Alberto Zanchetti教授   意大利米兰大学

　　<International Circulation>: As a member of the Task Force for the 2013 ESH/ESC guidelines for the management of arterial hypertension， could you outline the main features of the updates to the new guidelines compared with the previous ones?

　　Dr Zanchetti: The new guidelines concentrate on various aspects of the management of hypertension. But I would like to focus on that part concerning the treatment of hypertension， which is probably where the most important changes to these guidelines have occurred， compared to the previous one. These guidelines have tried to give a greater weight to the evidence obtained by trials more than expert opinion which has been done previously. So I think there was a very careful and critical revision of the type of agents that were used in randomized trials about when to start antihypertensive treatment and which blood pressure value should be achieved with treatment. The major difference between these guidelines is that now they say openly that the evidence in favor of treating low-risk individuals with moderate elevation of blood pressure (which the guidelines define as grade 1 hypertension i.e. between systolic 140mmHg and 160mmHg and diastolic 90mmHg and 99mmHg) is limited so the recommendation for the treatment of these patients is revised in terms of prudence more than of evidence and the recommendation is to start these subjects on lifestyle changes and proceed for many weeks or months with lifestyle changes and seeing whether losing weight， eating less salt and doing more exercise is reducing blood pressure. Only after several months of this lifestyle and if the blood pressure still remains in this elevated range then drug treatment can be considered. It is not urgent to be done but can be considered. As far as the blood pressure values to be achieved by treatment， again there is a revision in these guidelines where the previous guidelines recommended achieving a blood pressure <140mmHg in all patients but for high-risk patients like diabetics with previous cardiovascular disease and renal patients where the recommendation was to achieve a systolic blood pressure <130mmHg， the new guidelines recognize that the trial evidence is very poor in favor of going so low， so the new recommendation is just to go <140mmHg in all hypertensive patients independent of the degree of risk. They also recognize that for the elderly there is very good evidence for treating them beneficially when the pressure is >160mmHg than when it is between 140mmHg and 150mmHg. So treating them where there is grade 1 hypertension between 140mmHg and 150mmHg and bringing it below 140mmHg in the elderly is still of uncertain benefit.

　　《国际循环》：作为2013版ESH-ESC高血压指南的编委，您能否简要介绍一下与以往指南相比，新指南的主要特色有哪些？

　　Zanchetti教授：新指南关注了高血压管理的各个方面。不过我最关注的是高血压的治疗部分，这部分也是与既往指南相比新指南中的变化最为重要的部分。与专家意见或经验相比，新指南更多地以临床试验的证据为基础。所以，我认为新指南对随机试验中所应用的各类药物应在何时开始降压治疗以及降压治疗所要达到的血压目标值进行了仔细的关键性修订。与既往指南相比，新指南的重要差别在于其强调对血压轻度升高的低危人群（指南定义为1级高血压，收缩压为140～160 mmHg，舒张压为90～99 mmHg）进行治疗的证据有限，故对上述患者的治疗推荐进行了修订，推荐这些患者应进行生活方式改变，并在几周及几个月的生活方式改变后观察减重、减少钠盐摄入及增加体力活动能否降低血压。只有在经过几个月的生活方式改变后，如果血压仍然维持在较高的水平，才可以考虑药物治疗。而不是急于考虑实施药物治疗。此外，就降压治疗的目标值，新指南也进行了修订。既往指南推荐一般患者的降压目标值为收缩压<140mmHg，高危患者如伴有心血管疾病及肾病的糖尿病患者收缩压的降压目标值为<130mmHg；新指南则认为并无充分的临床证据支持将血压降至上述低水平，因此推荐不论危险程度如何所有的高血压患者收缩压的降压目标值均是<140mmHg。此外，对老年高血压患者而言，新指南认为在血压>160mmHg时进行治疗比血压水平在140mmHg～150mmHg范围内时进行治疗具有更充分的证据支持。因此，对收缩压在140mmHg～150mmHg范围内的老年1级高血压患者而言，将收缩压降至140 mmHg以下的获益仍不确定。