血管緊張素受體阻滯劑與血管緊張素轉換酶抑制劑治療冠心病患者有效性與安全性的Meta分析_《中國循證醫學雜志》

作者：

劉錫燕 ,  蘇立 , 殷躍輝 , 劉增長

重慶醫科大學附屬第二醫院心血管內科（重慶 400010）;

關鍵詞：

血管緊張素受體阻滯劑血管緊張素轉換酶抑制劑冠心病心血管事件 Meta分析隨機對照試驗系統評價

DOI：

10.7507/1672-2531.20120189

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目的　系統評價血管緊張素受體阻滯劑（ARB）與血管緊張素轉換酶抑制劑（ACEI）比較治療冠心病的療效和安全性，為臨床應用提供證據。
方法　計算機檢索MEDLINE、EMbase、BIOSIS Previews、Cochrane 圖書館、CBM、VIP、WanFang Data和CNKI數據庫，檢索時限從建庫至2011年7月，同時追索納入文章的參考文獻，納入有關ACEI與ARB比較治療冠心病的隨機對照試驗。由兩名研究者按納入與排除標準，獨立選擇文獻、提取資料和評價質量并交叉核對后，采用RevMan 5.1.1軟件進行Meta分析。
結果　納入18個RCT，共17 660例患者。Meta分析結果顯示，在全因死亡［RR=1.04，95%CI (0.98，1.11)，P=0.20］、心血管死亡［RR=1.04，95%CI（0.97，1.12），P=0.26］、心肌梗死［RR=0.98，95%CI（0.92，1.05），P=0.59］、因心衰住院［RR=1.14，95%CI（0.97，1.32），P=0.11］和腦卒中［RR=0.93，95%CI(0.80，1.08)，P=0.34］方面，ARB與ACEI的差異無統計學意義；但ARB在因不良反應而停藥［RR=0.77，95%CI（0.67，0.89），P=0.000 3］方面優于ACEI。
結論　ARB治療冠心病在全因死亡、心血管死亡、心肌梗死、因心衰而住院、腦卒中等方面，療效與ACEI相當且耐受性更好。但受納入研究質量和樣本量所限，上述結論仍需更多大樣本、多中心、前瞻性臨床研究證實。

引用本文： 劉錫燕,蘇立,殷躍輝,劉增長. 血管緊張素受體阻滯劑與血管緊張素轉換酶抑制劑治療冠心病患者有效性與安全性的Meta分析. 中國循證醫學雜志, 2012, 12(10): 1213-1222. doi: 10.7507/1672-2531.20120189 復制

