<International Circulation>: The long-expected European hypertension guidelines is finally released this year， compared with the 2007 guidelines and 2009 reappraisal version， how would you assess the changes in cardiovascular risk assessment， initiate time or goals of antihypertensive therapy and drug application?

　　《国际循环》：期待已久的欧洲高血压指南最终于今年公布，和2007年指南以及2009年再评估版相比，您如何评价新指南在心血管危险评估，启动治疗时间，降压治疗目标以及用药方面的改变？

　　Prof. Unger: The European guidelines will be presented at the congress， so I don’t know exactly what is inside them， and the authors wouldn’t tell me beforehand， but I can speculate a little bit. The guidelines that started in 2003， and then were amended in 2007 and 2009， as you mentioned， were pretty conservative. They still started with the concept of monotherapy in hypertensive patients， and then in severe cases of hypertension， you could also add another drug. And in real severe cases you could even start with low-dose combination， dual combination therapy. So that will certainly change in the new guidelines.

　　Unger教授：欧洲高血压指南将在大会上公布，我并不确切知道其中内容，作者也不会提前告诉我，但我能推测一些内容。指南最初于2003年制订，随后在2007年和2009年分别进行了修订。高血压患者仍是从单药治疗开始，对一些严重高血压，需加用另一种药物。对于一些真正严重的病例，甚至可以起始就进行低剂量联合用药。这些当然都将会在新指南中有所体现。
From what I heard and from what I have seen in several amendments and articles is that a doctor is probably allowed by the guidelines to start combination treatment earlier， that doctors need not confine their therapy to low dose drugs. The guidelines will be more specific in where they want low dose， where they allow for higher doses. That will change right from the beginning. And also， this extends to single pill combinations.

　　首先，我在一些修订文章中看到，指南可能允许医生更早的启动联合治疗，医生不需要将治疗限定为低剂量用药。指南会更详细的说明哪些情况下需用低剂量，哪些情况下应当使用更高剂量。这些从开始就会改变。而且会扩展到单片复方制剂。

　　And I think there will be something in the guidelines on single pill combinations being recommendable， as is anything that increases the patients’ compliance and persistence. From this view， the guidelines will change a bit in terms of allowing doctors to give more combinations at an earlier stage. Then the guidelines will certainly look at risk， and will try to evaluate more intermediate risk factors.

　　我认为指南会有关于单片复方制剂推荐的内容，以及其他增加患者依从性和持续性的措施。从这个角度来说，指南会做出改变，允许医生在较早阶段更多采用联合用药。指南还会着眼于风险评估，会对中间危险因素做出更多评估。

　　What risk factors do we have? We have， of course， those that we are responsible for in our lives， our lifestyles. This includes smoking， adiposity， obesity， male sex， and others. For some of these， there is nothing we can do. For others， there is something we can do.

　　我们有哪些危险因素？危险因素当然和生活方式相关。包括吸烟、肥胖、超重、男性和其他危险因素。其中有些我们无法改变，有些可以改变。

　　On the other hand， we have also risk factors that can be measured. For instance， hypertension itself， albumin urea， left ventricle hypertrophy， insulin sensitivity， and insulin resistance. These risk factors will be looked at more intensively in the new guidelines. The authors will try to sort out what doctors can use in their practice. They will also try to understand intermediate factors.

　　另一方面，我们也有一些可以检测的危险因素。例如高血压本身、蛋白尿、左心室肥厚、胰岛素敏感性和胰岛素抵抗。这些危险因素在新指南中会更加被重视。指南编写者试图选出临床实践中哪些可让医生使用的参考。他们也尝试理解中介因素。

　　Then， of course， the guidelines will have a chapter on evidence. Evidence in terms of event driven medicine and evidence based medicine. What kind of evidence have we gained in recent trails for drugs that reduce cardiovascular risk? What are the pitfalls of these trials? What would we like to have in future trials? Would we like to address large populations， as we did in the past? Or should we go for more personalized， individualized medicine with smaller trials? But in these groups， would then the drugs be designed or used in more specified groups of patients? Or， should we do as we do now， just trying out to see what helps?

　　指南有一章是关于事件驱动医学及循证医学方面的证据。关于降低心血管风险的药物，我们近期取得了哪些证据？这些试验存在哪些误区？我们将来的试验中希望有哪些内容？我们和过去一样强调大规模人群，还是应当进行更小规模的试验以进行更加个体化治疗？在这些组中，药物是否会被设计用于更细化的患者分组？或者，我们是否应当和现在一样，只是努力发现哪些有帮助？

　　And there will certainly be something in the guidelines which deals with other guidelines， and their ideas about treating hypertension. For instance， the U.S. guidelines， which came out 10 years ago haven’t been updated since. They’re heavily based on diuretics. Certainly， this is not what the European guidelines would recommend.

　　当然，指南中还会有其他推荐高血压治疗理念方面的相关内容。例如，大约10年前推出的美国指南目前尚未更新。美国指南更多的强调利尿剂。当然，欧洲指南并不会这样推荐。

　　On the other hand， they will certainly deal with the British guidelines and the NICE guidelines. They are quite special in that they are much more specified: what could be used in different groups of patients. For instance， consider the British guidelines. Their new version， published in 2011， says that when you have a patient below the age of 55， you should start with a limiter. If the patient is more than 55 years old， and is black at any age， you should instead start with a blocking agent. And then， in the next step， combine these two， and only in the third step， add a diuretic. And only in the fourth step， if necessary， add a beta blocker.

　　另一方面，欧洲指南也和英国指南以及NICE指南相关。这些指南非常详尽，可以用于不同的患者组。例如，2011年公布的最新版英国指南指出，如果患者年龄小于55岁，起始用药应当为ACEI或者ARB。如果患者年龄超过55岁，或者任何年龄的黑人，起始用药应当为钙通道阻滞剂。下一步是联合使用两种药物，第三步才是增加利尿剂。如果必要的话，只是在第四步，加用β受体阻滞剂。

　　So， they were quite specific in describing， at which step we can use which group of drugs. This was not the content so far of the European guidelines. The European guidelines just took the five groups of drugs and said， "Well， you can combine them. There are more preferable combinations， and less preferable combinations. But basically， do what you want， doctor." And this was criticized by many practicing doctors: "Well， this doesn’t really help us. What should be combined? What do the guidelines make us think about what we should combine?" So I think they will be a bit more specific about order of drug use and their combinations. "What is the place of diuretics? What is the place of beta blockers in hypertension treatment?"

　　因此，这些指南的推荐非常详细，在哪一步使用哪种药物。而目前欧洲指南中并未包含这些内容。欧洲指南只是推荐了五类药物，并且说“你可以联合使用这些药物，有更好的联合方法，也有不那么好的联合方法，但从根本上来说，还是根据你的想法来行动，医生。”这被很多临床医生所批评：“这并没有真正帮助我们，指南让我们认为应当联合使用哪些药物？”因此，我认为新指南中会对药物使用及联合用药做出更详细的推荐。“利尿剂的地位如何？β受体阻滞剂在高血压治疗中的地位如何？”

　　I think those will be in the new guidelines.

　　我认为新指南会有这些内容。