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[ESC2007]《国际循环》采访Nilsson教授
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 编辑:国际循环网 时间:2007/9/26 11:23:00    加入收藏

 标签:专家访谈(专题)  关键字:心衰 阻断剂 ARB 

 Dr.Ye: Ok,let’s start。I want to begin with the Advance trial . It was hot line yesterday. The fixed combination of perindoplril and indapamide achieved quite good result in type-2 diabetes, with 14% relatively risk reduction of total mortality and 18% relatively risk reduction of cardiac death. And the benefits were not dependent on baseline blood pressure and previous treatment. What’s is your interpretation of this result?
叶:我们开始吧。我想从ADVANCE试验开始。ADVANCE是昨天的热线,培多普利和吲哒帕胺的固定复方制剂治疗2型糖尿病取得相当好的效果,总死亡率的相对危险性减少14%,心源性死亡的相对危险性减少18%,且获益不依赖于基线血压和以前的治疗。您如何理解这个结果?

Professor Nilsson: I think the Advance trial is the most important intervention trial in diabetes ever since the UKPDS almost ten years ago。It was a placebo controlled trial。And it shows this benefit。So I think it’s another lesson to be learned that hypertension should be more vigorously treated in type-2 diabetes. Of course, we don’t know whether this drug combination is equally effective as another active treatment because this was a placebo control trial. But I think many drugs can achieve good results in diabetes. Another lesson is using combination therapy. This combination with perindoplril and indapamide, is an ACE inhibitor and a diuretic. In the Progress trial, perindopril and indapamide was shown to be useful also for secondary prevention of stroke. This is another risk group. I welcome this result and it will be very much debated.
Professor Nilsson:我认为ADVANCE试验是继大约10年前的UKPDS后,糖尿病领域最重要的干预试验。这是一个安慰剂对照的试验,得到获益的结果。所以我认为这个试验告诉我们,应该更积极地治疗2型糖尿病患者的高血压。当然,由于这是安慰剂对照的试验,我们不知道这种药物组合是否和其他治疗等效。但是我想许多药物可以在糖尿病患者取得良好的效果。另一个提示是联合用药,这个试验的联合是培多普利和吲哒帕胺,ACEI和利尿剂。在Progress试验中,培多普利和吲哒帕胺显示对中风的2级预防有效,这是另一个危险人群。我接受这个结果,对这个结果还会有很多讨论。

Dr.Ye: Shall we use antihypertensive therapy in diabetic patients with relatively normal blood pressure?
叶:我们应该对血压相对正常的糖尿病患者应用抗高血压治疗吗?

Professor Nilsson: In diabetes, we know there are different stages, we have pre-diabetes, we have early new-detected diabetes, we have more long-standing diabetes. I think it’s very important we start treatment very early on before we have this arterial stiffing going on. So we should enforce effective blood pressure control, and even treat more or less normal blood pressure in patients with diabetes,especially those with microalbuminuria, this is another risk factor. In my view, early vascular aging is a new and important topic. Early vascular aging, the so called EVA syndrome, is something new and important. European Society of Hypertension in the new guidelines advocates that we should measure, for example, pulse wave velocity, and other aspects of arterial stiffness. And many of the patients in Advance trial, I guess, had early vascular aging going on, why it makes sense to low blood pressure especially in these subjects. So if you add blood pressure elevation with diabetes and vascular aging, this is exactly the group we should target. One aspect of vascular aging is increased pulse pressure. You can imagine even some people with more or less normal blood pressure have a tendency for increased pulse pressure. So this is a very early sign that something risky is going on. And I guess in the future, there will be new techniques and devices to more easily measure arterial stiffness and vascular aging. I have been told there is a certain device (tonometer) carried around the wrist here for measuring augmentation index, This is one reflection of arterial stiffness, augmentation index. But we also know there are some devices for measuring pulse wave velocity over the aorta, between carotid and femoral artery. So coming back to the Advance trial, what we can learn is, for the future, it’s simple to learn that hypertension and diabetes are two bad companions, but we should try to learn more about vascular aging.
Professor Nilsson: 我们知道糖尿病可分为不同的阶段,有糖尿病前期,早期新发现的糖尿病和长期的糖尿病患者。在动脉硬化开始前及早开始治疗是非常重要的。所以应该加强有效的血压控制,包括治疗血压基本正常的糖尿病患者,尤其是伴微量白蛋白尿的患者,这是另一个危险因子。我认为,早期血管老化是个新的重要的话题,也叫EVA综合征。欧洲高血压协会在新指南中提倡应该测量脉搏波速率和其他动脉硬化的参数。我推测在ADVANCE中有很多正在发生早期血管老化的患者,这就是为什么在这些患者中降压有意义。高血压加糖尿病加血管老化,这就是我们应该选择的目标人群。血管老化的一个表现是脉压增加。你可以想象有些患者血压相对正常但脉压已有升高趋势。所以这是一个很早期的提示危险的征象。我推测将来会有新的技术和设备使检测动脉硬化和血管老化更简便。椐我所知,有一种戴在腕上的仪器(血压计)可以测量augmentation index,这是反映动脉硬化的一个指标。我们知道还有一些仪器可以测量主动脉脉搏波速率,在颈动脉和股动脉之间。再回到ADVANCE试验,我们可以从中认识到,将来,很容易认识高血压和糖尿病是两种坏的合并疾病,但我们需要更多地了解血管老化。

Dr.Ye: Yes, it’s a wonderful explanation, very interesting, but we still need time to find a good way to detect the EVA syndrome. What do you think the target of BP control is now for diabetes? Should it be a little bit lower?
叶:精彩的解读,很有意思,但我们仍需要时间去发现一个检测EVA综合征的好方法。您认为目前糖尿病患者的目标血压应该控制在多少?是不是应该更低一点?

Professor Nilsson:According to the guidelines, we should bring blood pressure below 130/80 mmHg. In addition we should at least try to find if there is an elevated pulse pressure and we should decrease it.
Professor Nilsson: 根据指南,应该降到130/80 mmHg以下。此外,我们至少应该努力去发现是否有脉压增高,并降低脉压。

Dr.Ye: Concerning the combination therapy, what if we change it to other combinations, such as  ACE inhibitors and CCB, will it bring the similar result as perindoplril and indapamide?
叶:关于联合治疗,其他的联合方案,比如ACEI和CCB,会产生如培多普利和吲哒帕胺相似的效果吗?

Professor Nilsson:Well,I hope so, but we will know more next year, the ONTARGET trial will be presented, and then we will learn that because this is the largest trial right now in hypertensive risk patients (n= 25,000) randomized to either an ACE inhibitor, and angiotensin-2 receptor blocker  or the  combination of both drugs
Professor Nilsson: 哦,我希望如此,但是明年,ONTARGET试验将会发表,我们可能会了解更多。因为ONTARGET试验是高血压危险人群中迄今最大的试验(n = 25,000),随机分入ACEI,或ARB或两药联合组。

Dr Ye: To find diabetes as early as possible is very important. How do you do this in Sweden? What about OGTT in cardiology department?
叶:尽早发现糖尿病非常重要。瑞典是如何开展这方面工作的?OGTT在心血管科的应用如何?

Professor Nilsson:Well, one thing would be to do is screening studies. You can start to do OGTT in the coronary care unit at hospitals after or at discharge, however to do that in the population is not feasible. But my idea is to focus on families with ve

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