1.	Carey RM, Siragy HM. Newly recognized components of the renin–angiotensin system: potential roles in cardiovascular and renal regulation. Endocr Rev, 2003, 24(3): 261-271.
2.	Nickenig G, Harrison DG. The AT(1)-type angiotensin receptor in oxida-tive stress and atherogenesis: part I: oxidative stress and atherogenesis. Circulation, 2002, 105(3): 393-396.
3.	Dickstein K, Kjekshus J. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet, 2002, 360(9335): 752-760.
4.	Pfeffer MA, McMurray J, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med, 2003, 349(20): 1893-1906.
5.	McMurray J, Solomon S, Pieper K, et al. The effect of valsartan, captopril, or both on atherosclerotic events after acute myocardial infarction: an analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT). J Am Coll Cardiol, 2006, 47(4): 726-733.
6.	Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials, 1996, 17(1): 1-12.
7.	麥勁壯, 李河, 方積乾, 等. Meta分析中失安全系數的估計. 循證醫學, 2006, 6(5): 297-303.
8.	Khan B, Lauten W, Khan Q, et al. Renin-angiotensin system inhibitors and coronary artery disease: a 3-year analysis of clinical outcomes in patients with coronary artery disease. European Heart Journal, 2003, 24(Abstract Supplement): 575.
9.	Maia LN, Nicolau JC, Vitola JV, et al. Prospective evaluation comparing the effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction. Am Heart J, 2003, 145(6): 27.
10.	Suzuki H, Geshi E, Nanjyo S, et al. Inhibitory effect of valsartan against progression of left ventricular dysfunction after myocardial infarction: T-VENTURE study. Circ J, 2009, 73(5): 918-924.
11.	Lauten WB, Khan QA, Rajagopalan S, et al. Usefulness of quinapril and irbesartan to improve the anti-inflammatory response of atorvastatin and aspirin in patients with coronary heart disease. Am J Cardiol, 2003, 91(9): 1116-1119.
12.	曾祥鴻, 李蕓蕓. 福辛普利與氯沙坦治療冠心病心衰伴慢性阻塞性肺部疾病的長期療效和安全性的比較. 實用醫院臨床雜志, 2004, 1(4): 11-12.
13.	彭曉玲, 林澤鵬, 劉強. 伴糖尿病及高血壓的不穩定型心絞痛患者介入治療后替米沙坦對血漿炎癥因子水平的影響. 中國康復理論與實踐, 2005, 11(6): 429-430.
14.	林澤鵬, 金光臨, 張志偉. 替米沙坦對老年高血壓不穩定性心絞痛患者脂聯素及C反應蛋白的影響. 中華老年醫學雜志, 2005, 24(8): 631-633.
15.	Suzuki H, Kusuyama T, Omori Y, et al. Inhibitory effect of candesartan cilexetil on left ventricular remodeling after myocardial infarction. Int Heart J, 2006, 47(5): 715-725.
16.	Ujiie Y, Hirosaka A, Mitsugi M, et al. Effects of angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker in combination with aspirin and cilostazol on in-stent restenosis. Int Heart J, 2006, 47(2): 173-184.
17.	陳欣, 劉欣, 陳華. 替米沙坦對陳舊前壁心肌梗死合并心衰的療效觀察. 中國醫師進修雜志, 2006, 29(7): 48-49.
18.	潘瑩, 張新霞, 李松. 培哚普利及纈沙坦預防冠狀動脈支架內再狹窄. 嶺南心血管病雜志, 2007, 13(4): 264-266.
19.	鄧金龍, 吳隱雄, 趙毅蘭. 培哚普利和氯沙坦治療心肌梗死抑制心肌重構的前瞻性隨機對比研究. 中國醫藥導刊, 2008, 10(1): 85-89.
20.	Tani S, Nagao K, Anazawa T, et al. Effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction: a possible mechanism of prevention of cardiac events by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk myocardial infarction. Inter Med, 2009, 48(11): 877-882.
21.	Montalescot G, Drexler H, Gallo R, et al. Effect of irbesartan and enalapril in non-ST elevation acute coronary syndrome: results of the randomized, double-blind ARCHIPELAGO study. European Heart Journal, 2009, 30(22): 2733-2741.
22.	Marinsek M, Sinkovic A. A randomized trial comparing the effect of ramipril and losartan in survivors of ST-elevation myocardial infarction. The Journal of International Medical Research, 2009, 37(5): 1577-1587.
23.	Yokota T, Osanai T, Hanada K, et al. Effects of telmisartan on markers of ventricular remodeling in patients with acute myocardial infarction: comparison with enalapril. Heart Vessels, 2010, 25(6): 460-468.
24.	The ONTARGET Investigators. Telmisartan, Ramipril, or both in patients at high risk for vascular events. N Engl J Med, 2008, 358(15): 1547-1559.
25.	Winkelmayer WC, Fischer MA, Schneeweiss S, et al. Angiotensin inhibition after myocardial infarction: does drug class matter? J Gen Intern Med, 2006, 21(12): 1242-1247.
26.	Verma S, Mamdani M, Al-Omran M, et al. Angiotensin receptor blockers vs. angiotensin converting enzyme inhibitors and acute coronary syndrome outcomes in elderly patients: a population-based cohort study (UMPIRE study results). J Am Soc Hypertens, 2007, 1(4): 286-294.
27.	Gianpaolo R, Fabio A, Claudio C, et al. Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis. Journal of Hypertension, 2008, 26(7): 1282-1288.
28.	Emmanuel EA, Yunbo K, John S, et al. Progress in Biophysics and Molecular Biology. 13th Edition. Pergamon Press: New York, 2010.
29.	Biollaz J, Brunner HR, Gavras, et al. Antihypertensive therapy with MK 421: angiotensin Ⅱ-renin relationships to evaluate efficacy of converting enzyme blockade. J Cardiovasc Pharmacol, 1982, 4(6): 966-972.
30.	Urata H, Healy B, Stevart RW, et al. Angiotensin Ⅱ-forming pathways in normal and failing human hearts. Circ Res, 1990, 66(4): 883-890.
31.	Bunier M, Brunner RH. Angiotensin II receptor antagonists. Lancet, 2000, 355(9204): 637?645.
32.	Funke-Kaiser H, Reinemund J, Steckelings UM, et al. Adapter proteins and promoter regulation of the angiotensin AT2 receptor--implications for cardiac pathophysiology. Journal of the Renin-Angiotensin-Aldosterone System, 2010, 11(1): 7-17.
33.	Jones ES, Vinh A, McCarthy CA, et al. AT2 receptors: functional relevance in cardiovascular disease. Pharmacology & Therapeutics, 2008, 120(3): 292-316.
34.	Fogari R, Zoppi A. Antihypertensive drugs and fibrinolytic function. Am J Hypertens, 2006, 19(12): 1293-1299.
35.	Moher D, Pham B, Klassen TP, et al. Does the language of publication of reports of randomized trials influence the estimates of intervention effectiveness reported in meta-analyses? 6th Cochrane Colloquium. 1998.

