International Circulation: There has been a lot of talk about ambulatory blood pressure recently and there is the question regarding even if someone has white coat hypertension， all of our studies have been based on clinic blood pressure measurements， so treating those with white coat hypertension might be beneficial. Maybe these people are at a higher risk or at least an intermediate risk. Your thoughts?
　　Dr Schmieder: People with white coat hypertension have an increased risk of developing hypertension and thereby for developing hypertension complications. If you have a patient with a blood pressure of 160mmHg in the office but when doing ambulatory blood pressure monitoring is perfectly fine at 125mmHg then the patient has white coat hypertension and should be monitored carefully at yearly intervals and when the levels go up then the conclusion is that they have developed hypertension and you can act on that. What is important and this comes the Spanish Ambulatory Blood Pressure Monitoring Registry and also from our German experience that in the treatment of resistant hypertension， up to one-third of these patients have the white coat effect. Despite hypertensive drugs， their blood pressure is still elevated above 150 or 160mmHg but according to the guidelines these levels need to be around 140mmHg， so ambulatory blood pressure monitoring should be done either by home measurements or even better by automatic devices over 24 hours and if then the levels are below the cut-off of 135mmHg for daytime blood pressure measurements， the patient has a white coat effect coming from 135mmHg to 155mmHg. This is not white coat hypertension which is the beginning of hypertensive disease. This is the white coat effect and should be excluded.
　　International Circulation: I have been asked to ask you about aliskiren as a possible replacement for spironolactone. Do you think this is a viable option in people who are not responding to spironolactone?
　　Dr Schmieder: In a Spanish study for which I was an advisor and author which has now been published， there was a protocol where you treated the hypertensive patients with spironolactone and if it is not effective and pseudohypertension has been excluded， use aliskiren. We found in those patients with true resistant hypertension who were non-responders to spironolactone， there was an excellent decrease in blood pressure on aliskiren. From that perspective it was a last option but now， the ALTITUDE Study has confirmed contraindications for the use of ACE and ARBs plus aliskiren in diabetic patients and in patients with reduced eGFR. At the moment in Europe， you are not allowed to use ACE or an ARB with aliskiren if your patient is diabetic or if the patients has eGFR <60. But usually these are the resistant patients so actually the option to use aliskiren is now more limited than before and coming back to our initial discussion， we are happy now that we have a completely different option for these patients.
　　《国际循环》：最近很多话题谈到动态血压，有观点认为由于我们所有的试验都是基于临床血压测量而得出的结果，所以即使是白大衣性高血压的患者在治疗中也是获益的。可能白大衣高血压患者有高风险或者至少有中度风险。您对这一问题有什么看法？
　　Dr Schmieder：白大衣高血压患者发生高血压的风险增加，发生高血压并发症的风险也增加。如果你的患者在就诊室测的血压大于160 mm Hg，但是动态血压的结果显示患者血压完全正常在125 mm Hg左右，那么这个患者就是白大衣高血压并且应该每隔1年就进行详细体检，当血压升高那么结论就是患者发生了高血压，这时你也可以对患者进行治疗。来自西班牙动态血压监测注册结果和我们德国的经验显示，重要的是在顽固性高血压的治疗中，超过三分之一的患者有白大衣高血压效应。尽管这些患者使用降压药物，他们的血压仍然超过150 或160 mm Hg，但是根据指南推荐，这些患者的血压应该降至140 mm Hg以下，因此患者应该在家里自己动态监测血压或更好的是用自动装置检测24小时血压，如果测得的白天血压都低于135 mm Hg，那么患者就存在白大衣高血压效应，就诊时血压会从平时的135 mm Hg 上升到155 mm Hg。这就不是作为高血压疾病前期的白大衣高血压，而是我们应该排除的白大衣效应。
　　《国际循环》：有人认为阿利吉仑是安体舒通的可能替代品。您认为对于安体舒通使用后无反应的患者，阿利吉仑是否是个可行的选择呢？
　　Dr Schmieder：我曾经是一项西班牙研究的顾问和作者，这项研究目前已经发表，研究中使用的方法就是在使用安体舒通治疗时如果患者没有反应，并且排除了假性高血压的情况下，就给患者使用阿利吉仑。结果我们发现这些对安体舒通无反应的真正顽固性高血压的患者，在使用阿利吉仑后血压会有显著的下降。从这个角度来说阿利吉仑以前是最后的选择，但是现在ALTITUDE研究已经证实了ACE和 ARBs联合阿利吉仑治疗糖尿病和eGFR降低的患者的禁忌证。现在在欧洲不允许给糖尿病或eGFR ＜60的患者使用ACE 或ARB联合阿利吉仑治疗。但是这些患者常常是顽固性高血压患者，因此实际上现在使用阿利吉仑的选择比以前更有限。回到我们开始谈论的话题，我们现在很庆幸这些患者的治疗有了完全不同的选择。