Department of Medicine, Division of Cardiology, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland.
Clin Interv Aging. 2009;4:137-51. doi: 10.2147/cia.s3216. Epub 2009 May 14.
The overall purpose of hypertension treatment is 2-fold. First, patients often have symptoms that are related to their high blood pressure and although subtle in many instances may be improved dramatically by blood pressure control. The main reason for blood pressure treatment, however, is to reduce the burden of cardiovascular complications and end organ damage related to the condition. This may be considered the ultimate goal of blood pressure treatment. In this respect, actual blood pressure measurements may be seen as surrogate end points as the organ protective effects of two antihypertensive agents may differ significantly even though their blood pressure lowering effects are similar. Thus beta-blockers, once seen as first-line treatment of hypertension for most patients, now are considered as third- or fourthline agents according to the latest NICE guidelines (National Institute for Health and Clinical Excellence, www.nice.org.uk/CG034). On the other hand, agents that inhibit the activity of the renin-angiotensin-aldosterone system (RAAS) system are being established as safe, effective and end organ protective in numerous clinical trials, resulting in their general acceptance as first-line treatment in most patients with stage 2 hypertension. This shift in emphasis from beta-blockers and thiazide diuretics is supported by numerous clinical trials and has proven safe and well tolerated by patients. The impact of this paradigm shift will have to be established in future long-term randomized clinical trials. The optimal combination treatment with respect to end organ protection has yet to be determined. Most combinations will include either a RAAS active agent and calcium channel blocker or two separate RAAS active agents working at different levels of the cascade. In this respect direct renin inhibitors and angiotensin receptor blockers seem particularly promising but the concept awaits evaluation in upcoming randomized clinical trials. Although safety data from the randomized clinical trials to date have been promising, we still lack data on the long-term effect of aliskiren on mortality and there still are patient groups where the safety of aliskiren is unexplored.
高血压治疗的总体目标有两个。首先，许多高血压患者都有相关症状，虽然这些症状在多数情况下较为轻微，但通过控制血压可以得到显著改善。然而，治疗高血压的主要原因是降低与该疾病相关的心血管并发症和靶器官损害的负担。这可以被认为是降压治疗的最终目标。在这方面，实际的血压测量值可以被视为替代终点，因为即使两种降压药物的降压效果相似，其保护器官的作用可能有很大差异。因此，β受体阻滞剂曾被视为大多数患者高血压治疗的一线药物，但根据最新的 NICE 指南（国家卫生与临床卓越研究所，www.nice.org.uk/CG034），现在被认为是三线或四线药物。另一方面，抑制肾素-血管紧张素-醛固酮系统（RAAS）系统活性的药物在许多临床试验中被证明是安全、有效且具有靶器官保护作用，因此被普遍接受为大多数 2 期高血压患者的一线治疗药物。这种从β受体阻滞剂和噻嗪类利尿剂的治疗重点的转变得到了许多临床试验的支持，并已被证明对患者是安全且耐受良好的。这种范式转变的影响将在未来的长期随机临床试验中得到证实。关于靶器官保护的最佳联合治疗方案仍有待确定。大多数联合治疗方案将包括 RAAS 活性药物和钙通道阻滞剂，或两种不同作用水平的 RAAS 活性药物。在这方面，直接肾素抑制剂和血管紧张素受体阻滞剂似乎特别有前景，但这一概念有待即将进行的随机临床试验评估。尽管迄今为止随机临床试验的安全性数据令人鼓舞，但我们仍缺乏关于阿利克仑对死亡率的长期影响的数据，并且仍有一些患者群体的阿利克仑安全性尚未得到探索。
