JACC：去肾神经术治疗难治性高血压患者

2012-12-04 张永燊 译 JACC

去肾神经术难治性高血压

　　目的  本研究旨在评价去肾神经术（RDN）治疗难治性高血压患者的成本效益和长期临床益处。 　　背景  难治性高血压累及12%的高血压患者。Symplicity HTN-2随机对照试验显示，RDN可使收缩压从基线时的（178 ± 18）mm Hg降低（32 ± 23）mm Hg。 　　方法  采用状态转换模型预测RDN和标准治疗对10年及终生卒中、心肌梗死、所有

　　目的  本研究旨在评价去肾神经术（RDN）治疗难治性高血压患者的成本效益和长期临床益处。

　　背景  难治性高血压累及12%的高血压患者。Symplicity HTN-2随机对照试验显示，RDN可使收缩压从基线时的（178 ± 18）mm Hg降低（32 ± 23）mm Hg。

　　方法  采用状态转换模型预测RDN和标准治疗对10年及终生卒中、心肌梗死、所有冠心病、心力衰竭、终末期肾病和中位生存概率的影响。研究立足于社会角度，对每个（生活）质量校正生命年的成本效益比（美元）增幅进行了估算，均采用每年3%的折现率。采用确定和概率敏感性分析评价稳健性和不确定性。

　　结果  RDN可明显降低事件概率（10-年/终生相对危险：卒中，0.70/0.83；心肌梗死，0.68/0.85；所有冠心病，0.78/0.90；心力衰竭，0.79/0.92；终末期肾病，0.72/0.81）。RDN与标准治疗的患者中位生存期分别为18.4年和17.1年。折现后，终生成本效益比增幅为每个生活质量校正生命年3071美元。除收缩压降幅、基线收缩压和作用持续时间外，结果对其他输入参数的变异相对不敏感。成本效益增幅的95%可信区间为每个生活质量校正生命年节省成本31460美元。

　　结论  该模型表明，在多种假设中，经导管去肾神经术均为一种经济有效的难治性高血压治疗策略，、有可能降低心血管发病率和死亡率。


Objectives  
The purpose of this study was to assess cost-effectiveness and long-term clinical benefits of renal denervation in resistant hypertensive patients.
Background  
Resistant hypertension affects 12% of hypertensive persons. In the Symplicity HTN-2 randomized controlled trial, catheter-based renal denervation (RDN) lowered systolic blood pressure by 32 ± 23 mm Hg from 178 ± 18 mm Hg at baseline.
Methods  
A state-transition model was used to predict the effect of RDN and standard of care on 10-year and lifetime probabilities of stroke, myocardial infarction, all coronary heart disease, heart failure, end-stage renal disease, and median survival. We adopted a societal perspective and estimated an incremental cost-effectiveness ratio in U.S. dollars per quality-adjusted life-year, both discounted at 3% per year. Robustness and uncertainty were evaluated using deterministic and probabilistic sensitivity analyses.
Results  
Renal denervation substantially reduced event probabilities (10-year/lifetime relative risks: stroke 0.70/0.83; myocardial infarction 0.68/0.85; all coronary heart disease 0.78/0.90; heart failure 0.79/0.92; end-stage renal disease 0.72/0.81). Median survival was 18.4 years for RDN versus 17.1 years for standard of care. The discounted lifetime incremental cost-effectiveness ratio was $3,071 per quality-adjusted life-year. Findings were relatively insensitive to variations in input parameters except for systolic blood pressure reduction, baseline systolic blood pressure, and effect duration. The 95% credible interval for incremental cost-effectiveness ratio was cost-saving to $31,460 per quality-adjusted life-year.
Conclusions  
The model suggests that catheter-based renal denervation, over a wide range of assumptions, is a cost-effective strategy for resistant hypertension that might result in lower cardiovascular morbidity and mortality.
    

作者：张永燊 译



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