《International international》: My first question is about the hypertension guideline. 2007 ESH and ESC hypertension guideline paid more attention to the total cardiovascular risk. They emphasize that diagnosis and management of hypertension should be based on the classification of cardiovascular risk. The topic of this satellite symposium is also about the total CV risk management. Why do we emphasize the total cardiovascular risk so much for today?
《国际循环》：我的第一个问题是关于高血压指南的。2007年ESH和ESC高血压指南更加关注整体心血管风险。指南中强调高血压的诊断和治疗应该以心血管风险的分级为基础。这次卫星会议的话题也主要几种在整体心血管风险管理上。为什么现在大家对整体心血管风险这么强调呢？

Rerhardt: The reason is very simple. That is all risk factors work together and make up an overall total risk to develop disease usually measured over the period of ten years. Hypertension is one of the most common risk factors. What we have learn is that people who have hypertension often have other risk factors such as too high cholesterol， obese， they smoke and they have metabolic problem with glucose control. So if you look at people with hypertension that have other risk factors， it’s not just the blood pressure that needs to be controlled， it’s the other risk factors. Whichever one of these risk factors you manage， the over all risk would be reduced. You rightly said that the ESC and ESH guidelines are based on risk， it is however different kind of risk assessment compared to the joined preventive guidelines we also presented this year. Because hypertensive guidelines categorize people into persons of one， two， three or more risk factors and/or persons of target organ damage. And then there is the blood pressure level to categorize people into risk categories. The joined guidelines make calculation based on cholesterol， smoking， gender…all the factors to get a number of risk， which is a little more sophisticated and is probably the way we should recommend people to calculate risk， because it weighs in much more elegantly various risk factors and makes the doctor aware of the actual risk rather than just categorizing them to low risk， medium risk and high risk.
Rerhardt：原因很简单。因为所有的危险因素会共同起作用从而导致疾病的发生，这个过程大概需要十年左右。高血压就是其中一个最重要、最常见的危险因素。根据我们过去的经验，高血压的患者常常还会伴有一些其他的危险因素，比如胆固醇水平太高、肥胖、吸烟以及血糖代谢控制方面问题。所以如果你仔细思考一下这些有其他危险因素的高血压患者，你会发现他们的治疗过程中需要控制的不仅仅是血压，还有其他危险因素。这些危险因素中无论你控制哪个，都会有助于患者整体风险的降低。你刚才说ESC和ESH指南中关于高血压的治疗应该以心血管风险为基础，这一点是对的，但它与我们今年提出的联合预防指南中提到的风险评估还不太一样。因为高血压指南只是根据患者有一个、两个、三个或更多的危险因素和/或靶器官损害，以及患者的血压水平高低将其分成不同的风险级别。而联合指南则是将患者的胆固醇、吸烟史、性别等所有的危险因素换算成风险的数值。这种算法更加复杂，但很可能这样做是对的，我们应该推荐这种计算风险数值的方法，因为它更充分地考虑了不同危险因素的权重，可以让医生清楚地了解患者真实的风险水平，而不只是简单地把他们分为低危、中危和高危患者。

《International international》: Thank you. Another question is—management of hypertension should be based on total cardiovascular risk， hence， what is the most optimal cost-effective solution to use Caduet?
《国际循环》：谢谢。还有一个问题：高血压的治疗应该以整体心血管风险为基础，那么应该如何使用Caduet这种药物才能使成本-效益比达到最高呢？

Rerhardt: Oh， that is a very good question. Let me first say that it’s not entirely true to say that management of hypertension should only based on risk. Number one， you need to control blood pressure. The issue here is that because you have cardiovascular risk factors in the majority of people. Actually four out of five people with hypertension have other risk factors. The problem is doctors only focus on blood pressure， they do not consider other risk factors in order to use the overall risk. So blood pressure should be controlled first， and at the same time you control blood pressure you should also mange other risk factors. Not wait to do it later， but do it at the same time. So that is a very important issue. With Caduet it’s another story， because it is a combination of two very good drugs， one for lowering blood pressure and one for controlling cholesterol. I think it is an innovative step to be taken to make it easier for people to take one medication and control two risk factors at the same time. Also we know that patients all over the world have big problems with what we called adherence. That is the doctor prescribes medication and the patient does not take the medication. We know that the more pills doctors prescribe， the less likely the patients are to take the drugs. We also know that diseases that have no symptoms such as hypertension， with or without other risk factors do not produce any symptoms， patients do not know whether they feel better or worse when they take the medication. In actual factor， some patients who feel well， when they take drugs， feel worse because they have side effects. So we have a problem. And Caduet is designed to manage the risk with one pill. Also it can make it more practical and easier for the patient to take the pill， because the more patients that would take the medication， obviously the better effect you would have on what you want to achieve， namely risk factor control.

Rerhardt：噢，这个问题问的很好。首先我想说的是，所谓高血压治疗唯一的根据就是患者的危险因素这种说法并不完全正确。第一，你需要控制血压。这里的问题就在于大多数的高血压患者都具有其他心血管危险因素。实际上每五名高血压患者中就有四人有其他心血管危险因素。问题在于医生往往会只关注血压本身，他们没有考虑其他危险因素。正确的做法是先控制血压，在控制血压的同时还应该顾及其他危险因素。不是拖延到以后再处理而是同时兼顾。这一点非常重要。Caduet这种药物则是另外一码事，因为它实际上是两种很好的药物的合剂，一种用于降低血压，还有一种用于控制胆固醇。能够让患者服用一种药物而同时控制两个危险因素，我认为这是一大创举。此外我们知道全世界的患者都存在一个很大的问题，就是我们所说的依从性问题。即医生开了处方，但患者并没有服药。我们知道医生开的药越多，患者吃药的可能性就越小。我们也知道有些疾病是没有症状的，比如高血压，无论患者有没有其他危险因素，他们无法感觉出他们服药以后病情是好转了还是恶化了。而事实就是，有些患者本来感觉良好但服药以后却感觉不好了，因为出现了药物的副作用。所以我们确实面临这样一个问题。而Caduet设计之初就是为了达到用一粒药物来控制危险因素的目的。它的实用性就表现在患者服药的过程变的更容易了。而愿意服药的患者越多，作为医生要达到治疗目标，比如危险因素控制就变得更加容易了。

《International international》: Can you use Caduet in patients without dyslipidemia?
《国际循环》：没有血脂紊乱的患者能够服用Caduet吗？

Rerhardt: Yes. You see the new knowledge based on not only the ASCOT trial but several observations from the HPS trial， from the TNT trial， from the CARE trial show that it’s not about high cholesterol， it’s about cholesterol that should below it. And all people， even people in China， Japan have too high cholesterol values as compared to what they should have been if we have led the life of a stone-age man. The LDL receptor was designed by sum to operate at the level of one mmol.