<International Circulation>: The new European hypertension guidelines compared with the 2007 guidelines and 2009 reappraisal version， are there any changes in cardiovascular risk assessment， initiate time， goals of antihypertensive therapy or drugs application?
Prof. Nilsson: Well， as I have mentioned previously， there are so many patients so we need to have different solutions. First of all we should go for the simple things， the clinical examination to find out about signs of target organ damage， for example microalbuminuria， then we should do some technical investigations like ECG. If echocardiology is available， then it could be used.  If other technical investigations then of course they can be used but in many settings we have to rely on very simple things.  So the risk stratification is important and I would like to emphasize something much more important in a country like China， and that is to investigate the family history of cardiovascular disease and stroke because if there is a large family history of stroke， then the children and the offspring are at increased risk without measuring anything， we know from the family history already that they are at increased risk. You ask about targets， and of course we should realize that most of the studies have been based on office blood pressure but as my colleague pointed out that office blood pressure measurements are also very important. I really hope that we all will be using much more home blood pressure recordings and ambulatory blood pressure recordings， I would say especially in the high risk patients with diabetes for instance. Coming back to the question about drugs， we know that men and women can use the same drugs with a few exceptions for example in pregnant women， it is not good to use drugs that block the renin angiotensin system because of some adverse effects. In some other patients there might be some contraindications for a specific drug. For example if there is bad lung function， some drugs might interfere with lung function， but on the other hand， we can use most of the drugs in monotherapy or in combination therapy.  Also in the elderly， previously we had different recommendation in the young and the elderly and the opinion of my society is that you can use all the drugs in the old， in the young， in men， and in women with a few exceptions. Combination treatment means many times that we should try different combinations， in my personal experience， I prescribed test packets of combination drugs and I ask the patient to try the first combination for the first few weeks and the second combination for another few weeks. When the patient returns to me， I simply ask the patient， which drug combination did you prefer. This is a new way to involve the patient， not only to prescribe but also to listen to the patient because modern patients would like to be more involved and that is why providing information， increasing knowledge， teaching， and listening to patients can bring a great benefit and that is compliance adherence to therapy because some physicians believe their patients always take the drugs and tablets， but that is not so.  In fact it is a hidden problem that so many patients are not convinced to take the tablets， and I would like to ask my Chinese colleague， what do you think about this.  Can this be approached， this problem?
Prof. Zhang: I think in Chinese hypertension patients， they always take the CCB alone or combined with another antihypertensive drugs， usually they use combined agents with ACEI or ARB. If they cannot achieve the target， then combined with HCTZ that is diuretic. So I think the new guidelines mentioned five classes of antihypertensive drugs should be used equally because the benefit of antihypertensive effects largely and mainly come from the blood pressure lowering. Of course every class of drugs has adverse reaction. If from the point of complications， I think the RAS inhibitors and CCB and diuretic should be better. That is clincal application for the patient.
Prof. Nilsson: Of course we also have some patient with angina pectoris， coronary heart disease， with tachycardia， and some of them would benefit from a beta blocker. There are new beta blockers and old beta blockers. Some of them modern drugs are better than old ones.  China is well known to have a population with a very high stroke risk and of course this could also be discussed in terms of secondary prevention because it is so important to help these patients who have had one stroke， not to get another one， so this is a way to convince many patients to adhere to treatment to bring their blood pressure down if they have had a TIA or a first stroke.  I think we should not only consider primary prevention， we should also consider secondary prevention， and some patients are lost to follow up.

　　《国际循环》：与07版指南及09再评估版相比，新指南在心血管风险评估、起始治疗时间、降压目标值及药物选择及应用方面做了哪些更新？
Nilsson教授：正如我前面提到的，高血压患者太多了，我们需要选用不同的治疗方法。首先，我们应该从简单的事情开始，对患者进行临床评估看其是否存在微量白蛋白尿等靶器官损害情况，然后进行ECG等检查。如果可能的话，最好进行超声心动图检查及其他技术性检查。但在多数情况下，我们主要还需要依靠那些较为简单的检查进行评估。危险分层具有重要意义，对中国等国家来说有些事情更需要强调，这就是需要询问心血管疾病及卒中家族史，因为如果存在卒中家族史，即使不测量其他指标我们也知道该家庭中的儿童及其后代存在高风险。我们通过其具有家族史便可知道其心血管风险增高。你提到的降压目标，当然我们应该意识到大多数研究主要是根据诊室血压而提出的，正如我的同事所提出的那样，非诊室血压也非常重要。我真的希望我们将能够更多地应用家庭血压及动态血压，尤其是在伴有糖尿病的高危患者中。回到降压药物上来，有些药物男性和女性都能应用，但妊娠女性不宜选用RAS抑制剂，因为其具有很多不良反应。此外，某些患者可能存在某种药物的应用禁忌证。例如，有些药物会影响肺功能，不能用于肺功能不好的患者。另一方面，大多数药物都能用于单药或联合治疗。既往指南对老年患者的推荐与对年轻患者有所不同，现在的观点认为除特殊情况外，所有的药物均无年龄及性别的应用限制。联合治疗意味着很多时候我们需要不同的联合方案，以个人经验来说，我常选择对联合治疗先进行测试，首先要求患者在最初几周尝试应用第一种联合治疗方案，随后几周应用第二种联合治疗方案。在患者复诊时，我会询问患者他更喜欢哪种联合治疗。这是能够让患者积极参与到治疗中，倾听患者的意见，而非仅仅由医生处方药物的治疗方法。现在很多患者希望更积极地参与到自己的治疗中，这是向患者提供信息、普及知识、患者教育及倾听患者意见能带来巨大获益的原因所在，同时也有助于提高患者的依从性，因为虽然很多医生认为患者通常会坚持服药但情况并非如此。潜在的问题是，很多患者并不愿意服药。我想问一下我的中国同道对此有何看法？如何解决这一问题？
张教授：中国高血压患者通常选择应用CCB类药物单药治疗或联合其他降压药物（通常是ACEI或ARB类药物）治疗，如果血压仍不达标，将联用利尿剂HCTZ。新指南强调，降压治疗的获益主要源于其降压效应，故五类降压药物推荐应用时并无先后顺序。当然每一种降压药物都有其不良反应。从并发症角度来说，我认为RAS阻断剂、CCB及利尿剂的作用可能更好。这是中国患者的临床应用情况。
Nilsson教授：当然有些伴有心绞痛、冠心病及心动过速患者应用β受体阻滞剂后能够获益，有些患者中则新药优于老药。众所周知，中国卒中发生风险较高，卒中的二级预防非常重要。对既往曾发生过卒中的患者而言，预防卒中复发意义重大。所以如果患者既往有TIA或卒中病史，这是一种说服患者坚持降压治疗使其血压降低的方法。临床实践中很多患者会失访。我认为我们不应只关注一级预防，也应同样关注二级预防。