Mancia G, Giannattasio C, Seravalle G, Quarti-Trevano F, Grassi G
Clinica Medica, Dipartimento di Medicina Clinica e Prevenzione, Università di Milano-Bicocca, Ospedale San Gerardo, Milan, Italy.
J Hum Hypertens. 2009 Sep;23(9):570-7. doi: 10.1038/jhh.2008.171. Epub 2009 Jan 29.
Antihypertensive drugs exert a number of blood pressure-independent benefits. However, demonstrating the clinical significance of these effects may be difficult for a number of reasons. First, blood pressure can be measured in the clinic, at home and over the 24-h period by ambulatory monitoring. Second, differences between these measures mean that achieving equivalent blood pressure reductions in two treatment arms may be difficult, if not impossible. Furthermore, even small differences in blood pressure can translate into significant effects on cardiovascular risk, especially in the later stages of the cardiovascular continuum. In large clinical trials, other errors limiting the sensitivity to treatment differences include high patient dropouts and unplanned crossover. In addition, as so many patients fail to achieve blood pressure goals even in clinical trials where patient's and physician's motivation is high, the need for cardiovascular protection beyond blood pressure control is unequivocal. Clinical trials of angiotensin II receptor blockers have suggested significant effects beyond blood pressure control, which are observed throughout and with greater consistency in the early phases of the cardiovascular continuum. There may also be differences between angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors. Conclusive demonstration that these blood pressure-independent effects do exist will require, however, a much more accurate and extended assessment of the blood pressure effects of the drugs.
抗高血压药物具有许多不依赖于血压降低的益处。然而，由于多种原因，证明这些作用的临床意义可能会很困难。首先，血压可以在诊所、家中通过动态血压监测在24小时内进行测量。其次，这些测量方法之间的差异意味着，要在两个治疗组中实现等效的血压降低即便不是不可能，也可能很困难。此外，即使血压的微小差异也可能转化为对心血管风险的显著影响，尤其是在心血管病变的后期阶段。在大型临床试验中，其他限制对治疗差异敏感性的误差包括高患者脱落率和非计划的交叉。此外，即使在患者和医生积极性很高的临床试验中，仍有许多患者未能达到血压目标，因此明确需要在控制血压之外进行心血管保护。血管紧张素II受体阻滞剂的临床试验表明，其作用超出了血压控制范围，在心血管病变的整个过程中均有观察到，且在早期阶段更为一致。血管紧张素II受体阻滞剂和血管紧张素转换酶抑制剂之间也可能存在差异。然而，要确凿证明这些不依赖于血压的作用确实存在，将需要对药物的血压作用进行更准确和更广泛的评估。
