Clin Exp Hypertens:如何选择降压药?单纯收缩压或舒张压高怎么办?

2017-12-08 沿若 医学论坛网

单药治疗高血压往往效果不好,需要几种降压药联合用药。还有很多老年人是单纯收缩压(高压)高,或者很多中青年单纯舒张压(低压)高,对此该如何选择降压药呢?


单药治疗高血压往往效果不好,需要几种降压药联合用药。还有很多老年人是单纯收缩压(高压)高,或者很多中青年单纯舒张压(低压)高,对此该如何选择降压药呢?

临床上,关于门诊血压(BP)的信息记录很少,在日常实践中最常见应用的是抗高血压药物组合治疗。哪种组合的降压效果好?我们从联合两种到三种不同种属降压药组合治疗方案中寻找答案。
 
实验中,对17187名患者分成6组,分别以两种药物组合治疗;并对9724名患者分成6组,分别给以三种不同的药物组合治疗,他们的血压检测值被记录下来,对比了可获得的所有随机和动态血压值,随机血压目标控制范围(< 140/90 mmHg)和动态血压目标控制范围(24小时BP < 130/ 80;白日BP < 135/ 85,夜间BP < 120/70 mmHg)。
 
数据分析显示:

肾素-血管紧张素系统(RAS)受体阻滞剂与利尿剂两种药物组合、肾素-血管紧张素系统(RAS)受体阻滞剂、利尿剂和钙通道阻滞剂(CCB)的三重组合,可有效降低24小时动态血压低,尤其与降低夜间血压相关。与此两类组合相比,其他双种组合的降压效果甚微。此外,含有α受体阻滞剂的三重组合也显著的降压效果。
 
我们得出结论,不同药物即使有相似的随机血压控制效果,在治疗期间,不同抗高血压药物组合之间存在一定差异,RAS阻滞剂/利尿剂组合和RAS阻断剂/ CCBs /利尿剂组合可获得更好的疗效。可以帮助临床医生在药物组合中选择用药,以获得更好的临床获益。

临床上常见的情况是,很多老年人是单纯收缩压(高压)高,或者很多中青年单纯舒张压(低压)高,对此该如何选择降压药呢?郭艺芳教授做了详细解释:
 
对于这一问题,现行的美国、欧洲、加拿大、日本以及中国等指南性文件均未明确表述。但认真分析各指南的推荐建议,仍然可以得到一些启示。单纯收缩压增高主要见于老年患者,而单纯舒张压增高常见于中青年患者。对于不同年龄阶段高血压患者的降压药物选择,相关指南中有所描述。
 
2010版中国高血压防治指南提到:对于舒张压<60mmHg的老年单纯收缩期高血压患者,若收缩压<150 mmHg可不用药;如收缩压150-179 mmHg,谨慎小剂量用药;如收缩压≥l80 mmHg,则小剂量用药,此时可选择小剂量利尿剂、CCB、ACEI或ARB,未推荐使用BB。
2013年加拿大高血压指南认为:所有高血压患者均可考虑选用利尿剂、CCB、ACEI或ARB。60岁以下的患者(常伴舒张压增高)也可选择BB。单纯性收缩压增高者首先选用利尿剂、CCB或ARB。
 
2011年英国高血压指南建议:55岁以下的高血压患者首选ACEI或ARB;55岁以上者首选CCB,不适于或不耐受CCB者则选用利尿剂。一般不建议将BB作为一线降压药物。然而,若年轻高血压患者不能耐受ACEI或ARB、或伴有交感张力增高表现者,可考虑选用BB。
 
其他权威指南如2013年ESH/ESC指南、2013年AHA/ACC/CDC指南、2014ASH/ISH指南、JNC8指南以及2014年日本高血压指南,或未涉及此类话题,或提出了与上述指南相似的观点。

