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[ASH2009]社区保健和家庭医疗专家Louis Kuritzky教授访谈:预估JNC8及高血压前期治疗

作者:  L.Kuritzky   日期:2009/5/14 11:21:00

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《国际循环》:JNC8指南将于今年年底或明年年初公布,您认为该指南最重要的部分是什么? Kuritzky教授:很显然,目前我们尚未有已发表的指南,因此我们的想法仅属于一种推测。由于先前发表的JNC指南主要根据重要的标志性临床试验,JNC8很可能看到相同的情景,可以预测某些重要的试验,如ONTARGET试验和ACCOMPLISH试验,会帮助我们确定方向。目前这只是一种推测,我想在实际指南发表之前,应该对判断有所保留。

International Circulation:  JNC 8 guidelines will be released late in the year or published next year.  What do you think are the most important relevant parts of this guideline?
Prof. Louis Kuritzky:  Obviously at this point we do not yet have the published guidelines so our thoughts will be somewhat speculative.  It is likely since JNC previous publications have been highly dependent on important landmark clinical trials that we will be seeing the same thing with JNC 8 so I anticipate that some of the major trails, for instance the ONTARGET trial and the ACCOMPLISH trial may shape the direction of the content.  At this point it is somewhat speculative so I think we will have to withhold judgment until we actually see the publication. 

《国际循环》:JNC8指南将于今年年底或明年年初公布,您认为该指南最重要的部分是什么?
Kuritzky教授:很显然,目前我们尚未有已发表的指南,因此我们的想法仅属于一种推测。由于先前发表的JNC指南主要根据重要的标志性临床试验,JNC8很可能看到相同的情景,可以预测某些重要的试验,如ONTARGET试验和ACCOMPLISH试验,会帮助我们确定方向。目前这只是一种推测,我想在实际指南发表之前,应该对判断有所保留。

International Circulation:  What do you think cardiovascular risk will be changed under the new guidelines. 
Prof. Louis Kuritzky:  We have some fairly compelling suggestions in joint documents from the American Heart Association and cardiologist groups that suggest to us that risk markers, for instance like Coronary Calcium scores, may be more important in predicting risk and I think inclusion of data, in particularly successful trial of the combination of ACE inhibitors with calcium channel blockers may influence therapy directly and I think there has also been some pushback from the combination of ARB and ACE that may affect clinician prescribing.

《国际循环》:您认为新指南会变动心血管危险因素吗?
Kuritzky教授:在美国心脏协会和心脏病学家组织的联合文件中,我们会看到许多相当引人注目的建议,像冠脉钙积分这样的风险标志物,可能在预测风险上更加重要。我想,指南所入选的资料,尤其ACEI和CCB联合治疗的成功试验,可能会直接影响治疗;此外,可能会见到ARB和ACEI联合治疗地位有所削弱,也可能影响临床医师的用药。

International Circulation:  Do you agree with the new risk factor supplement for hypertension?
Prof. Louis Kuritzky:  For the risk factor supplement I think that we are going to more towards biologic markers like target organ damage.  But I don’t think that we have yet been able to prove that stepping beyond the Framingham Risk Score is on solid ground yet.  We still get a lot of excellent service from using that methodology; it may be that the Rasmussen scoring system will provide additional scoring information.  I think it is too soon to tell. 

《国际循环》: 您是否赞同应补充新的高血压危险因素? 
Kuritzky教授: 如果补充危险因素,我想应该更多考虑像靶器官损伤这样的生物标记物。但是,我不认为我们有了超过Framingham风险积分的进展。通过前述方法,我们仍能获得许多良好的信息。Rasmussen积分系统可能会提供额外的积分信息。我想说这个为时过早。


International Circulation:  What is your opinion about pre hypertension needing additional drug treatment or only lifestyle changes? 
Prof. Louis Kuritzky:  I think the TROPHY trial is very influential in convincing us that early intervention really pays off.  We have a very well tolerated class of drugs – the ARB and in this particular trial candesartan, and it showed to us that if you intervene early, not only do you reduce the development of hypertension over the short term while you are treating hypertension but over the long term when you have stopped, the so called legacy effect so early intervention really pays off.  If it were my brother or sister, I would be inclined to treat.

《国际循环》: 您如何看待高血压前期额外的药物治疗或仅需生活方式调整?
Kuritzky教授: 我想,TROPHY试验很有影响力,说服我们早期干预可获得真实回报。我们有许多耐受性良好的药物—ARB和该试验所用的坎地沙坦,提示我们如果早期进行干预,不仅能够减少短期内发展成高血压,而且停用后效应仍可长期存在,即所谓的“遗留效应”;因此干预越早,越得回报。如果是您的兄弟姊妹,我建议进行治疗。


International Circulation:  Describe the legacy effect?
Prof. Louis Kuritzky:  The legacy effect is when we intervene when we believe the process is early and by that early intervention we have long reaching benefits, far beyond when we have even stopped the therapy as if changing the course early makes a difference in ultimate outcome. 

《国际循环》: 请描述一下“遗留效应”?
Kuritzky教授: 遗留效应是指在我们干预时,当我们相信早期处理并通过早期干预时,可获得长期的收益远超出我们停止治疗的时间。这类似早期改变了过程,导致最终结果的不同。

International Circulation:  So that seems to suggest that environment plays a larger part than genetics?
Prof. Louis Kuritzky:  Well I do not know which is really playing a larger part and it probably varies from person to person.  I think when we talk about drug therapy it is important only so far as much we have not been able to harness the true power of lifestyle.  All of us would love for our patients to exercise regularly, reduce salt, have ideal body weights, and watch the fat in their diet but many times our patients either cannot or are unwilling to fully comply with these directions so in this case we must rely on pharmacotherapy.

《国际循环》: 环境似乎比遗传的作用更明显?
Kuritzky教授: 我不知道谁的作用更大,或许人与人不同。我想当我们讨论药物治疗时,重要的是我们不能仅依靠调整生活方式的力量。我们都喜欢患者定期锻炼、限盐、体重完美,注意饮食中的脂肪含量。但许多时候患者不能或者不愿意完全遵守这些要求,此时必须依靠药物治疗。

International Circulation:  On that same thing, if you discover a patient with pre-hypertension, what steps do you take to make sure they do not go into full blown hypertension?
Prof. Louis Kuritzky:  Well it becomes a negotiated decision.  Remember that patients sometimes are going to change their behavior sometimes only when something scary happens to them.  We certainly have people who wait until they get pneumonia or something terrible in their lung to stop smoking.  Hypertension is no different and so sometime we have to build strong allegiance with the patient and say “Look, you are at the lucky point now where you do not have a disease that is strongly enough established to cause you terrible adverse effects yet but we can defeat this if we work early” either with lifestyle, pharmacotherapy, or a combination of the both.

《国际循环》: 如果发现一位高血压前期患者,您会采取什么步骤使其不成为高血压?
Kuritzky教授: 这需要与患者进行沟通。记住有时患者只有当某些令他们感到害怕的事情发生时,才会改变他们的行为。我们知道,有些人只有患肺炎或其他肺病时,才会戒烟。高血压没有什么不同,有时我们必须与患者建立良好关系,并且说:“看,您现在很幸运没得病,但足以使您有严重的不良后果;如果我们早点努力将有可能消除它”,这需要调整生活方式、药物治疗或两者联合。
 

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JNC8心血管危险因素高血压前期高血压危险因素

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