利尿剂在高血压治疗中的过去、现在和未来

2017-06-09 伊文 中国心血管杂志

噻嗪类利尿剂用于治疗高血压的历史已超过半个世纪,是高血压治疗中获得广泛推荐的一线用药。然而,随着钙拮抗剂(calcium channel blockers,CCB)、血管紧张素转换酶抑制剂(angiotension converting enzyme inhibitors,ACEI)及血管紧张素受体拮抗剂(angiotensin receptor blockers,ARB)的问世及广泛应用,利尿剂

噻嗪类利尿剂用于治疗高血压的历史已超过半个世纪,是高血压治疗中获得广泛推荐的一线用药。然而,随着钙拮抗剂(calcium channel blockers,CCB)、血管紧张素转换酶抑制剂(angiotension converting enzyme inhibitors,ACEI)及血管紧张素受体拮抗剂(angiotensin receptor blockers,ARB)的问世及广泛应用,利尿剂在高血压患者中的使用率明显降低。我国幅员辽阔,各地经济发展不平衡,利尿剂在广大农村和基层,仍有很大的用武之地;加之我国老龄化日益加剧,利尿剂是老年高血压治疗的基础用药;另外我国居民摄盐量大,盐敏感高血压多,利尿剂降压效果较好;同时利尿剂也是难治性高血压的必用药物之一。因此,合理使用利尿剂仍然是高血压治疗的重要内容之一。

01

利尿剂的分类及抗高血压机制

利尿剂主要分为噻嗪类利尿剂、袢利尿剂和保钾利尿剂。

噻嗪类利尿剂降低血压的机制尚未完全清楚。其最初的降压反应是由血浆容量和心输出量的轻度下降介导的。维持血压长期下降时,初始血流动力学变化出现部分逆转。噻嗪类利尿剂长期降压机制主要与降低外周血管阻力有关,可能因其降低血管平滑肌对血管收缩物质的反应性,以及增强对血管舒张物质的敏感性。尚存争议的降压机制包括抑制碳酸酐酶活性,另有少数观点认为噻嗪类利尿剂可下调血管紧张素1型受体,使血管平滑肌细胞钾通道部分开放。

噻嗪类药物又可分为噻嗪型和噻嗪样利尿剂,噻嗪型药物包括氢氯噻嗪和苄氟噻嗪等。噻嗪样利尿剂的化学结构不同于噻嗪型,包括氯噻酮、吲达帕胺等。相同剂量时,氯噻酮的效价是氢氯噻嗪的1.5~2.0倍,且前者作用时间更长。

袢利尿剂利尿作用强大,主要抑制对氯化钠的主动重吸收,代表药物有呋塞米、托拉塞米、布美他尼等。

保钾利尿剂中的氨苯蝶啶和阿米洛利抑制远曲小管和集合管的钠-氢共同转运体,抑制Na+再吸收和减少K+分泌,其作用不依赖醛固酮,利尿作用弱。醛固酮受体拮抗剂螺内酯和依普利酮可与醛固酮受体结合,竞争性拮抗醛固酮的排钾保钠作用。

对肾功能正常的患者,噻嗪类利尿剂(特别是氯噻酮)比袢利尿剂降压效应更强,可能与噻嗪类利尿剂比大多数袢利尿剂作用时间更长有关。

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    2017-06-12 大爰

    学习了谢谢分享!!

    0

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    2017-06-11 杨利洪

    学习了。分享了

    0

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    2017-06-10 131****1460

    学习了,受益匪浅。

    0

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    2017-06-10 lou.minghong

    学习了

    0

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    2017-06-10 189****7206

    学习了谢谢分享。

    0

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