Anti-hypertension drug reasonable application

Since 1997 the United States JNC VI, 1999 WHO-ISH China and the announcement of the hypertension treatment guidelines, and have completed several clinical trials and drug comparative study of hypertensive patients on how to choose the different circumstances of anti-hypertensive drugs, the risk factors of hypertension intervention , and strictly control blood pressure, the effective protection of the target organ, these awareness of the problem has reached a new height, it is necessary to sum up in order to facilitate the rational application of clinical practice in anti-hypertension drug.

A comprehensive assessment of risk factors and intervention

New guide highlights the level of blood pressure and coexistence of the risk factors are equally important. The level of blood pressure and cardiovascular disease was continuity, and even in the normal range of blood pressure, blood pressure lowest in the crowd the incidence of cardiovascular disease is low. Hypertension is not just hemodynamic disorders, but also metabolic disorders, the Framingham Heart Study found that over 80% of the patients with hypertension associated with one or more risk factors of cardiovascular disease morbidity and mortality not only directly related to the level of blood pressure, and also depends on the accompanying risk factors and the coexistence of other clinical disease. Prognostic risk factors include age, male, smoking, family history of early cardiovascular disease, lipid disorders, overweight obesity, impaired glucose tolerance, diabetes mellitus and microalbuminuria, blood fibrinogen levels and resting lifestyle, with diabetes or other cardiovascular and cerebrovascular diseases. In recent years, research suggests that heart rate by fast, high uric acid, with a high of hyperhomocysteinemia and other cardiovascular disease may be an independent risk factor. Many studies suggested that heart rate and blood pressure are closely related, high heart rate have a higher level of blood pressure. Framingham study on heart rate forecast because of the mortality rate and systolic blood pressure and smoking as men in the risk of Sudden cardiac death with a resting heart rate increased by fast, fast heart rate by hypertension and cardiovascular death is an independent risk factor. Heart rate increased 10 times per minute, a 20% increase in the entire cause of death and 14 per cent of cardiovascular deaths. Hyperuricemia is promoting inflammation and thrombosis, research shows that hyperuricemia is an independent risk factor for coronary heart disease, Framingham study failed to find such an association exists. Hyperuricemia in patients with hypertension increase in cardiovascular and cerebrovascular events of the risk of further study to be verified. Whether in the hypertensive population in the individual or hypertension, the risk factors often gathered there, the mutual influence and role of mutual stack and accelerate the occurrence of cardiovascular complications and development. Hypertension itself is the most important risk factors. 1999 WHO / ISH Hypertension control and guide our country both according to the above risk factors, target organ damage and other cardiovascular clinical hypertension patients will be in quantifying the risk of cardiovascular events for the low-risk, risk, high risk, very high risk Group 4th speed. The more risk factors, the absolute risk of cardiovascular disease on the higher risk factors for these efforts should be greater.

What is the ideal target blood pressure level? HOT study found no J-curve with the relevance of coronary events, eight older systolic hypertension meta-analysis of the clinical trial did not prove the existence of J-curve. Cardiovascular disease risk and the relationship between blood pressure was continuity, in the normal blood pressure range no minimum threshold, blood pressure should be reduced to the greatest degree of tolerance to this level of the degree of risk of cardiovascular complications minimum. HOT on £ 80 mmHg in diastolic blood pressure than £ 90 mmHg in diastolic blood pressure in patients with cardiovascular complications of diabetes and cardiovascular mortality were reduced, £ 80 mmHg and diastolic blood pressure than £ 90 mmHg diastolic blood pressure of all patients with myocardial infarction were randomly incidents decreased diastolic blood pressure <80mmHg also no adverse events. For proteinuria> 1 g / day in patients with blood pressure should be reduced to below 125/75 mmHg, in the MDRD this positive test can be effective in reducing blood pressure urinary protein excretion and prevent the deterioration of renal function. For clinicians attending a hypertensive patients should be asked by history, physical examination and laboratory investigations, and conscientiously blood pressure and the risk factors of monitoring and comprehensive assessment. According to the treatment of patients with both risk factors of blood pressure control will be in the ideal range, also focus on the risk factors can be reversed comprehensive intervention to reduce the risk to a minimum, reduce cardiovascular and cerebrovascular events.

