[ESH2007]ESH2006年会主席Ruilope教授：难治性高血压——真的难治吗？

作者:L.M.Ruilope   日期:2007/6/29 14:51:00

国际循环网版权所有，谢绝任何形式转载，侵犯版权者必予法律追究。

Hospital 12 de Octubre, Madrid, Spain. Luis Ruilope is Associate Professor of Internal Medicine at Complutense University and Head of the Hypertension Unit at the Hospital 12 de Octubre in Madrid, Spain. His principal area of interest is hypertension and the kidney. Dr Ruilope received his MD degree from the University of Madrid and completed his residency and fellowship in nephrology at the Jiménez Díaz Foundation in Madrid. A member of the Scientific Council of the International Society of Hypertension and an International Fellow of the Council of High Blood Pressure Resarch, Dr Ruilope is on the Editorial Boards of the Journal of Hypertension, Blood Pressure, High Blood Pressure & Cardiovascular Prevention, Medicina Clínica, Nephrology Dialysis Transplantation, and the Journal of Human Hypertension. He si board member of the Spanish Society of Hypertension and a member of the Council on the Kidney in Cardiovascular Disease ( American Heart Association). He served on the International Society of Hypertension 2000 International Scientific Program Committee and was a member of the Steering Committee in the studies Hypertension Optimal Treatment (HOT), International Nifedipine GITS Study: Intertvention as a Goal in Hypertension Treatment (INSGHT), Study on Cognition and Prognosis in the Elderly (SCOPE), and Controlled Onset Verapamil Investigation of Cardiovascular Endpoints (CONVINCE).

《International Circulation》：I’m International Circulation from China, and I would like to give you an interview, thank you, Mr. Puilope. The first question is: It was mentioned for the first time that β-blockers are no longer preferred as a routine initial therapy for hypertension in British Hypertensive Society Guidelines 2006. How to comment the current status of β blockers in hypertension treatment? How to use β blocker, especially according to the new guideline of ESH. And when to use? Who is supposed to use? Are β blockers still the initial therapy for hypertension?

《国际循环》：我是来自中国的《国际循环》的记者，感谢您接受我们的采访。2006年英国高血压指南中，第一次提出了β受体阻滞剂不再是多数高血压患者的首选降压治疗药物。如何评价β受体阻滞剂治疗高血压的临床地位？β受体阻滞剂应该如何使用？何时应用？哪些为适应人群？β受体阻滞剂是否还应作为降压治疗的一线用药？

Pro.Ruilope：Well, the European guidelines still keep the β blockers as one of the classic drugs which can be used as the first step of initial treatment in hypertension population. And reasons to maintain it, unlike British guidelines, and the opinions of some other people are that: first, all of the British trials have been made to study in which the β blocker was used alone. But there is other study with β blocker that are new β blocker, that can be seen therapy in other opinion, because β blocker has very specific and frequent indications in the hypertension population, and we abandon β blocker as the first step therapy, probably we should use it under even in the specific indications, there should be something doubtly inadequate.

Ruilope教授：好的。欧洲指南目前还把β受体阻滞剂作为高血压治疗的一线药物。与英国的指南不同，仍继续保留的原因是有观点认为英国的临床试验仅单独应用β受体阻滞剂。而其他研究中应用β受体阻滞剂采用了新型的药物。另外因为β受体阻滞剂在高血压治疗中有特定的适应征，将其从一线药物中去除，可能出于应用于相应适应征的情况考虑，但是目前来看证据还不十分成熟。

《International Circulation》：Okay, thank you, my second question is : In recent years, the limitation of brachial blood pressure for BP-lowing evaluation has been known, while the obvious relationship between pressure gradient and cardiovascular events is found according to recent studies, some scholars have suggested that the Arterial Hardness Value should be one of important index for high pressure evaluation and medicine selection. How to view this opinion? Which the objective standards can be used to evaluate high pressure and anti-hypertension drugs?

