美国明尼阿波利斯VA医疗保健系统Areef Ishani团队比较了氯噻酮与氢氯噻嗪治疗高血压对心血管事件的影响。相关论文于2022年12月14日发表在《新英格兰医学杂志》上。

氯噻酮在预防高血压患者重大心血管不良事件方面是否优于氢氯噻嗪尚不清楚。

在一项实用性试验中，研究组招募65岁及以上的成年人，他们是退伍军人事务部卫生系统的患者，接受每日剂量为25或50 mg的氢氯噻嗪，将其随机分配以继续使用氢氯噻嗪进行治疗，或改用每日剂量为12.5或25 mg的氯噻酮治疗。主要结局是非致死性心肌梗死、中风、导致住院的心力衰竭、不稳定型心绞痛的紧急冠状动脉血运重建以及非癌症相关死亡。还评估了安全性。

共有13523名患者接受了随机分组。平均年龄为72岁。在基线时，12781名患者（94.5%）接受了每日25 mg的氢氯噻嗪处方。各组的平均基线收缩压为139 mm Hg。在2.4年的中位随访中，氯噻酮组（702名患者[10.4%]）和氢氯噻嗪组（675名患者[10.0%]）的主要结局事件发生率几乎没有差异（风险比为1.04）。主要结局任何组成部分的发生率组间亦无差异。氯噻酮组的低钾血症发生率为6.0%，显著高于氢氯噻嗪组的4.4%。

综上，在这项临床实践常用剂量的噻嗪类利尿剂的大型实用试验中，患者接受氯噻酮治疗与接受氢氯噻嗪治疗相比，并不能降低重大心血管事件或非癌症相关死亡的发生率。

附：英文原文

Title: Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

Author: Areef Ishani, M.D.,, William C. Cushman, M.D.,, Sarah M. Leatherman, Ph.D.,, Robert A. Lew, Ph.D.,, Patricia Woods, M.S.N., R.N.,, Peter A. Glassman, M.B., B.S.,, Addison A. Taylor, M.D.,, Cynthia Hau, M.P.H.,, Alison Klint, M.S.,, Grant D. Huang, Ph.D., M.P.H.,, Mary T. Brophy, M.D., M.P.H.,, Louis D. Fiore, M.D., M.P.H.,, and Ryan E. Ferguson, Sc.D., M.P.H.

Issue&Volume: 2022-12-14

Abstract:

Background

Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear.

Methods

In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non–cancer-related death. Safety was also assessed.

Results

A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P=0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001).

Conclusions

In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non–cancer-related deaths than patients who received hydrochlorothiazide.

DOI: 10.1056/NEJMoa2212270

Source: https://www.nejm.org/doi/full/10.1056/NEJMoa2212270