuria and progression of retinopathy in trials done in patients with diabetes.
Findings
We identified 19 trials including 44 989 participants, in whom 2496 major cardiovascular events were recorded during a mean 3•8 years of follow-up (range 1•0–8•4 years). Our meta-analysis showed that after randomisation, patients in the more intensive blood pressure-lowering treatment group had mean blood pressure levels of 133/76 mm Hg, compared with 140/81 mm Hg in the less intensive treatment group. Intensive blood pressure-lowering treatment achieved RR reductions for major cardiovascular events (14% [95% CI 4–22]), myocardial infarction (13% [0–24]), stroke (22% [10–32]), albuminuria (10% [3–16]), and retinopathy progression (19% [0–34]).However, more intensive treatment had no clear effects on heart failure (15% [95% CI −11 to 34]), cardiovascular death (9% [–11 to 26]), total mortality (9% [–3 to 19]), or end-stage kidney disease (10% [–6 to 23]). The reduction in major cardiovascular events was consistent across patient groups, and additional blood pressure lowering had a clear benefit even in patients with systolic blood pressure lower than 140 mm Hg.The absolute benefits were greatest in trials in which all enrolled patients had vascular disease, renal disease, or diabetes.Serious adverse events associated with blood pressure lowering were only reported by six trials and had an event rate of 1•2% per year in intensive blood pressure-lowering group participants, compared with 0•9% in the less intensive treatment group (RR 1•35 [95% CI 0•93–1•97]). Severe hypotension was more frequent in the more intensive treatment regimen (RR 2•68 [1•21–5•89], p=0•015), but the absolute excess was small (0•3% vs 0•1% per person-year for the duration of follow-up).
Interpretation
Intensive blood pressure lowering provided greater vascular protection than standard regimens. In high-risk patients, there are additional benefits from more intensive blood pressure lowering, including for those with systolic blood pressure below 140 mmHg. The net absolute benefits of intensive blood pressure lowering in high-risk individuals are large.