《国际循环》：血压水平与心血管风险之间可能存在J曲线，这提示过度降压可能增加心血管风险。您认为降压治疗是否应当有低限？

    <International Circulation>:  The fact that the relationship between the level of blood pressure and risk may be “J” shaped suggests that vigorous lowering of blood pressure may increase cardiovascular risk. Do you think it is necessary to set a low limit in antihypertensive therapy?

    Henry Black教授：我非常高兴你问了这个问题，这主要是来自ACCORD试验的结果。ACCORD试验观察了2型糖尿病患者的降压目标值。常规降压组的目标收缩压为<140 mmHg，而强化降压组为<120 mmHg，而后者很难达到。ACCORD试验入选了10，000例2型糖尿病患者，其中高血压分支试验有4，800例患者。此外，ACCORD试验还有血脂试验和观察糖化血红蛋白（HbA1c）目标值的血糖试验。非常有意思的不是ACCORD试验的结果，而是对试验的解读。ACCORD试验的一级终点是包括多个心血管转归指标在内的复合终点，结果常规降压组和强化降压组的复合终点发生率无显著差异。有趣的是，降压目标值为<140 mmHg的研究中心可以应用任何的降压药物。结果显示，将平均收缩压降至133 mmHg平均要应用2.5种降压药物。这个结果相当不错，令人惊奇。而强化降压组最后将血压降至119 mmHg，这非常令人印象深刻。我们很高兴，普通治疗组和强化治疗组的血压有显著差异。但是，两组的复合终点无显著差异。如果进一步深入分析的话，我们会发现一些有趣的结果。比如，强化降压能够显著减少2型糖尿病患者卒中的发生。在高血压患者的并发症中，卒中是我们最担心发生的。这对中国来讲尤其有意义，因为在中国卒中比冠心病更常见，而对糖尿病患者这一心血管高危人群的血压进行强化控制确实能够使患者显著获得卒中方面的益处。某些媒体将ACCORD试验解读为强化降压没有必要，这是一种不负责任的作法，我本人不赞同这种看法，这甚至可能对患者有害。如果广大医生能够将2型糖尿病患者的血压降至133 mmHg一下的话，那么更为严格的血压控制可能更好。不过，我可以大胆地说，在大多数情况下，很多患者不会达到这么理想的血压水平，虽然我目前还没有证据来证明这一点。参与ACCORD试验的研究中心能够方便地得到来自电子医疗记录的反馈，同时也知道试验监察的结果。如果常规的治疗手段能够使患者的平均收缩压降至133 mmHg，这是一个很大的进展。因此，这是一个教育医生的绝佳机会。要告诉广大医生，基于目前的证据，只要注意的话，我们能够将患者的血压降得比我们预想的还要低。对于卒中预防来讲，将收缩压降至120 mmHg以下可能是值得的。在本次ASH年会的最新临床试验环节，William Cushman教授将会公布这方面的一项最新试验的结果。

    Professor Henry Black: I am very happy that this question is asked this is a result predominantly from the ACCORD study which looked at type 2 diabetics and set goals. One of these goals which was in the control group was less than 140 mm/Hg there was another goal of less than 120 mm/Hg systolic which was thought to be very difficult to achieve. This study had over 10，000 individuals of which around 4800 had hypertension; there was another group which looked at lipids and another group which looked at diabetes control using HbA1C goals. The very interesting thing is not the results but the interpretation. If you look at the combined endpoints they used which included a whole range of cardiovascular outcomes there was no real difference between the group that was supposed to go under 140 mm/Hg and the group that was supposed to go under 120 mm/Hg. The interesting thing was that the clinical sites which had the 140 mm/Hg goal could use anything they had available. They averaged about 2.5 drugs which were all routinely available got down to 133 mm/Hg on average systolic. This is an astonishingly good result， the group which had to go below 120 mm/Hg got down to 119 mm Hg which is very impressive and happily there was a substantial difference between the usual care and the aggressive care cohorts. The combined end point did not show any difference if you dig deeper into the results you see more interesting results. For example for stroke the group which had the aggressive therapy did best. Now stroke is a complication of having hypetension that all of us fear most. This is especially pertinient in China where stroke is more common than coronary disease and aggressive therapy for these type 2 diabetics， which represents the high risk spectrum， of the population did benefit significantly from aggressive therapy. The interpretation from some of the media was that aggressive therapy was not necessary which personally borders on being irresponsible and an interpretation that I do not like and could even hurt our patients. If the average physician in practice can get to 133 mm/Hg then maybe more aggressive therapy is in necessarily helpful but I would venture to say even though I can’t prove it， that in most clinical encounters these excellent results will not be ache