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研究生:林佳穎
研究生(外文):Chia-Ying Lin
論文名稱:探討頑固型高血壓病患併用三類抗高血壓藥物之療效比較分析
論文名稱(外文):Comparative Effectiveness Analysis of Triple Antihypertensive Combination Therapy for Patients with Resistant Hypertension in Taiwan
指導教授:湯澡薰湯澡薰引用關係
口試委員:蔡旼珊簡麗年
口試日期:2015-06-29
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:醫務管理學研究所
學門:商業及管理學門
學類:醫管學類
論文種類:學術論文
論文出版年:2015
畢業學年度:103
語文別:中文
論文頁數:112
中文關鍵詞:頑固型高血壓抗高血壓藥物中風心肌梗塞死亡重大心血管事件
外文關鍵詞:Resistant HypertensionAntihypertensive Combination TherapyStrokeAcute Myocardial InfarctionMajor Adverse Cardiovascular Events
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研究背景:
高血壓係為全球健康之重要問題,因其盛行率高且會影響其他心血管相關之疾病。根據國內行政院衛生署十大死亡原因包括高血壓以及其併發症。然而同時使用三種以上不同抗高血壓藥物(anti-hypertension drug)且每種抗高血壓藥物都是已達到適當劑量,仍無法控制於目標血壓值之頑固型高血壓病患(resistant hypertension),因血壓長期處於不受控制狀態下,罹患心血管疾病之風險也會隨之增加。因此針對頑固型高血壓病患需要更加積極治療,降低心血管疾病之發生率。
研究目的:
本研究目的為利用台灣「全民健康保險學術研究資料庫」分析,進一步了解同時併用三種不同類型抗高血壓藥物的頑固型高血壓病患之存活分析以及其罹患併發症的發生率。
研究方法:
本研究資料來源為「全民健康保險學術研究資料庫」2001至2011年特殊需求檔,研究對象為2004-2006年新發個案之頑固型高血壓患者,於三年內使用三類抗高血壓藥物之用藥遵從性≥0.7,且前一年未使用者,其定義之。以第一次使用三類抗高血壓藥物之日期定為index date,將其新發個案之頑固型高血壓病患進行用藥分組A+B+C組別(ACEI/ARB+Beta-blocker+CCB)和A+C+D組別(ACEI/ARB+CCB+利尿劑)歸成為主要研究族群主要分析之研究族群,再將此以分層分析方式,分為兩組研究次族群無病史者無病史者以及有病史者有病史者。利用Kaplan-Meier Analysis和 Cox Regression Analysis分析其兩組罹患中風、心肌梗塞、發生重大心血管事件(MACE)以及存活情形之差異性。

研究結果:
新發個案之頑固型高血壓病患共為13551人,結果顯示於主要研究族群的頑固型高血壓患者,使用A+B+C藥物組別比使用A+C+D藥物組別,有較低的心肌梗塞event free存活情形,HR值為1.2, (p=0.0439)以及次要族群中往前有病史之頑固型高血壓病患,使用A+B+C藥物組別比使用A+C+D藥物組別,有較低的心肌梗塞event free存活情形,HR值為1.58, (p=0.0007)。
結論:
本研究發現使用A+C+D組別比A+B+C組別,於心肌梗塞之疾病治療中有較好的效果。
Objectives:
Resistant hypertension (RH) is highly associated with cardiovascular risks. The difficulty in enrolling large numbers of study participants limits studies on treatment effects of RH. This study aims to compare the effectiveness of triple antihypertensive combination therapy for RH patients with in Taiwan.
Methods:
Patients who had 3 antihypertensive agents of different classes concurrently prescribed in outpatient clinics with their medication possession ratio (MPR)≥0.7 during 2004-2006 were identified as the RH cases from the National Health Insurance Research database. The 1st outpatient visit with 3 antihypertensive agents of different classes being prescribed was defined as the index date. Patients were further classified into two treatment groups according to the combination of antihypertensive therapy; the A+B+C group was defined as those who received concurrent therapy of ACEI/ARB in combination with beta-blocker and CCB, and the A+C+D group was those who received ACEI/ARB together with CCB and diuretics. The Cox proportional regression analysis was performed to investigate the risk of major adverse cardiovascular events (MACE) between the two treatment groups. Subgroup analysis was further performed by classifying patients into those with or without previous history of stroke, myocardial Infarction or end stage renal diseases.
Results:
There were 13,551 patients identified as the new incidence cases of RH during 2004-2006. Results showed the A+B+C group had a higher risk of Acute Myocardial Infarction when
compared to the A+C+D of group (adjusted HR=1.2; p=0.0439) and subgroup analysis showed there has significant in the risk of Acute Myocardial Infarction between the A+B+C and the A+C+D groups in patients with prior disease history (adjusted HR =1.58; p=0.0007).
Conclusion:
The A+C+D combination therapy seemed to be more effective than the A+B+C therapy in preventing Acute Myocardial Infarction among patients with RH.
目錄
誌謝 I
中文摘要 II
Abstract IV
目錄 VI
表目錄 VIII
圖目錄 X
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 2
第二章 文獻探討 3
第一節 頑固型高血壓概論 3
第二節 高血壓常用之藥物 7
第三節 高血壓之併發症 11
第三章 研究方法 14
第一節 研究架構 14
第二節 研究假設 16
第三節 研究對象與資料來源 17
第四節 研究變項及操作型定義 21
第五節 資料分析方法 27
第四章 研究結果 28
第一節 兩組藥物組別之描述性統計 28
第二節 傾向分數之估計與特性 37
第三節 傾向分數配對後之描述性統計 46
第四節 傾向分數前後之雙變項分析 53
第五節 傾向分數前後之迴歸分析 76
第五章 討論 94
第一節 研究結果討論 94
第二節 研究結論與限制 96
第三節 建議 100
參考文獻 101
中文文獻 101
英文文獻 102
附錄 108
附錄一、口服抗高血壓藥物 108
附錄二、台灣地區359鄉鎮市區分層研究結果表 110


