Moser Marvin
Yale University School of Medicine, New Haven, CT, USA.
J Clin Hypertens (Greenwich). 2004 Oct;6(10 Suppl 2):4-13. doi: 10.1111/j.1524-6175.2004.03830.x.
The following issues are highlighted: Emphasis is placed on the importance of systolic blood pressure elevations in estimating risk and in determining prognosis. A review of placebo-controlled clinical trials indicates that cardiovascular events are statistically significantly reduced with diuretic- or b blocker-based treatment regimens. The question of whether blood pressure lowering alone or specific medications make the difference in outcome is discussed. Based on the results of numerous trials, it is apparent that blood pressure lowering itself is probably of greater importance in reducing cardiovascular events than the specific medication used. Meta-analyses suggest, however, that the use of an agent that blocks the renin-angiotensin aldosterone system is probably more effective in diabetics and in patients with nephropathy than a regimen based on calcium channel blocker therapy. The Antihypertensive and Lipid-Lowering treatment to Prevent Heart Attack Trial (ALLHAT) reported no overall difference in coronary heart disease outcome among patients treated with a diuretic-based compared to a calcium channel blocker- or an angiotensin-converting enzyme inhibitor-based treatment program. However, patients in the diuretic group experienced fewer episodes of heart failure than in the calcium channel blocker group and fewer episodes of heart failure and strokes than those in the angiotensin-converting enzyme inhibitor group. Results were similar in diabetics and nondiabetics. Possible reasons for this outcome are discussed. The Australian National Blood Pressure 2 study, which was unblinded, reported a marginally significantly better outcome only in male patients receiving an angiotensin-converting enzyme inhibitor-based regimen compared to those receiving a diuretic-based program. Finally, the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) is reviewed. Highlights of this report include the new designation of prehypertension, i.e., blood pressures of 120-139 mm Hg/80-89 mm Hg. The JNC 7 suggested that diuretics should be the first-step drug of choice in most patients, but listed numerous specific reasons why other agents should be used in special situations. The report stressed that the majority of patients will require two or more medications to achieve goal blood pressure.
强调收缩压升高在评估风险和确定预后方面的重要性。对安慰剂对照临床试验的回顾表明，基于利尿剂或β受体阻滞剂的治疗方案能使心血管事件在统计学上显著减少。讨论了仅降低血压还是特定药物对治疗结果产生影响的问题。基于众多试验的结果，很明显，在减少心血管事件方面，降低血压本身可能比所用的特定药物更为重要。然而，荟萃分析表明，与基于钙通道阻滞剂治疗的方案相比，使用阻断肾素 - 血管紧张素 - 醛固酮系统的药物在糖尿病患者和肾病患者中可能更有效。抗高血压和降脂治疗预防心脏病发作试验（ALLHAT）报告称，与基于钙通道阻滞剂或血管紧张素转换酶抑制剂的治疗方案相比，接受基于利尿剂治疗的患者在冠心病治疗结果上没有总体差异。然而，利尿剂组的患者发生心力衰竭的次数比钙通道阻滞剂组少，且比血管紧张素转换酶抑制剂组发生心力衰竭和中风的次数少。糖尿病患者和非糖尿病患者的结果相似。文中讨论了出现这一结果的可能原因。澳大利亚全国血压2研究未设盲，报告称与接受基于利尿剂方案的男性患者相比，接受基于血管紧张素转换酶抑制剂方案的男性患者的治疗结果仅略好一些。最后，对美国预防、检测、评估与治疗高血压联合委员会第七次报告（JNC 7）进行了回顾。该报告的重点包括对高血压前期的新定义，即血压为120 - 139毫米汞柱/80 - 89毫米汞柱。JNC 7建议利尿剂应作为大多数患者的首选一线药物，但列出了在特殊情况下应使用其他药物的众多具体原因。该报告强调，大多数患者需要两种或更多药物才能达到目标血压。
