Wilbert S Aronow教授   美国纽约医学院

　　<International Circulation>: Recently ESH has announced its latest hypertension guidelines which relax the optimal blood pressure goal to some extent. Were these changes based on clinical research outcomes and in your opinion， how should we set optimal blood pressure goals for patients who are at a higher risk for cardiovascular events? And how should we choose the appropriate medications for such patients?

　　Prof. Aronow: Well， first of all， that is a topic that I discussed at the World Congress on Heart Disease and I concur with the 2013 European Society of Hypertension and European Society of Cardiology guidelines. The 2013 European Society of Hypertension and European Society of Cardiology guidelines recommend that reducing blood pressure to less than 130/80 mm Hg in patients at high risk for cardiovascular events was unsupported by prospective trial data and that the systolic blood pressure should be reduced to less than 140 mm Hg in these patients， between 140 to 150 mm Hg if the patients are 80 years of age or older. The American College of Cardiology Foundation/American Heart Association 2011 Hypertension guidelines， and I am actually the first author of those guidelines and co-chair of the guideline committee， recommended on the basis of randomized clinical trial data that those younger than 80 years with hypertension should have a blood pressure reduced to less than 140/90 mm Hg on the basis of the Hypertension in the Very Elderly Trial (HYVET) persons aged 80 years and older with hypertension should have their systolic blood pressure reduced to 140 to 145 mm Hg as tolerated. During the talk that I gave， I discussed the various trials and the reasons for these guidelines.

　　《国际循环》：最近ESH公布了其制订的最新高血压指南，新指南在一定程度上放宽了最佳血压控制目标。这些改变是否具有临床研究证据的支持？在您看来，在临床实践中对心血管事件高危患者我们应如何设定最佳血压控制目标值？对上述患者应如何选择适宜的药物治疗？

　　Aronow教授：首先，这是我在世界心脏病大会上所讨论的一个问题。我对ESH和ESC发布的2013版指南持支持态度。新指南认为将心血管事件高危患者的血压降至130/80 mm Hg以下缺乏前瞻性试验数据的支持，故推荐上述患者的血压控制目标为将收缩压降至140 mm Hg以下，如果患者年龄≥80岁则其收缩压控制在140~150 mm Hg即可。我是美国心脏病学学会基金会/美国心脏协会（ACCF/AHA）2011版高血压指南的第一作者及指南编写委员会的共同主席，该指南以随机临床试验数据为依据推荐80岁以下的高血压患者应将血压控制在140 mm Hg以下，并根据HYVET试验结果推荐≥80岁的老年高血压患者如果能耐受，可将其收缩压控制在140~150 mm Hg范围内。在我的讲座中，我介绍了各项临床试验，并解析了这些指南推荐的证据及原因。

　　<International Circulation>: To follow up， in clinical practice what would be the most appropriate way to choose the optimal medication for such patients?

　　Prof. Aronow: As we stated in the American College of Cardiology Foundation/American Heart Association 2011 hypertension guidelines which were also endorsed by seven other professional societies， you can use either of diuretics， beta blockers， ACE inhibitors， angiotensin receptor blockers， or calcium channel blockers.  A meta-analysis was performed over 147 randomized trials including one with 64，000 persons.  Except for the extra protective effect of beta blockers given after myocardial infarction， and a minor extra effect of calcium channel blockers in reducing stroke， beta blockers， ACE inhibitors， angiotensin receptor blockers， thiazide diuretics， and calcium channel blockers were similar in reducing coronary events and stroke for a given decrease in blood pressure. The proportional decrease of cardiovascular events with use of beta blockers， ACE inhibitors， angiotensin receptor blockers， diuretics， or calcium channel blockers was the same or similar regardless of pre-treatment blood pressure and the presence or absence of existing cardiovascular disease.  The overall data suggests that the reduction of stroke in patients with hypertension reduction is related more to the reduction of blood pressure than the type of antihypertensive drug used. The American College of Cardiology Foundation and American Heart Association 2011 Hypertension guidelines state that diuretics， ACE inhibitors， angiotensin receptor blockers， beta-blockers， and calcium channel blockers have all shown benefits in cardiovascular outcomes in randomized trials.  The choice of a specific drug depends on efficacy， tolerability， presence of specific comorbidities， and cost. There is no good evidence to support the use of a lower systolic blood pressure goal to 130 to 139 mm Hg in high risk patients aged younger than 80 years and the systolic blood pressure should be reduced to 140 to 145 mm Hg as tolerated in patients aged 80 years and older. The optimum diastolic blood pressure goal in isolated systolic hypertension is unclear but the diastolic should not be reduced to less than 60 mm Hg.

　　《国际循环》：在临床实践中，对心血管事件高危患者而言实现理想降压目标的最佳方法及药物有哪些？

　　Aronow教授：正如其他7个专业学会所支持的ACCF/AHA 2011版高血压指南中所指出，患者可应用利尿剂、β受体阻滞剂、ACEI、ARB及钙离子拮抗剂。一项对147项随机试验（其中一项入选64000例患者）的荟萃分析显示，除β受体阻滞剂对心肌梗死具有额外保护效应、钙离子拮抗剂有减少卒中的微弱额外优势外，β受体阻滞剂、ACEI、ARB、噻嗪类利尿剂及钙离子拮抗剂使血压降低同等程度时的降低冠状动脉事件及卒中的作用相当。不论治疗前的血压如何、是否存在心血管疾病，应用β受体阻滞剂、ACEI、ARB、噻嗪类利尿剂或钙离子拮抗剂后心血管事件的降低比例相当。整体数据提示，在血压降低的高血压患者中，卒中风险的降低与血压的降低有更为密切的相关性，而与应用的降压药物种类关系并不大。ACCF/AHA 2011版高血压指南指出，随机临床试验结果显示，利尿剂、ACEI、ARB、β受体阻滞剂及钙离子拮抗剂均能为患者带来心血管结局方面的获益。要根据药物的疗效、耐受性、患者有无特殊合并症以及治疗成本进行药物选择。目前尚无很好的证据支持将80岁以下高危患者的收缩压降至130~139 mm Hg，将≥80岁的老年高危患者收缩压降至140~145 mm Hg。同时，单纯收缩期高血压患者的最佳舒张压控制目标也尚不确定，其中明确的是其舒张压不能降低至60 mm Hg以下。