Chalmers J
Department of Medicine, Flinders Medical Centre, Adelaide, Australia.
J Hypertens Suppl. 1996 Nov;14(4):S3-8. doi: 10.1097/00004872-199606234-00002.
Among the many guidelines and recommendations put forward by national and international authorities in recent years, there has been close agreement that the physician should assess each patient carefully over many months, should address the total profile of cardiovascular risk not just the raised blood pressure, and should treat patients right up to the age of 85 years with either classical essential hypertension or isolated systolic hypertension. The major guidelines described five groups of first-line antihypertensive drugs: diuretics, beta-blockers, angiotensin converting enzyme (ACE) inhibitors, calcium antagonists and alpha-blockers.
In other areas, the various guidelines were either united in uncertainty, or divided on the best course of action. The availability of many new methods and approaches for the measurement of blood pressure has introduced greater uncertainty into the interpretation of the blood pressure level in the individual patient, with question marks still surrounding the interpretation of white-coat hypertension, of ambulatory blood pressure monitoring and of home blood pressure readings in relation to clinic blood pressure. There is lack of uniformity in recommendations for the threshold values at which raised blood pressure should be lowered and in the recommendations for the target blood pressure the physician should set in the individual patient.
Since the publication of the major guidelines in 1993 and 1994, the greatest uncertainty has surrounded the choice of drugs to initiate treatment. This reflects the fact that so far no major trials have been completed confirming that the newer agents such as ACE inhibitors, calcium antagonists or alpha-blockers reduce cardiovascular morbidity and mortality in hypertensive patients. While awaiting the results of the many prospective randomized trials that are in progress with these newer agents, a number of case-control studies have raised concerns that non-potassium-sparing diuretics may increase the incidence of sudden cardiac death and that calcium antagonists might increase the occurrence of coronary heart disease in hypertensive subjects.
These issues highlight the importance of initiating prospective, randomized, controlled trials early in the development of all new drugs. While awaiting the results of trials currently in progress, the physician should continue to use all five groups of antihypertensive drugs, tailoring the choice of drug to suit the individual patient, and should use low doses of antihypertensive drugs either alone, or in appropriate combinations.
在近年来国家和国际权威机构提出的众多指南和建议中，已达成的一个相近共识是，医生应在数月内仔细评估每位患者，应关注心血管风险的整体状况，而不仅仅是升高的血压，并且对于患有经典原发性高血压或单纯收缩期高血压的患者，应一直治疗到85岁。主要指南描述了五类一线抗高血压药物：利尿剂、β受体阻滞剂、血管紧张素转换酶（ACE）抑制剂、钙拮抗剂和α受体阻滞剂。
在其他领域，各种指南要么在不确定性上达成一致，要么在最佳行动方案上存在分歧。许多测量血压的新方法和途径的出现，给个体患者血压水平的解读带来了更大的不确定性，白大褂高血压、动态血压监测以及家庭血压读数相对于诊室血压的解读仍存在疑问。对于应降低升高血压的阈值的建议以及医生应在个体患者中设定的目标血压的建议，缺乏一致性。
自1993年和1994年主要指南发布以来，关于起始治疗药物的选择存在最大的不确定性。这反映出这样一个事实，即到目前为止，尚未完成任何大型试验来证实诸如ACE抑制剂、钙拮抗剂或α受体阻滞剂等新型药物能降低高血压患者的心血管发病率和死亡率。在等待这些新型药物众多前瞻性随机试验结果的同时，一些病例对照研究引发了人们的担忧，即非保钾利尿剂可能会增加心源性猝死的发生率，而钙拮抗剂可能会增加高血压患者冠心病的发生率。
这些问题凸显了在所有新药研发早期就开展前瞻性、随机、对照试验的重要性。在等待当前正在进行的试验结果期间，医生应继续使用所有五类抗高血压药物，根据个体患者情况调整药物选择，并应单独或适当联合使用低剂量的抗高血压药物。
