【正文】 還可獲得多種降壓外的有益作用 )。 Sacks, et al. NEJM 2022。 134 哪些患者適用聯(lián)合用藥 ? 135 哪些患者適用聯(lián)合用藥 ? 136 FDCs—臨床的選擇 Coexisting condition First choice Ischaemic heart disease Amlodipine + Atenolol Diabetes Amlodipine + Lisinopril Amlodipine + Losartan Hyperlipidemia Amlodipine + Lisinopril Amlodipine + Losartan Congestive heart failure Lisinopril + HCTZ Losartan + HCTZ Tachycardia Amlodipine + Atenolol Bradycardia Amlodipine + Lisinopril Amlodipine + Losartan Asthma/COPD Amlodipine + Losartan Amlodipine + Lisinopril Elderly hypertensives Amlodipine + Losartan Amlodipine + Lisinopril Lisinopril/Losartan + HCTZ 137 FDCs—不同患者 的臨床選擇 Coexisting condition First choice Peripheral vascular disease Amlodipine + Lisinopril Amlodipine + Losartan Losartan + HCTZ Lisinopril + HCTZ Gout Amlodipine + Lisinopril Amlodipine + Losartan Amlodipine + Atenolol Anxiety Amlodipine + Atenolol Depression Amlodipine + Lisinopril Amlodipine + Losartan Lisinopril + HCTZ Losartan + HCTZ Renal insufficiency (not due to renal Amlodipine + Lisinopril artery stenosis) Amlodipine + Losartan 138 Intervention Exercise Weight reduction Alcohol intake reduction Sodium intake reduction DASH diet 藥物降圧切不可忽視生活方式的改善 Blood Pressure Effect 510 mm Hg (30 min 3x/wk) 12 mm Hg/Kg? 1 mm Hg/drink/d? 13 mm Hg/40 mmol/d? 310 mm Hg ? Adapted from Cushman et al. Endocrine Practice 1997。 4,高血壓 Ⅰ 期患者為改善單藥的不良反應 ,亦可聯(lián)合用藥 。 132 優(yōu)良抗高血壓藥的新標準 ━ 不僅降低平均收縮壓而應有效降低收縮壓的變異性 ? 大量研究表明， BPV增加與血管事件尤其是卒中的高風險密切相關 ,是預測卒中風險的強指標 ,且獨立于平均 SBP,因此 ,能有效控制 24h血 ,降低 BPV的藥物可能將為高血壓患者帶來更多效益 ,目前抗高血壓藥物中 ,長效 CCB對 BPV影響相對更具有優(yōu)勢 。老年人抗高血壓治療可明顯降低心血管疾病的發(fā)病率及死亡率。80。 3,起始聯(lián)合用藥雖可較早達標 ,但對 長期控制血壓并無優(yōu)勢 。 ? Optimum BP reduction was achieved as early as two weeks and was maintained throughout the study。 ? BP reduction with the bination of nifedipine GITS/telmisartan in TALENT was consistent throughout the 24h period。/Kinzal174。 TALENT is the first trial to examine bination treatment with the calcium channel blocker (CCB) nifedipine (Adalat174。 Kimura Circ 1999。 Nighttime BP 0 5 10 15 20 25C C BD H PC C Bn on D H PA C EIARBDA C EI + DA R B+ DN i gh tD ay Change of SBP with Treatment mmHg Weiner, Rieckmann, amp。 Portaluppi, et al. 1991. 115 24Hour Blood Pressure Profile: The Morning Blood Pressure ?Surge‘ Time of day Blood pressure (mm Hg) 18:00 22:00 02:00 06:00 10:00 14:00 18:00 Time of awakening Sleep 180 160 140 120 100 80 Adapted from: MillarCraig, et al. 1978。 Baumgart, et al. 1989。 Mancia, et al. 1983。 Parati, et al. 1987。 Devereux, et al. 1983。 8,體液因素 。 5,內分泌激素 。 3,節(jié)律影響 。” 112 影響血壓變異性的因素 1,壓力感受器敏感性 (最重要 )。 110 預測血壓變異性的重要性 111 預測血壓變異性的重要性 倫敦皇家學院國際循環(huán)系統(tǒng)健康中心(International Centre for Circulatory Health)副主任 Sever博士觀察指出 ：“一個關鍵信息是，假如你在接受治療，就結局而言，血壓較高而波動較小遠勝于血壓較低而波動較大，此狀況令人堪憂。與 P相比 , CCBs顯著降低 VR達 24%,P. SD2表示治療中不同個體間或同一個體血壓的變異 . Lancet 2022。375。0001, for VR≤071–00015) accounted for effects on stroke risk (eg, odds ratio 00006) and on mean SBP (r2=00001). Effects were consistent in parallel group and crossover design trials, and in analyses of doseresponse. Across all trials, effects of treatment on VR of SBP (r2=067–00007). Compared with placebo only, interindividual variation in SBP was reduced the most by calciumchannel blockers (007–10002), and β blockers (107–1008), angiotensinreceptor blockers (102–1007), and increased by angiotensinconverting enzyme (ACE) inhibitors (179–00001) and nonloop diuretic drugs (076–0 375: 906–15 105 Effects of antihypertensivedrug class on interindividual variation in blood pressure and risk of stroke: a systematic review and metaanalysis Mean (SD) SBP at followup was reported in 389 (28%) of 1372 eligible trials. There was substantial heterogeneity between trials in VR (p1 10?40), 68% of which was attributable to allocated drug class. Compared with other drugs, interindividual variation in SBP was reduced by calciumchannel blockers (VR 0現(xiàn)有結果提示 ,長效鈣道阻滯劑如氨 氯地平 /左旋氨氯地平對于患者長期血壓變異性的良好控制是其更有效減少腦卒中的重要原因 。 ? 專家指出一個關鍵信息是， 假如你在接受治療，就結局而言，血壓較高而波動較小者遠勝于血壓較低而波動較大者，此狀況令人堪憂。 96 ASCOT研究的最新分析結果表明 血壓波動 對事件的預測力優(yōu)于治療后的平均血壓 New ASCOT Analysis Indicates BP Variability Predicts Events Better Than Mean Treatment BP ? ASCOT 試驗的最新分析結果顯示，接受高血壓治療的患者相鄰兩次就診間的診室血壓波動對卒中和冠狀動脈事件的預測力遠遠優(yōu)于平均血壓，這不同于以往的觀點。 ? 根據(jù)觀察周期的長短 ,血壓變異又分為 短時血壓變異和長時血壓變異 ,前者指 24h內的 BPV。 2， Some evidence suggests that diuretics and calcium channel blockers may offer advantages over ACE inhibitors/A2RAs and betablockers in treating those with variable blood pressure. 3， The NICE guideline remendation that diuretics or calcium channel blockers should be used firstline for most people (those over the age of 55 or black) with unplicated h