McKenney J M
Drug Intell Clin Pharm. 1985 Sep;19(9):629-41. doi: 10.1177/106002808501900904.
Recent clinical trials in hypertension report more deaths due to coronary heart disease in mild hypertensives who received aggressive antihypertensive drug therapy and achieved better blood pressure control. Subset analyses of these trials suggest that diuretic therapy may have contributed to this outcome, possibly through a reduction in serum potassium or an elevation in serum lipids. Because of this, patients with an abnormal pretreatment electrocardiogram, history of myocardial infarction, unstable coronary heart disease, or diuretic-induced hyperlipidemia or hypokalemia unresponsive to management are candidates for alternative antihypertensive agents. A review of the literature suggests that most of the currently available beta-blockers, the alpha 1-antagonist prazosin, the angiotensin-converting enzyme inhibitor captopril, and the vasodilator hydralazine are effective alternatives to thiazide therapy in the initial management of hypertension and are recommended for particular subgroups of patients. Monotherapy with the centrally and peripherally acting sympatholytic agents is not recommended because of the frequent side effects encountered and the inferior hypotensive efficacy reported. Calcium channel blocking agents also appear to be suitable alternatives to thiazides in hypertension, but more experience with these is needed. Alternative pharmacologic agents may be selected on the basis of age, and, to a lesser extent, race.
近期高血压临床试验报告显示，接受积极降压药物治疗且血压控制更佳的轻度高血压患者中，因冠心病导致的死亡人数更多。这些试验的亚组分析表明，利尿剂治疗可能导致了这一结果，可能是通过降低血清钾或升高血脂。因此，治疗前心电图异常、有心肌梗死病史、不稳定型冠心病、或利尿剂诱发的高脂血症或低钾血症且治疗无效的患者，适合选用其他抗高血压药物。文献综述表明，目前大多数可用的β受体阻滞剂、α1拮抗剂哌唑嗪、血管紧张素转换酶抑制剂卡托普利以及血管扩张剂肼屈嗪，在高血压初始治疗中是噻嗪类治疗的有效替代药物，且推荐用于特定亚组患者。不推荐使用中枢和外周作用的交感神经阻滞剂进行单一治疗，因为会频繁出现副作用且报道的降压效果较差。钙通道阻滞剂在高血压治疗中似乎也是噻嗪类药物的合适替代药物，但还需要更多这方面的经验。可根据年龄，并在较小程度上根据种族选择替代药物。