1. Carey RM, Siragy HM. Newly recognized components of the renin–angiotensin system: potential roles in cardiovascular and renal regulation. Endocr Rev, 2003, 24(3): 261-271.
2. Nickenig G, Harrison DG. The AT(1)-type angiotensin receptor in oxida-tive stress and atherogenesis: part I: oxidative stress and atherogenesis. Circulation, 2002, 105(3): 393-396.
3. Dickstein K, Kjekshus J. Effects of losartan and captopril on mortality and morbidity in high-risk patients after acute myocardial infarction: the OPTIMAAL randomised trial. Lancet, 2002, 360(9335): 752-760.
4. Pfeffer MA, McMurray J, Velazquez EJ, et al. Valsartan, captopril, or both in myocardial infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med, 2003, 349(20): 1893-1906.
5. McMurray J, Solomon S, Pieper K, et al. The effect of valsartan, captopril, or both on atherosclerotic events after acute myocardial infarction: an analysis of the Valsartan in Acute Myocardial Infarction Trial (VALIANT). J Am Coll Cardiol, 2006, 47(4): 726-733.
6. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary?. Control Clin Trials, 1996, 17(1): 1-12.
7. 麥勁壯, 李河, 方積乾, 等. Meta分析中失安全系數的估計. 循證醫學, 2006, 6(5): 297-303.
8. Khan B, Lauten W, Khan Q, et al. Renin-angiotensin system inhibitors and coronary artery disease: a 3-year analysis of clinical outcomes in patients with coronary artery disease. European Heart Journal, 2003, 24(Abstract Supplement): 575.
9. Maia LN, Nicolau JC, Vitola JV, et al. Prospective evaluation comparing the effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction. Am Heart J, 2003, 145(6): 27.
10. Suzuki H, Geshi E, Nanjyo S, et al. Inhibitory effect of valsartan against progression of left ventricular dysfunction after myocardial infarction: T-VENTURE study. Circ J, 2009, 73(5): 918-924.
11. Lauten WB, Khan QA, Rajagopalan S, et al. Usefulness of quinapril and irbesartan to improve the anti-inflammatory response of atorvastatin and aspirin in patients with coronary heart disease. Am J Cardiol, 2003, 91(9): 1116-1119.
12. 曾祥鴻, 李蕓蕓. 福辛普利與氯沙坦治療冠心病心衰伴慢性阻塞性肺部疾病的長期療效和安全性的比較. 實用醫院臨床雜志, 2004, 1(4): 11-12.
13. 彭曉玲, 林澤鵬, 劉強. 伴糖尿病及高血壓的不穩定型心絞痛患者介入治療后替米沙坦對血漿炎癥因子水平的影響. 中國康復理論與實踐, 2005, 11(6): 429-430.
14. 林澤鵬, 金光臨, 張志偉. 替米沙坦對老年高血壓不穩定性心絞痛患者脂聯素及C反應蛋白的影響. 中華老年醫學雜志, 2005, 24(8): 631-633.
15. Suzuki H, Kusuyama T, Omori Y, et al. Inhibitory effect of candesartan cilexetil on left ventricular remodeling after myocardial infarction. Int Heart J, 2006, 47(5): 715-725.
16. Ujiie Y, Hirosaka A, Mitsugi M, et al. Effects of angiotensin-converting enzyme inhibitors or an angiotensin receptor blocker in combination with aspirin and cilostazol on in-stent restenosis. Int Heart J, 2006, 47(2): 173-184.
17. 陳欣, 劉欣, 陳華. 替米沙坦對陳舊前壁心肌梗死合并心衰的療效觀察. 中國醫師進修雜志, 2006, 29(7): 48-49.
18. 潘瑩, 張新霞, 李松. 培哚普利及纈沙坦預防冠狀動脈支架內再狹窄. 嶺南心血管病雜志, 2007, 13(4): 264-266.
19. 鄧金龍, 吳隱雄, 趙毅蘭. 培哚普利和氯沙坦治療心肌梗死抑制心肌重構的前瞻性隨機對比研究. 中國醫藥導刊, 2008, 10(1): 85-89.
20. Tani S, Nagao K, Anazawa T, et al. Effects of enalapril and losartan in left ventricular remodeling after acute myocardial infarction: a possible mechanism of prevention of cardiac events by angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in high-risk myocardial infarction. Inter Med, 2009, 48(11): 877-882.