表目錄
表2-1-1、高血壓定義 3
表2-1-2、頑固型高血壓病患之病因 4
表2-1-3、台灣國人高血壓盛行率 6
表2-2-1、JNC對各類降血壓藥品之使用建議 9
表2-3-1、心血管危險因子 12
表3-1-1、各類藥品之簡稱 14
表3-1-2、三類抗血壓藥物之組合 14
表3-4-1、操作型定義 24
表4-1-1、主要研究族群樣本特性分布 31
表4-1-2、無病史者樣本特性分布 33
表4-1-3、有病史者 樣本特性分布 35
表4-2-1、主要研究族群 傾向分數估計模型 40
表4-2-2、無病史者 傾向分數估計模型 42
表4-2-3、有病史者 傾向分數估計模型 44
表4-3-1、主要研究族群 傾向分數配對後樣本特性分布 47
表4-3-2、無病史者 傾向分數配對後樣本特性分布 49
表4-3-3、有病史者 傾向分數配對後樣本特性分布 51
表4-4-1、主要研究族群 中風之雙變項分析 56
表4-4-2、無病史者 中風之雙變項分析 57
表4-4-3、有病史者 中風之雙變項分析 58
表4-4-4、主要研究族群 心肌梗塞之雙變項分析 61
表4-4-5、無病史者 心肌梗塞之雙變項分析 62
表4-4-6、有病史者 心肌梗塞之雙變項分析 63
表4-4-7、主要研究族群 存活情形之雙變項分析 66
表4-4-8、無病史者 存活情形之雙變項分析 67
表4-4-9、有病史者 存活情形之雙變項分析 68
表4-4-10、主要研究族群 MACE之雙變項分析 71
表4-4-11、無病史者 MACE之雙變項分析 72
表4-4-12、有病史者 MACE之雙變項分析 73
表4-5-1、主要研究族群 中風之event-free survival 分析結果 82
表4-5-2、無病史者 中風之event-free survival 分析結果 83
表4-5-3、有病史者 中風之event-free survival 分析結果 84
表4-5-4、主要研究族群 心肌梗塞之event-free survival 分析結果85
表4-5-5、無病史者 心肌梗塞之event-free survival 分析結果 86
表4-5-6、有病史者 心肌梗塞之event-free survival 分析結果 87
表4-5-7、主要研究族群 存活情形之event-free survival 分析結果88
表4-5-8、無病史者 存活情形之event-free survival 分析結果 89
表4-5-9、有病史者 存活情形之event-free survival 分析結果 90
表4-5-10、主要研究族群 MACE之event-free survival 分析結果 91
表4-5-11、無病史者 MACE之event-free survival 分析結果 92
表4-5-12、有病史者 MACE之event-free survival 分析結果 93


圖目錄
圖2-1-1、頑固型高血壓相關之因素 5
圖2-2-1、英國高血壓協會建議之藥物組合療法 10
圖3-1-1、研究架構 15
圖3-3-1、研究時間軸圖 18
圖3-3-2 流程圖 20
圖4-4-1、兩組抗高血壓用藥組別之中風event-free存活曲線(配對前) 59
圖4-4-2、兩組抗高血壓用藥組別之中風event-free存活曲線(配對後) 60
圖4-4-3、兩組抗高血壓用藥組別之心肌梗塞event-free存活曲線(配對前) 64
圖4-4-4、兩組抗高血壓用藥組別之心肌梗塞event-free存活曲線(配對後) 65
圖4-4-5、兩組抗高血壓用藥組別之存活曲線(配對前) 69
圖4-4-6、兩組抗高血壓用藥組別之存活曲線(配對後) 70
圖4-4-7、兩組抗高血壓用藥組別之MACEevent-free存活曲線(配對前) 74
圖4-4-8、兩組抗高血壓用藥組別之MACEevent-free存活曲線(配對後) 75
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