<International Circulation>:  After clinical validation， ACE inhibitors were widely used in the treatment of hypertension， heart failure， and myocardial infarction， high risk of cardiovascular diseases， and kidney diseases. Dr. Morgan， what is your opinion on the goal of these measures for the treatment of hypertension and the related disease?

　　Professor Morgan: I have no doubt that once you have related conditions such as heart failure or renal disease， ACE inhibitors or ARBs are renin-angiotensin?system is an absolutely crucial part of management. Even if you get blood pressure down with the other drugs and they have those associated conditions， an ACE inhibitor or an ARB should be used.

　　Dr. Yan: In China， we have relatively high rates of cough after the treatment with ACE inhibitors. Recent meta analysis showed that the cough rate of the patients treated with ACE inhibitors is about 10% to 11%. That means that the majority of the patients still tend to be treated with ACE inhibitors. I do believe the ACE inhibitor is a very effective kind of drug in the treatment of hypertension， also in the heart failure and coronary arterial disease.

　　Professor Morgan: I agree very much. Cough in Asia is a major problem prescribing the use of ACE inhibitors in some people. ACE inhibitors may have some benefits over ARBs in certain people.

　　Dr. Yan: I agree. Over 90% of Chinese can tolerate ACE inhibitors.

　　《国际循环》：经临床验证，ACEI在治疗高血压、心力衰竭和心肌梗死、高危心血管疾病以及肾脏病方面应用广泛。Morgan教授，您对治疗高血压及其相关疾病的目标有何看法？

　　Prof. Morgan：毫无疑问，一旦有了相关疾病，如心力衰竭或肾脏病，那么作用于肾素-血管紧张素系统的ACEI或者ARB就是治疗的重要组成部分。即使使用其他降压药已经使血压降低，仍然需要使用ACEI或者ARB。

　　严晓伟教授：在中国，ACEI治疗的患者发生咳嗽的比例相对较高。近期meta分析显示使用ACEI治疗患者发生咳嗽的比例在10%~11%。这意味着大部分患者仍然倾向于使用ACEI治疗。我认为ACEI是治疗高血压和慢性心力衰竭非常有效的药物。

　　Prof. Morgan：我非常同意。在亚洲，ACEI引起的咳嗽是一个重要问题，使得一些患者无法使用ACEI。对于一些人群来说，ACEI的获益可能超过ARB。

　　严晓伟教授：我同意。超过90%的中国患者可以耐受ACEI。

　　<International Circulation>: For my final question， the ACCOMPLISH study demonstrated that the initial treatment with benazepril and CCB can reduce cardiovascular risk and composite endpoint risk of chronic kidney disease and cardiovascular death. ROAD， AIPRI and ESBARI showed the renal protective effect of benazepril reduced proteinuria and delayed the development of end stage renal disease. Dr. Morgan， how would you evaluate the target organ protective effect of benazepril in patients with high risk factors?

　　Professor Morgan: There is no question benazepril used at dosed of 40 mg/d is a very potent force in reducing renal progression and improving end organ damage. It needs to be given in that dose in my view， because 24-hour protection is very important. Also， the ACCOMPLISH study clearly showed that the addition of a calcium channel blocking drug amlodipine was more effective than adding a diuretic， however， adding a diuretic is very effective over having monotherapy， so you do not want to wipe out using the diuretic. Benazepril has been shown to be a very very successful ACE inhibitor.

　　Dr. Yan: Actually in the ACCOMPLISH trial， the combination of ACE inhibitor with an calcium antagonist is better than just ACE inhibitor plus a diuretic. That’s no problem for the ACCOMPLISH trial， but in China because we have about 60% salt sensitive hypertension， also in the north and west of China， the daily salt intake is about 15 grams to 20 grams， so with this high prevalence of salt sensitive hypertension population， and those with very high intake of salt population， diuretics are still very important.

　　Professor Morgan: Diuretics are very important but what should be noted is that the dihydropyridine calcium channel blocking drugs work independent of the salt intake and that is really why they can be used in people. And if you are just in the population you describe， giving ACE inhibitor by itself， it may not have a lot of effect so you need to give something else， either a diuretic or the other. And in factual， in China partly because of the cost， there is some indication that you should possible even starts with a diuretic drug but very rapidly and control with an ACE inhibitor like benazepril.

　　Dr. Yan: In China， we expect to carry out a randomized clinical trial to compare ARB and CCB， CCB and a diuretic. We have included more than 30，000 patients. And preliminary results showed the blood pressure reduction between the two groups are almost the same， and also the clinical endpoints comparisons between the groups; of course it is just a preliminary result.

　　Professor Morgan: This I think is very important study because it really the recommendation for calcium channel blocking drugs instead of a diuretic is based on only one study at the moment， and I think it is very important that this data， and particularly in the different populations because the short impact of this population may completely skew and alter the results.

　　Dr. Yan: And it is cheap， it is a cheap drug

　　Professor Morgan: And government and populations have to consider the economics of it. I agree.

　　《国际循环》：我的最后一个问题，ACCOMPLISH研究证实使用贝那普利和CCB作为起始治疗可以降低心血管风险，以及慢性肾脏病和心血管死亡复合终点的风险。ROAD、AIPRI和ESBARI研究显示贝那普利的肾脏保护作用可以降低蛋白尿，延缓终末期肾脏病的进展。Morgan教授，您如何评价贝那普利对高危患者的靶器官保护作用？

　　Prof. Morgan：毫无疑问，贝那普利40 mg/d的剂量能够有力延缓肾脏疾病进展和终末器官损害。我认为需要使用这个剂量，因为24小时的持续保护非常重要。同样，ACCOMPLISH研究清晰地表明了联合使用钙通道阻滞剂——氨氯地平，比加用利尿剂效果更好。然而，加用利尿剂优于ACEI单药治疗。因此并不需要抛弃利尿剂。贝那普利被证实是非常成功的ACEI类药物。

　　严晓伟教授：在ACCOMPLISH试验中，ACEI联合钙通道拮抗剂优于ACEI联合利尿剂。但是在中国，有60%的高血压为盐敏感型高血压，其中大多数分布于北方和西部地区。这些地区人均每日盐摄入量大约为15~20 g，因此，考虑到中国如此高的盐敏感型高血压患病率，这些患者又是如此高盐饮食的情况下，利尿剂仍然非常重要。

　　Prof. Morgan：利尿剂的确非常重要。但应当注意，二氢吡啶类钙通道阻滞剂的作用独立于盐摄入，这也正是他们得以使用的原因。如果患者属于你描述的那类人群，只使用ACEI单药，可能效果并不理想，需要联合利尿剂或者其他药物。事实上，在中国，部分由于费用原因，在一些情况下甚至可以使用利尿剂作为起始治疗，但是联合ACEI例如贝那普利，可以更快地控制血压。

　　严晓伟教授：在中国，我们期望进行一项临床试验，比较ARB和CCB，CCB和利尿剂。我们已经入选了超过30，000例患者。初步结果显示，两组血压降低情况相似，还有两组临床终点的比较，当然，这只是初步研究结果。

　　Prof. Morgan：我认为这个研究非常重要。因为目前推荐钙通道阻滞剂而非利尿剂仅基于一个研究。这些数据非常重要，尤其是缺少这组人群数据的情况下。因为这一人群结果的影响可能会完全改变目前的结论。

　　严晓伟教授：而且这个药物很便宜。

　　Prof. Morgan：政府和人民也必须考虑到药物的经济性。我同意这一点。