<International Circulation>: In what ways does the management of hypertensive patients differ between those who have coronary artery disease and those who do not?
　　Dr Rosendorff: One should think of this problem in terms of the prevention of coronary artery disease in patients who do not have coronary disease and then the management strategies that we should use in patients who have established coronary artery disease. In that latter category， you can further subdivide them into those who have stable angina and those who have some acute coronary syndrome. That last subgroup can be further subdivided into unstable angina and non-ST-elevation MI and ST-elevation MI. Another category is those patients who have ischemic heart failure. So there are lots of different nuances to this question. Let’s deal firstly with primary prevention. This is in patients who do not have coronary artery disease but may be at risk for developing coronary artery disease. There， the management of hypertension is according to well-known principles. There are a number of drugs that are known to lower blood pressure safely and effectively and protect against cardiovascular events including coronary disease. These include ACE inhibitors， angiotensin receptor blockers， calcium channel blockers and diuretics. Notice that I have conspicuously omitted to mention beta-blockers because the evidence for beta-blockers is rather poor. Beta-blockers do not prevent the development of coronary artery disease or coronary events any more effectively than does placebo and certainly less effectively than the other categories of drugs I just mentioned. So we do not recommend beta-blockers as first-line treatment for patients with hypertension because they are not effective in preventing coronary artery disease. Having said that， I am talking about the commonly used beta-blockers particularly atenolol， because all of the clinical trials that have shown the ineffectiveness of beta-blockers have really been related to atenolol. What I am saying may not be relevant to the newer beta-blockers particularly those that are vasodilatory like carvedilol and nebivolol. Once a patient has developed coronary artery disease， it is a different category altogether. There the beta-blockers move from limbo where I have just consigned them to centre stage. In general， they would be the first-line of treatment in patients with hypertension with established coronary artery disease because they have been shown in that situation to be cardioprotective and also of course， they are important in the management of the symptoms of coronary artery disease particularly angina pectoris. Of course all of the other drugs are also important: ACE inhibitors， ARBs， calcium channel blockers and diuretics. It is probably beta-blockers as first-line treatment and then adding one or other of the other drugs I have just mentioned and if blood pressure is not controlled then add a third. Now acute coronary syndromes. This is where the patient is admitted to hospital with an acute coronary event (unstable angina or myocardial infarction) and there the management of hypertension is very important because very high blood pressures will result in poorer outcomes in patients with acute heart attacks. Again， the treatment here would be a beta-blocker and (rather than or) an ACE inhibitor or ARB and a calcium channel blocker and a diuretic. All of those would probably be appropriate in patients with acute coronary syndrome. When I say calcium channel blocker， in this context I am talking about dihydropyridine (amlodipine， felodipine， nifedipine， etc). The non-dihydropyridine calcium channel blockers like verapamil and diltiazem can be used instead of beta-blockers because they also improve angina but they should never be used with beta-blockers. They should also never be used in patients who have impaired left ventricular function or heart failure.

　　《国际循环》：合并冠心病和不合并冠心病的高血压患者在治疗上有哪些区别？
　　Rosendorff博士：我们应当从两个方面来考虑这个问题，一方面是在没有冠心病的患者预防冠心病发生的治疗策略；另外一个方面是已经被确诊冠心病患者的治疗策略。后者可以进一步分为稳定型心绞痛和急性冠状动脉综合征患者的治疗策略。急性冠状动脉综合征患者又可以被进一步分为不稳定型心绞痛、NSTEMI和STEMI。另外，还有心肌梗死后合并心力衰竭的患者。因此，你提的这个问题分为不同的患者。
　　首先，我来说一下一级预防的策略。这是针对目前没有冠心病但是可能有发生冠心病风险的患者。此时，高血压的治疗是根据当前已经明确的原则。我们已经知道，有些药物能够安全、有效地降低血压，同时对包括冠心病在内的心血管事件具有保护作用。这些药物包括ACEI、ARB、CCB和利尿剂。要注意到，我故意略去了β受体阻滞剂，因为β受体阻滞剂的证据相当有限。β受体阻滞剂预防冠心病或冠状动脉事件发生并不比安慰剂更有效。当然比刚才我提到的其他四类药物要差。因此，我们不推荐β受体阻滞剂作为高血压患者的一线治疗，因为β受体阻滞剂不能够有效地预防冠心病。说到这里，我想谈谈常用的β受体阻滞剂阿替洛尔，因为所有显示β受体阻滞剂无效的试验是观察了阿替洛尔，可能并不是指新型β受体阻滞剂，尤其是像卡维地洛和奈必洛尔这样的血管扩张药物。
　　一旦患者患上了冠心病，情况就不同了。此时，β受体阻滞剂从最底层转到舞台的中央。通常来讲，β受体阻滞剂是高血压合并冠心病患者的一线治疗，因为研究显示β受体阻滞剂此时具有心脏保护作用，当然β受体阻滞剂对于冠心病的症状治疗，尤其是心绞痛。当然，其他药物也很重要：ACEI、ARB、CCB和利尿剂。可以把β受体阻滞剂作为一线治疗，加上我提到的一种其他药物。如果血压控制不好的话，就加上第三种降压药物。
　　下面，我谈谈急性冠状动脉综合征。也就是患者因为急性冠状动脉事件（不稳定型心绞痛或心肌梗死）住院治疗，此时高血压的管理非常重要，因为血压过高会导致心脏病患者的转归差。治疗仍然是β受体阻滞剂联合ACEI、ARB、CCB或利尿剂。ACS患者联合这四类药物都是可以的。这里的CCB是指二氢吡啶类CCB（氨氯地平、非洛地平、硝苯地平等）。非二氢吡啶类CCB（例如维拉帕米、地尔硫卓）可以替代β受体阻滞剂，因为非二氢吡啶类CCB同样能够改善心绞痛，但是两类药物不能联用。两者也不能用于左室功能障碍或心力衰竭的患者。

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