Dustan H P
Cardiovascular Research and Training Center, University of Alabama at Birmingham 35294.
Clin Invest Med. 1987 Nov;10(6):621-4.
Treatment of hypertension is changing rapidly because drugs with greater specificity are being developed and knowledge is evolving concerning factors that determine responses to available drugs. For almost a decade US physicians have relied on national guidelines called Stepped-Care. Step 1 calls for using either a diuretic or a beta blocker; in subsequent steps other drugs are added. Because of the new drugs and the new knowledge it is likely that Step 1 will soon be broadened to include many other drugs. The short-term changes in Step-1 will be based upon those factors now known to influence pressure responsiveness: age--young vs old; race--black vs white; type--renovascular vs essential; and severity--mild-to-moderate vs severe. In young hypertensives, much evidence suggests a dominant neurogenic component of central origin; therefore, a central sympatholytic drug or an alpha-beta receptor blocker seem to be preferable as firstline drugs. Hypertension, primarily systolic, in elderly patients responds well to diuretics or calcium channel blockers. Mild-to-moderate hypertension in blacks is particularly responsive to diuretics, while beta blockers are relatively ineffective. Renovascular hypertension is predominantly caused by increased angiotensin II, so converting enzyme (ACE) inhibition is indicated in unilateral stenosis. The hallmark of severe hypertension is vasoconstriction, so a vasodilator (nifedipine, minoxidil, or an ACE inhibitor) is indicated as first treatment, not a diuretic or a beta blocker alone. Long term changes will depend on development of drugs with specificity for newly, or better defined, pressor mechanisms.
高血压的治疗正在迅速变化，因为具有更高特异性的药物正在研发中，而且对于决定对现有药物反应的因素的认识也在不断发展。近十年来，美国医生一直依赖名为“阶梯治疗”的国家指南。第一步要求使用利尿剂或β受体阻滞剂；在后续步骤中添加其他药物。由于新药和新知识的出现，第一步可能很快会扩大到包括许多其他药物。第一步的短期变化将基于目前已知影响血压反应性的因素：年龄——年轻人与老年人；种族——黑人与白人；类型——肾血管性与原发性；以及严重程度——轻度至中度与重度。在年轻高血压患者中，大量证据表明主要是中枢起源的神经源性成分；因此，中枢性抗交感神经药物或α-β受体阻滞剂似乎更适合作为一线药物。老年患者以收缩压升高为主的高血压对利尿剂或钙通道阻滞剂反应良好。黑人的轻度至中度高血压对利尿剂特别敏感，而β受体阻滞剂相对无效。肾血管性高血压主要由血管紧张素II增加引起，因此在单侧狭窄时应使用转换酶（ACE）抑制剂。重度高血压的标志是血管收缩，因此应首先使用血管扩张剂（硝苯地平、米诺地尔或ACE抑制剂）进行治疗，而不是单独使用利尿剂或β受体阻滞剂。长期变化将取决于针对新的或定义更明确的升压机制具有特异性的药物的研发。