Second, comprehensive intervention and individualized therapy treatment

(1) the treatment of antihypertensive drugs

Large randomized clinical trial results showed that a significant reduction in antihypertensive treatment of major cardiovascular disease morbidity and mortality. Once clinically diagnosed hypertension, patients should be advised lifestyle adjustments, began non-drug treatment. Non-drug hypertension treatment is important, because the vast majority of hypertensive patients need antihypertensive agents in the control of blood pressure can be an ideal target blood pressure level, in clinical practice, we should attach importance to drug treatment. Single drug treatment often can not achieve the target blood pressure. Currently promoting small dose combination of antihypertensive drug, as different mechanism of action, and in the combination of different drugs can be caused by adverse reactions to prevent the blood pressure-lowering drug therapy triggered compensatory response to increased antihypertensive effect, with increased resistance sexual. HOT more fully the results of the study that combined the need for over 70% of the patients treated by the combination of drugs to achieve target blood pressure level objectives. With essential hypertension pathophysiological mechanisms, the most rational drug joint programme are as follows: 1) ACEI or diuretics and angiotensin II receptor blockers (ARB), 2) Diuretics and b receptor blocker; 3) b receptor blockers and calcium antagonists dihydrochloride pyridine 4) b receptor blockers and a1 receptor blocker; 5) or calcium antagonists and ACEI ARB. Another advantage of the treatment can improve cost-effectiveness ratio, in a randomized, double-blind study, each reduced by 1 mmHg diastolic blood pressure or diastolic blood pressure of each patient to return to normal, calcium antagonists and b-blockers in the treatment of Individual than ACEI cost-effective treatment is high 6%. In addition in the treatment of medical treatment to reduce the frequency of the 4-week treatment can achieve target blood pressure levels. In recent years small fixed dose combination of the two drugs combined rapid development of these drugs will become mainstream treatment of hypertension. In fact small fixed-dose combination drugs can be used as first-line hypertension drug treatment option because it can fully enhance the antihypertensive effects of drugs, drug-dose-dependent reduction of drug side effects in patients with convenient at the same time, improve compliance. The United States and Europe have agreed to such drugs as the initial treatment of hypertension, is the most representative of perindopril and indapamide, bisoprolol and dihydrotestosterone grams of urine thiadiazole.

(2), individual treatment of hypertension

In the treatment of hypertension should focus on the principle of individual treatment, the patients with cardiovascular risk factors different from the target organ damage and other cardiovascular diseases vary, naturally have other drug treatment, it advocates the principle of individual treatment.

1, elderly patients with hypertension

Syst-Eur, Syst-China antihypertensive therapy clinical trials that can reduce cardiovascular complications such patients especially with the occurrence of stroke mortality. Long-acting calcium antagonist nitrendipine preferred. Syst-Eur test data show that calcium antagonist treatment can reduce elderly patients with isolated systolic hypertension and the risk of dementia. STOP-2 comparative study of the b-receptor blockers, diuretics, and the long-term ACEI pyridine calcium antagonist treatment dihydrochloride 70-84-year-old patients with hypertension, with 4-6 years of follow-up, no in between them reduce cardiovascular mortality and the differences between primary endpoint events. NORDIL trial that diltiazem with b-receptor blockers and diuretics, 50-74 years of age can reduce the occurrence of stroke in patients with hypertension, myocardial infarction and other cardiovascular disease deaths. Old there are still disputes over whether to treatment, or have high blood pressure target organ damage should be used medication. Currently HYVET study is ongoing, aims to assess anti-hypertensive therapy on the significance of how the elderly senior citizens.

2, left ventricular hypertrophy (LVH)

LVH is the heart of chronic pressure or increase the load capacity of compensatory response. LVMI reduce the current of the most important ways to reduce blood pressure in patients with essential hypertension. ACEI or preferred AgII receptor antagonist. LIFE tests confirmed the essential hypertension in patients with left ventricular hypertrophy, losartan than atenolol reduced to a greater extent, cardiovascular and cerebrovascular disease morbidity and mortality composite end point (defined as stroke, myocardial infarction and cardiovascular and cerebrovascular disease deaths).

