Post Date December, 02 2023
Hypertension is one of the most common chronic diseases that seriously threaten people's health, and is also an important risk factor for cardiovascular and cerebrovascular events, chronic kidney disease (CKD) and death. The incidence rate of hypertension among elderly patients over 65 years old is as high as 60%~80%. Taking the National Health and Nutrition Research (NHANES) as an example, the prevalence of hypertension among adults over 60 years old is 67%; With the change of lifestyle and the intensification of population aging, this proportion is still rising year by year. The incidence of hypertension in CKD patients is as high as 80%~85%. Controlling blood pressure, especially lowering blood pressure to the target value, can significantly reduce or prevent the risk of complications and death. The following will take hypertension treatment of CKD patients as an example to talk about the principles of hypertension treatment supported by evidence-based medical evidence.
Prevention and treatment of hypertension should focus on reaching the standard of blood pressure reduction
The prevention and treatment of hypertension focuses on reaching the standard of blood pressure reduction, which has always been the consistent purpose in clinical practice. In 2007, the American Heart Association and the 2013 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines both pointed out that the main determinant of reducing cardiovascular events in patients with hypertension (including young and elderly people) is the standard of blood pressure, rather than the choice of antihypertensive drugs.
This view is based on the results of many large clinical studies. With the same degree of target control of blood pressure, most antihypertensive drugs can provide cardiovascular protection with similar effects. For example, CAPPP, STOP-Hypertension-2, NORDIL, UKPDS and INSIGHT studies have found that the overall prognosis of hypertensive patients treated with traditional antihypertensive drugs (such as diuretics and P-receptor blockers) is similar to that of new antihypertensive drugs (such as angiotensin converting enzyme inhibitors (ACEI) and calcium channel blockers (CCB)); CAMEL0T study compared two new antihypertensive drugs, amlodipine and enalapril, in the treatment of hypertension. There was no significant difference in the prognosis of patients. Similar conclusions were obtained in the analysis of subgroups of patients with increased cardiovascular events.
At present, the commonly used antihypertensive drugs in clinic include thiazide diuretics, ACEI/angiotensin II receptor antagonist (ARB), CCB β Receptor blockers α Receptor blockers, etc. The majority of antihypertensive drugs have good antihypertensive effect in 30%~50% of patients, but there are still individual differences in their efficacy. For example, black and elderly patients generally respond better to thiazide diuretics or CCB monotherapy, while ACEI or β The treatment response of receptor blockers is relatively poor. Therefore, on the premise of reaching the standard of blood pressure reduction, individualized treatment should also be emphasized.
◆ Callback of the new guideline on the target of blood pressure reduction: the lower the blood pressure, the better
The 2013 ESH/ESC hypertension guideline recommended that the target systolic blood pressure of patients at high and low risk of cardiovascular disease should be<140mmHg; Target diastolic pressure<90mmHg, diabetes patients push<85mmHg. Different from the 2007 guideline, the 2013 guideline raised the target blood pressure of the high-risk group<130/80mmHg to the same level as the low-risk group (<140/90mmHg). Because there is not enough evidence from randomized controlled studies to support the target recommended in 2007. The up-regulation of the target of blood pressure reduction emphasizes that stable blood pressure reduction is the fundamental principle for reducing long-term cardiovascular and cerebrovascular events.
In 2012, KIDG0 guidelines recommended that the target of CKD patients without albuminuria should be ≤ 140/90mmHg; The target blood pressure of CKD patients with albuminuria and kidney transplantation is ≤ 130/80mmHg.
By listing the target blood pressure recommended by different recent guidelines, it is not difficult to find that the recent guidelines have a general callback to the target blood pressure. The lower the target of blood pressure reduction is not the better, but more emphasis is placed on stable blood pressure reduction and long-term prognosis. Moreover, according to the patient's age, primary disease and urinary albumin excretion rate, the target of blood pressure reduction is different, and the target of blood pressure control also pays attention to individualization.
