Messerli F H, Ventura H O
Drugs. 1985;30 Suppl 1:25-34. doi: 10.2165/00003495-198500301-00005.
Arterial hypertension is by definition a haemodynamic disorder. At least 3 different subsets of cardiovascular pathophysiological features can be identified in so-called essential hypertension: The young lean patient characterised by an elevated cardiac output and renal blood flow, elevated plasma renin activity and circulating catecholamine levels, as well as symptoms and signs of hyperadrenergic hypertension. The elderly patient characterised by a low cardiac output often with left ventricular hypertrophy, elevated total peripheral resistance, nephrosclerosis, and symptoms and signs of target organ disease. The obese patient (and to a lesser degree the black patient) characterised by expanded fluid volume state, elevated cardiac output, a normal to low total peripheral resistance, and symptoms and signs of volume overload. To initiate antihypertensive therapy, the drug of choice in the young patient is a beta-adrenergic receptor blocker; in the elderly it is a haemodynamic vasodilator (anti-adrenergic drug, slow channel calcium blocker, or converting enzyme (ACE) inhibitor), and in black or obese patients it remains a thiazide diuretic. Enalapril, a new ACE inhibitor is indicated as a first-step agent in the great majority of hypertensive patients in whom the elevated arterial pressure should be reduced by a decrease in total peripheral resistance, without compromising systemic or regional blood flow. In contrast to other antihypertensive agents, enalapril will lower preload and afterload to the left ventricle while improving systemic and regional flow in elderly patients with latent or manifest congestive heart failure.
根据定义，动脉高血压是一种血液动力学紊乱。在所谓的原发性高血压中，至少可以识别出3种不同的心血管病理生理特征子集：年轻瘦型患者，其特点是心输出量和肾血流量升高、血浆肾素活性和循环儿茶酚胺水平升高，以及高肾上腺素能性高血压的症状和体征。老年患者，其特点是心输出量低，常伴有左心室肥厚、总外周阻力升高、肾硬化，以及靶器官疾病的症状和体征。肥胖患者（以及程度较轻的黑人患者），其特点是血容量状态扩大、心输出量升高、总外周阻力正常至降低，以及容量超负荷的症状和体征。开始抗高血压治疗时，年轻患者的首选药物是β-肾上腺素能受体阻滞剂；老年患者是血液动力学血管扩张剂（抗肾上腺素能药物、慢通道钙阻滞剂或转化酶（ACE）抑制剂），而黑人或肥胖患者的首选药物仍是噻嗪类利尿剂。依那普利是一种新型ACE抑制剂，在大多数高血压患者中被用作一线药物，这些患者应通过降低总外周阻力来降低动脉压升高，同时不影响全身或局部血流。与其他抗高血压药物不同，依那普利在降低左心室前负荷和后负荷的同时，还能改善患有潜在或明显充血性心力衰竭的老年患者的全身和局部血流。