《国际循环》：我的第二个问题是：近年来，上臂血压作为降压指标的局限性已被大家所公认，而许多研究显示脉压与心血管事件存在显著相关性，为此许多学者建议应将动脉血管硬度作为评价高血压和选择药物选择的重要指标。对于这种观点如何看待？如何选择客观指标评估高血压和选择降压药？

Pro.Ruilope：What index are you referring to?
Ruilope教授：你指的是哪个指标？
Pro.Ruilope：Well, finally, hypertension is a disease of atherosclerosis disease, the artery suffers from the consequences of evaluation of blood pressure and, to discuss this question we assess cardiovascular risk factors, which is heavy, so we are thinking particularly in patients with hypertension, the artery become stiffer, I mean they lose the capacity to be elastic. As a consequence of that, first, this loss of elasticity is a predictor that something is bad for the future of the patients; for both possibilities for cardiovascular disease and death are high. And also this is combined by an increase, particularly, the systolic blood pressure, and once this happens, I mean the control of this blood pressure in people with arterial stiffness is very difficult. And in these patients, we need combination therapy, in particularly all of them, and even with combination therapy, I mean the control remains frequently above the desired goal pressure. So in my opinion, the relevance shows that we need to start therapy earlier than what we are doing so. We might wait too much, and we allow the stiffness to grow, and then it’s late to regulate this, it’s like a vicious circle. But start the therapy earlier, we can repair the stiffness, and we can slow down the elasticity progression of stiffness and then the control blood pressure is going to be better.

Ruilope教授：总体来讲，高血压实际上是血管粥样硬化导致的疾病，动脉反过来又受到血压升高带来的影响，我们先了解和评价一下心血管危险因素，危险因素多则情况严重。患有高血压的患者，其动脉会变得更加硬和脆，我的意思是说它失去了弹性能力。因此，弹性降低量可作为预测病人预后的一个指标，如果该指标比较差，则患有心血管疾病或死亡的风险就高。同时，还伴有血压升高，特别是收缩压升高，而且一旦发生，对这类病人进行血压控制则比较棘手。因此，我们需要联合治疗，尤其是这类人群，但是有时候即使应用了联合治疗，血压还是高于理想值。因此，我认为通过这些分析，可以发现对于高血压的治疗应该趁早着手。我们可能等的时间太长了，我们纵容血管硬化，等到开始用药调节时也错过了最好治疗时机，从而形成恶性循环。但是一旦及早治疗，我们就可以还原硬化的血管，降低血管硬化的进展并使血压控制更为良好。

《International Circulation》：Another question is the target blood pressure for patients with hypertension 120/80 mmHg or 130/80 mmHg or lower level? How to achieve the target blood pressure control for patients with refractory hypertension?

《国际循环》：对于目标血压的控制，是将血压降低到120/80mmHg或130/80mmHg, 还是血压降的低一些好，还是越低越好呢？对于难控制血压患者如何使血压达标？

Pro.Ruilope：Well, the refractory hypertension is frequent, and well, usually it is defined as patients receiving three drugs, in adequate doses, and one of these drugs is diuretics. Well, we nowadays have data in Spain in the blood pressure monitoring, in more than 30,000patients, that those patients are recorded as refractory, I mean many of them are not refractory; It’s a problem of measurement of blood pressure, because when ABPM is made, so blood pressure monitoring for 24 hours to see those patients are well controlled, so this is the first point, and probably one of the indications, clearly the indications of blood pressure monitoring is refractory hypertension, because by using ABPM, you will see that many of the patients are very well controlled. Second, what we can do is in the refractory hypertension, I mean frequently the refractory hypertension is due to primary hyperaldosteronism, it has been efficiently shown in different studies, and this should be the cause for the secondary hypertension, which is not well adequately treated, and so what we do with these patients is to treat them with spirolactone, which is a kind of aldosterone blocker, and relatively a part of the patients, you know, become well controlled, with the aldosterone blocker, because after this, there is secondary hypertension, because of aldosteronism. I mean this is not always the case, what we used to do winnow out these three possibilities, basically, I mean, first is to diagnosis in particular reno-vascular hypertensions, some of the patients have reno-vascular hypertensions. Second, we need to change the therapy, change the therapy can be done to increase the dose what the patient is taking increasing the number of drugs taken by the patients, or redistributing the drugs. So, you know what to redistribute the pills, from the early morning, to the time to go to bed, and release of pill can be improved, also they control the refractory hypertension.

Ruilope教授：难治性高血压比较常见，通常它定义为接受三种降压药物治疗且剂量足够但降压效果不显著，同时含有一种利尿剂，符合以上情况，则可定义为难治性高血压。我们目前有一项含有30，000病人的统计结果，其中的很多人记录为难治性高血压，但是其中相当一部分并不是难治性；这可能是血压测量的问题，因为动态血压监测得以应用，24小