Individualized antihypertensive therapy for CKD patients
Individualization of blood pressure control standard Due to different etiology and pathogenesis of hypertension, clinical medication should be treated separately, and the most appropriate drug and dose should be selected to obtain the best effect.
Taking CKD patients as an example, the treatment of hypertension in CKD patients usually requires the combination of multiple antihypertensive drugs.
First-line treatment
ACEI or ARB drugs are recommended for first-line antihypertensive treatment of CKD patients with proteinuria, because they can not only lower blood pressure, but also delay the progress of CKD. The common adverse reactions are the rapid decline of glomerular filtration rate (GFR) and hyperkalemia. In addition, ACEI/ARB drugs are prohibited for pregnant women. The existing randomized controlled studies (such as ONTARGET) also do not recommend the combination of ACEI and ARB in terms of safety.
Second-line and third-line treatment
It is recommended to evaluate drug selection according to the overall volume load of patients. For patients with proteinuria and edema, the initial treatment usually includes ACEI and loop diuretics. Loop diuretics may enhance the hypotensive effect of ACEI drugs by increasing the release of renin. The use of diuretics may also restore the unsatisfactory hypotensive effect of ACEI, because the excessive volume load reduces the release of angiotensin II and the dependence of blood pressure on angiotensin II. If further antihypertensive treatment is still needed, we recommend non-dihydropyridine CCB (diltiazem, verapamil) because these drugs also have the effect of reducing proteinuria. On the contrary, dihydropyridine CCB has little effect on reducing urinary protein excretion.
For CKD patients with proteinuria without edema, diuretics or non-dihydropyridine CCB can be used as second-line or third-line drugs. Even without edema, volume overload usually plays an important role in hypertension in CKD patients.
◆ Treatment of hypertension in CKD patients without proteinuria
Compared with CKD patients with proteinuria, ACEI has no advantages over other antihypertensive drugs. For patients with edema, loop diuretics are recommended for initial treatment. Once the edema is controlled, ACEI/ARB or dihydropyridine CCB can be considered if there is still hypertension. For patients without edema, ACEI/ARB can be used at first, and then dihydropyridine CCB can be added. This method has not been specially studied in CKD patients without proteinuria. In addition, according to the recommendations of ACCOMPLISH study, we recommend adding diuretics as the third-line treatment if necessary.
Four-line treatment
Aldosterone antagonists (spironolactone, epridone) can be considered for intractable hypertension. Therefore, on the premise that the antihypertensive treatment of CKD patients reaches the standard, individualized treatment is also very important. However, the reality is that there are problems such as low awareness rate and nonstandard treatment of hypertension in China, especially in CKD patients. Taking the CCMR-3B study participated by the author as an example, a cross-sectional study of 25454 patients with type 2 diabetes selected from outpatients in six regions of China found that 73.0% of patients with hypertension were treated with antihypertensive drugs, and 39.7% of them were treated with ACEI/ARB.
Of 2157 patients with hypertension and proteinuria, 48.3% used ACEI/ARB. In non-hypertensive patients with proteinuria, the use of ACEI/ARB is less than 1%. Multiple regression analysis showed that the use of ACEI/ARB was related to the complications, the region, the level of hospital, the specialty of doctors and the education of patients.
Summary
The prevention and treatment of hypertension should focus on reaching the standard of blood pressure reduction, which is the basic principle of clinical practice; On the premise of reaching the standard of blood pressure reduction, it is also necessary to emphasize the individualized principle of blood pressure reduction treatment, and "give medicine according to disease and treat according to people" to obtain the best treatment effect. In addition, hypertension often exists in combination with other risk factors of cardiovascular and cerebrovascular diseases, such as hyperlipidemia, obesity, diabetes, etc., which aggravate the risk of cardiovascular diseases. Therefore, the treatment measures for hypertension should also be comprehensive, from lifestyle, diet structure, drug treatment and other aspects.
