高血壓的認知與控制,是目前醫(yī)學上主要的挑戰(zhàn)之一

1、高血壓的認知與控制，是目前醫(yī)學上主要的挑戰(zhàn)之一在1990年代，NHANE 的國際調查發(fā)現只有27的高血壓病人，其血壓值可以控制在收縮壓140mmHg及舒張壓90mmHg的理想狀態(tài)，大部分病人的血壓還是未能有效地獲得控制。早期的study如Framingham會建議高血壓病人應同時有效地控制其收縮壓（Systolic）及舒張壓（Diastolic）。但這些study，以現今標準而言，都太小了，且無法釐清收縮性高血壓及舒張性高血壓，孰重孰輕。而在NIH所Support的一項大型study：MRFIT，則可釐清此一情形，在MRFIT的研究中發(fā)現，如果高血壓病人的收縮壓能夠有效地獲得控制，則能有效地減

2、低其冠狀動脈疾病的發(fā)生。MRFIT是針對362,662位中年男性<罹患有高血壓、高膽固醇及抽煙>以2年的時間選出其中350,000位，追蹤15年<1973-1975>後發(fā)現收縮性高血壓（Systolic Hypertension）是造成CHD的第一危險因子。同樣的結果可以在HOT及TOMHS中發(fā)現，嚴謹地控制病人的收縮壓，才能減少其Mortality，尤其是下列三類病人：1. 原發(fā)性高血壓<Essential HTN>病人血壓應140mmHg2. 糖尿病併有高血壓<Diabetic HTN>病人血壓應130mmHg3. 有蛋白尿的高血壓<P

3、roteinuric HTN>病人應125mmHg1-blockers應該被考慮包含在多種藥物治療的組合中，因為它是治療高血壓藥物中的一大主類，並且它在血脂肪及空腹血糖均有良性的影響。ALLHAT包含了在625各美國及加拿大的臨床醫(yī)院、診所的42,450各高危險性高血壓病人。病人隨機分為四群：1. 利尿劑（Chorthalidone）2. 鈣離子阻斷劑（Amlodipine）3. ACE-I（Lisnopril）4. 1-blockers（Doxazosin）Doxazosin組與利尿劑組比較具相同療效，雖造成較多鬱血性心衰竭情況，而提早結束研究。然而，對於設定的primary endp

4、oint CHD與利尿劑組並無差異。1-blockers對於降低血壓，改善血脂肪代謝，提高Insulin sensitivity有其獨特效果，它還是被建議在組合療法中的最佳選擇。MANAGING HYPERTENSION IN THE 21ST CENTURY: LESSONS LEARNED FROM CLINICAL TRIALSRICHARD H GRIMM JR., MD, PHDDIRECTOR BERMAN CENTER FOR OUTCOMES AND CLINICAL RESEARCHHENNEPIN COUNTY MEDICAL CENTERPROFESSOR OF CARD

5、IOLOGY AND EPIDEMIOLOGYUNIVERSITY OF MINNESOTAMINNEAPOLIS, MINNESOTAHypertension awareness and control continues to be one of the main challenges of medicine today. Hypertension worldwide is extremely common; in the US alone one in four adults are affected. Fortunately we currently have several diff

6、erent classes of well-tolerated and highly efficacious drugs to use for treating hypertension. It is known clearly that lowering blood pressure with drugs can have impressive results for preventing the major cardiovascular diseases.However, in spite of this potential, across the world hypertension i

7、s poorly controlled. In the US, which has one of the best control rates in the NHANES III national survey in the mid-1990s, only 27% of hypertensives were controlled to <140 and < 90 mmHg. More recent surveys suggest the control has gotten worse.One factor that may help improve control rates i

8、s a change in focus from diastolic blood pressure to systolic. Although the early epidemiological observations (i.e., Framingham) suggested that both pressures were important, these studies were small by todays standards, and the independent contribution of systolic versus diastolic could not be est

9、ablished. The Multiple Risk Factor Intervention Trial (MRFIT) has provided this data. MRFIT was an NIH sponsored study carried out between 1973-1982. It was one of the first large scale trials to test the effects of lowering CVD risk factors. To identify the highest CHD risk men, 362,662 middle-aged

10、 men were screened for blood pressure, serum cholesterol and cigarette smoking between 1973 and 1975.350,000 of these men have been followed for 15 years for cause-specific mortality. This data shows beyond any reasonable doubt that systolic pressure is the primary force determining CVD risk. Also c

11、ontributing independently to risk were those older men with higher systolic pressures and lower diastolic, or wider pulse pressure.Several newer trials have now examined the value of lowering systolic pressure. The first to report results was the NIH sponsored Systolic Hypertension in the Elderly Pr

12、ogram (SHEP).SHEP and several other trials have now resolved that lowering systolic pressure is the most important goal in managing hypertension, and for preventing stroke, CHD, congestive heart failure and even total mortality.The results of studies such as the TOMHS and HOT have mandated revision

13、of goal pressures to even lower levels < 140 mmHg systolic in essential hypertensives and < 130 in diabetic hypertensives. The recommended systolic goal for proteinuric patients is 125mmHg. Clearly in order to achieve these goals almost all hypertensives will need to be treated with multiple d

14、rug regimens.Alpha blockers are one of the agents that should be considered for inclusion in multiple drug treatment because it represents a separate class of drugs which is additive to BP lowering with other major classes of drugs, and also has favorable metabolic effects on lipids and fasting gluc

15、ose.ALLHAT is the largest hypertension study to date and involves 42,450 high-risk hypertensive patients whom have been followed by 625 community based clinics in the US and Canada. Patients were randomized to blinded treatment to one of four drugs: a diuretic, chlorthalidone; a Calcium blocker, aml

16、odipine; an ACE inhibitor, lisinopril or the alpha-blocker, doxazosin. The doxazosin group was terminated early due to the high unlikelihood that it would perform better than the diuretic and also because, compared to the diuretic, there was more CHF, a secondary endpoint, reported in this group. Th

17、e results compared with the primary endpoint CHD were no different compared to the diuretic. The reasons for this result are not clear, but may relate to the fact there could have been more fluid accumulation in this group, especially in those patients treated with diuretics just prior to randomizat

18、ion, which were discontinued at entry. The research group recommended that alpha-blockers not be used for initial treatment in this high risk patient population but be reserved for second and third line treatment with other drugs to achieve pressure control. This result is also not relevant to alpha-blocker treatment of benign prostatic hyperplasia (BPH) where these drugs are also indicat