21. Montalescot G, Drexler H, Gallo R, et al. Effect of irbesartan and enalapril in non-ST elevation acute coronary syndrome: results of the randomized, double-blind ARCHIPELAGO study. European Heart Journal, 2009, 30(22): 2733-2741.
22. Marinsek M, Sinkovic A. A randomized trial comparing the effect of ramipril and losartan in survivors of ST-elevation myocardial infarction. The Journal of International Medical Research, 2009, 37(5): 1577-1587.
23. Yokota T, Osanai T, Hanada K, et al. Effects of telmisartan on markers of ventricular remodeling in patients with acute myocardial infarction: comparison with enalapril. Heart Vessels, 2010, 25(6): 460-468.
24. The ONTARGET Investigators. Telmisartan, Ramipril, or both in patients at high risk for vascular events. N Engl J Med, 2008, 358(15): 1547-1559.
25. Winkelmayer WC, Fischer MA, Schneeweiss S, et al. Angiotensin inhibition after myocardial infarction: does drug class matter? J Gen Intern Med, 2006, 21(12): 1242-1247.
26. Verma S, Mamdani M, Al-Omran M, et al. Angiotensin receptor blockers vs. angiotensin converting enzyme inhibitors and acute coronary syndrome outcomes in elderly patients: a population-based cohort study (UMPIRE study results). J Am Soc Hypertens, 2007, 1(4): 286-294.
27. Gianpaolo R, Fabio A, Claudio C, et al. Comparison between angiotensin-converting enzyme inhibitors and angiotensin receptor blockers on the risk of myocardial infarction, stroke and death: a meta-analysis. Journal of Hypertension, 2008, 26(7): 1282-1288.
28. Emmanuel EA, Yunbo K, John S, et al. Progress in Biophysics and Molecular Biology. 13th Edition. Pergamon Press: New York, 2010.
29. Biollaz J, Brunner HR, Gavras, et al. Antihypertensive therapy with MK 421: angiotensin Ⅱ-renin relationships to evaluate efficacy of converting enzyme blockade. J Cardiovasc Pharmacol, 1982, 4(6): 966-972.
30. Urata H, Healy B, Stevart RW, et al. Angiotensin Ⅱ-forming pathways in normal and failing human hearts. Circ Res, 1990, 66(4): 883-890.
31. Bunier M, Brunner RH. Angiotensin II receptor antagonists. Lancet, 2000, 355(9204): 637?645.
32. Funke-Kaiser H, Reinemund J, Steckelings UM, et al. Adapter proteins and promoter regulation of the angiotensin AT2 receptor--implications for cardiac pathophysiology. Journal of the Renin-Angiotensin-Aldosterone System, 2010, 11(1): 7-17.
33. Jones ES, Vinh A, McCarthy CA, et al. AT2 receptors: functional relevance in cardiovascular disease. Pharmacology & Therapeutics, 2008, 120(3): 292-316.
34. Fogari R, Zoppi A. Antihypertensive drugs and fibrinolytic function. Am J Hypertens, 2006, 19(12): 1293-1299.
35. Moher D, Pham B, Klassen TP, et al. Does the language of publication of reports of randomized trials influence the estimates of intervention effectiveness reported in meta-analyses? 6th Cochrane Colloquium. 1998.

《中國循證醫學雜志》

血管緊張素受體阻滯劑與血管緊張素轉換酶抑制劑治療冠心病患者有效性與安全性的Meta分析

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《中國循證醫學雜志》

血管緊張素受體阻滯劑與血管緊張素轉換酶抑制劑治療冠心病患者有效性與安全性的Meta分析

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