3, heart failure

Treatment to a combination of diuretics and ACEI or ARB. Diuretics effective to improve clinical symptoms, dose sufficient ACEI and b-blockers have been proven in large-scale clinical trials to reduce the mortality rates of heart failure.

4, coronary heart disease

Buck certainly beneficial to patients with coronary heart disease, but to avoid excessive hypotension caused reflex tachycardia, tension increased sympathetic activation of RAS. Such patients preferred b receptor blocker and ACEI. After myocardial infarction should be used to be no inherent sympathetic role of the b-blockers can reduce the recurrence of myocardial infarction and sudden death. Good heart function after myocardial infarction are available verapamil or diltiazem.

5, cerebrovascular disease

Hypertension is ischemic or hemorrhagic stroke the most dangerous factors. Generally believed that in the early acute ischemic stroke, high blood pressure unless, as> 180/105 mmHg, should be suspended with antihypertensive agents, or excessive hypotension cerebral blood flow will be significantly less. Thrombolysis in cerebral infarction, the first 24 hours to monitor blood pressure, only SBP> 180mmHg, DBP> 105mmHg when it can be used intravenous antihypertensive drug control blood pressure. Hemorrhagic stroke significantly increased blood pressure, intracranial pressure should be down, if blood pressure is 200/120 mmHg also need antihypertensive treatment.

6, kidney disease

ACEI known, ARB and CCB have kidney protection. PRIME famous AIPRI and test results show Mingbei enalapril (Benazapril) Yibeishatan application can reduce the long-term renal dysfunction in patients with urinary protein, delaying the process of renal failure. Blood pressure should be reduced to below 130/85 mmHg; if proteinuria> 1 g / d, goals for blood pressure 125/75 mmHg.

7, diabetes

For hypertensive patients with diabetes, treatment will focus on strict control of blood pressure in the target blood pressure below HOT study showed that diabetic patients with hypertension will be reduced to the lowest levels of blood pressure (diastolic blood pressure <80 mmHg), can significantly reduce the risk of cardiovascular events. UKPDS test evidence that tight control of blood pressure can microvascular major events and the risk of major vascular events of a significant reduction. American Kidney Foundation hypertension and diabetes Executive Committee Working Group recalled the recent completion of a series of related large-scale randomized clinical trials on hypertension with or without diabetic nephropathy in patients with the latest treatment by consensus: the target in the control of blood pressure 130/80mmHg or less, which is more effective to prevent kidney progress and reduce the risk of cardiovascular disease. INSIGHT study found that hypertensive patients with type 2 diabetes in order to achieve target blood pressure in patients with almost 100 per cent in the treatment needs. Meta-analysis suggested that active control of hypertension and diabetes blood pressure an average of 3.2 antihypertensive drugs. ACEI, ARB, a receptor blockers, calcium antagonists, small dose of Hydrochlorothiazide grams of urine thiadiazole applied to hypertension and diabetes patients; diabetic patients with small doses of urine thiadiazole dihydrochloride grams plus b receptor blocker therapy on the reduction CHD mortality and total cardiovascular events certainly effective. UKPDS Study Table Argentina atenolol and captopril on with type 2 diabetes control blood pressure in patients with hypertension equally effective. HOT findings and ALLHAT trial interim results are confirmed long-acting CCB in diabetic patients with hypertension in the safety and effectiveness. Antihypertensive treatment can delay or prevent the progress of renal damage, extended life expectancy. ACEI, ARB, a-receptor blockers and diuretics can proteinuria in the patients after a 10-year survival rate from 30% to 80%. Recently completed RENAL, LIFE clinical trial highlights the ARB in hypertension special populations such as the unique role of diabetes, such people can gain greater benefits of the treatment. To the general blood pressure dropped to the lowest level, the main organ of the perfusion pressure can be, this can enhance the efficacy of nephropathy.