由此可见,无论舒张压和(或)收缩压增高,利尿剂、CCB、ACEI、ARB均可考虑选用。对于以舒张压增高更为常见的年轻高血压患者,ACEI或ARB或可优先考虑选用;若年轻患者伴有交感张力增高表现(如心率快)且有心悸等不适症状,也可考虑选用BB,但需注意其对男性性功能的影响。对于收缩压增高更为常见的老年高血压患者,CCB或利尿剂可能更适于作为首选药物。
 
需要强调的是,无论收缩压增高还是舒张压增高,积极有效的生活方式干预均是必不可少的。对于单纯舒张压增高的中青年患者尤为如此。很多年轻高血压患者常伴有肥胖、酗酒、精神紧张等,限酒、减重是降低舒张压的有效措施。若整天大碗喝酒、大块吃肉、睡眠不足、不肯运动,什么药也不会有好的效果。

原始出处:

de la Sierra A1, Banegas JR2, Vinyoles E,et al.Office and ambulatory blood pressure control in hypertensive patients treated with different two-drug and three-drug combinations.Clin Exp Hypertens. 2016;38(4):409-14. doi: 10.3109/10641963.2016.1148160. Epub 2016 May 9.
 
 

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    2017-12-09 lyh994

    生活方式与药物

    0

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不是降压药却能引起低血压的药物

体循环动脉血压是血液在血管中流动时对血管壁的压力,是血液流动的动力。血压是血液循环流动的前提,血压在多种因素调节下保持正常,从而提供各组织器官以足够的血量,以维持正常的新陈代谢。血压有极其重要的生物学意义,过低过高都会造成严重后果。提到降血压,一般会想到降压药,除常规的降压药物外,很多药物也具有一定的心血管活性,可降低血压,不合理使用或可导致低血压事件发生,下面对这些药物进行归纳总结,方便临床参考

吃降压药有副作用,咋办?

1一些高血压患者服用降压药后可能会出现不适反应。遇到这种情况,一般不要自行停药,而是应该咨询医生,在医生指导下酌情处理。2这些不良反应有的是某种类型降压药所特有的副作用,也有的是血压降低所引起的。例如,一些平时血压很高但没有接受治疗的患者,服用降压药降低血压后可能会出现头晕、头痛、心慌、由坐位站起来时眼前发黑等。遇到这种情况一般不用停药,适当减小药物剂量后症状多可缓解。对于刚开始用药的患者,不要用

Circ Cardiovasc Qual Outcomes:3种非专利降压药商业化对不良事件有何影响?

当专利药品的专利保护到期时,非专利药品生产商就能够合法地制作同样配方的药品,并以更便宜的价格出售。但非专利药物与专利药品完全等效吗?不良事件的发生率又会如何呢?2017年10月,发表在《Circ Cardiovasc Qual Outcomes》的一项基于人群的时间序列分析调查了3种非专利血管紧张素II受体阻滞剂氯沙坦、缬沙坦和坎地沙坦的商业化对不良事件的影响。

六类降压药:作用特点、临床选择和注意事项,全在这里!

临床工作中,经常遇到患者提出这样的疑问:这么多降压药,我该怎么使用?不只是患者不知道怎么用,一些非专科医生也可能不知道降压药的合理使用。前一段时间,曾经在我科住院的一个老年患者春节后回来复查,自诉春节期间和春节后血压特别高,无论怎么都控制不住。这个老爷子不到70岁,高血压20余年,近两年血压维持在180 mmHg左右,稍一激动就到200 mmHg。去年因双下肢水肿、血肌酐升高住院治疗,诊断为高

盘点:降压药近期又有啥重要研究发现?

高血压是一种以动脉血压持续升高为特征的进行性“心血管综合征”,常伴有其它危险因素、靶器官损害或临床疾患,需要进行综合干预。抗高血压治疗包括非药物和药物两种方法,大多数患者需长期、甚至终身坚持药物治疗,这里梅斯小编整理了近期关于降压药的重要研究进展与大家一同分享。【1】降压药物晚间给药对CKD合并高血压患者BP模式有何影响2017年8月,发表在《Intern Med J》的一项系统评价和荟萃分析调查