Prevention and treatment of hypertension should focus on lowering blood pressure.
The prevention and treatment of hypertension should focus on lowering blood pressure and reaching the standard, which is the consistent purpose of clinical practice. The guidelines of American Heart Association in 2007 and European Hypertension Association/European Cardiology Association (ESH/ESC) in 2065438+03 all pointed out that the main determinant of reducing cardiovascular events in patients with hypertension (including young people and the elderly) is the standard of blood pressure reduction, not the choice of antihypertensive drugs.
This view has been supported by many large-scale clinical research results. Most antihypertensive drugs can provide similar cardiovascular protection under the same degree of blood pressure target control. For example, CAPPP, STOP- Hypertension -2, NORDIL, UKPDS and INSIGHT all found that the overall prognosis of hypertensive patients treated with traditional antihypertensive drugs (such as diuretics and receptor blockers) is similar to that of new antihypertensive drugs (such as angiotensin converting enzyme inhibitors (ACEI) and calcium channel blockers (CCB)). CAMEL0T study compared the efficacy of amlodipine and enalapril in the treatment of hypertension, and there was no significant difference in the prognosis of patients. A similar conclusion was reached in the subgroup analysis of patients with increased cardiovascular events.
At present, commonly used antihypertensive drugs in clinic include thiazide diuretics, ACEI/ angiotensin receptor antagonists (ARB), CCB, receptor blockers, receptor blockers and so on. Most antihypertensive drugs have good antihypertensive effect in 30%~50% of patients, but there are still individual differences in their efficacy. For example, black and elderly patients usually respond well to thiazide diuretics or CCB monotherapy, but relatively poorly to ACEI or receptor blockers. Therefore, individualized treatment should be emphasized on the premise of reaching the standard of blood pressure reduction.
The callback of the new guideline to the target of blood pressure reduction: the lower the blood pressure, the better.
20 13 ESH/ESC hypertension guidelines suggest that the target systolic blood pressure should be 140mmHg for patients with high or low cardiovascular risk. The target diastolic blood pressure is 90mmHg, and the diabetic patient pushes 85mmHg. Different from the 2007 guideline, the 20 13 guideline raised the target blood pressure of high-risk population from 130/80mmHg to the same as that of low-risk population (140/90mmHg). At present, there is not enough randomized controlled research evidence to support the goals recommended in the 2007 edition. The upward adjustment of antihypertensive target emphasizes that for the reduction of long-term cardiovascular and cerebrovascular events, stable hypotension is the fundamental principle of antihypertensive.
KIDG0 guideline 20 12 recommended the index of CKD patients without proteinuria as140/90mmhg; The target blood pressure of renal transplant patients with CKD proteinuria is 130/80mmHg.
By listing the target blood pressure recommended by different recent guidelines, it is not difficult to find that the target blood pressure has been generally adjusted in recent guidelines, and the lower the target, the better, with more emphasis on stable blood pressure reduction and long-term prognosis. Moreover, according to the patient's age, primary disease and urinary albumin excretion rate, the goal of blood pressure reduction is different, and the goal of blood pressure control is also individualized.
Individualized antihypertensive therapy for patients with chronic kidney disease
Individualization of blood pressure control standards Because of the different etiology and pathogenesis of hypertension, clinical medication should be treated differently, and the most appropriate drugs and doses should be selected to obtain the best curative effect.
It is suggested that drug selection should be evaluated according to the overall volume load of patients. The initial treatment of patients with proteinuria and edema usually includes ACEI and loop diuretics. Loop diuretics may enhance the antihypertensive effect of ACEI drugs by increasing renin release. The use of diuretics may also restore the unsatisfactory antihypertensive effect of ACEI, because excessive volume load reduces the release of angiotensin, thus reducing the dependence of blood pressure on angiotensin. If further antihypertensive treatment is still needed, we suggest using non-dihydropyridine CCB (diltiazem, verapamil) because these drugs can also reduce proteinuria. On the contrary, dihydropyridine CCB has little effect on reducing urinary protein excretion.
For CKD patients without edematous proteinuria, diuretics or non-dihydropyridine CCB can be used as second-or third-line drugs. Even without edema, excessive volume load usually plays an important role in hypertension of CKD patients.
Treatment of hypertension in patients with chronic kidney disease without proteinuria
Compared with CKD patients with proteinuria, ACEI has no advantages over other antihypertensive drugs. For patients with edema, loop diuretics are recommended for initial treatment. Once the edema is controlled, if hypertension still exists, ACEI/ARB or dihydropyridine CCB can be considered. Patients without edema can use ACEI/ARB first, and then add dihydropyridine CCB. This method has not been specially studied in CKD patients without proteinuria. In addition, from the common hypertension patients, according to the recommendations of the complete study, if necessary, we suggest adding diuretics as the third-line treatment.
Four-line therapy
For refractory hypertension, aldosterone antagonists (spironolactone, eplerenone) can be considered. Therefore, under the premise that the antihypertensive treatment of CKD patients meets the standard, individualized treatment is also emphasized. However, the reality is that patients with hypertension in China, especially CKD patients, have problems such as low awareness rate and irregular antihypertensive treatment. Taking CCMR-3B as an example, a cross-sectional study of 25454 patients with type 2 diabetes mellitus in 6 outpatient departments in China found that 73.0% of patients with hypertension received antihypertensive drugs, and 39.7% of them received ACEI/ARB treatment.
Among 257 patients with hypertension and proteinuria, 48.3% used ACEI/ARB. Among non-hypertensive patients with proteinuria, the utilization rate of ACEI/ARB was 65438 0%. Multiple regression analysis showed that complications, location, hospital level, doctor's specialty and patient's education level were all related to the use of ACEI/ARB.
abstract
The prevention and treatment of hypertension should focus on lowering blood pressure, which is the basic criterion of clinical practice. On the premise of reaching the standard of blood pressure reduction, it is necessary to emphasize the individualized principle of blood pressure reduction treatment and "treat according to the symptoms" in order to obtain the best treatment effect. In addition, hypertension often coexists with other risk factors of cardiovascular and cerebrovascular diseases, such as hyperlipidemia, obesity and diabetes. Synergy will increase the risk of cardiovascular disease. Therefore, the treatment of hypertension should be comprehensive, including lifestyle, diet structure and drug treatment.