International Circulation: International Circulation is honored to speak to Professor Suzanne Oparil on the occasion of WHC2009 in Beijing and this Chinese guidelines preparatory meeting.
We know the ESH/ESC and the Japanese JSH just updated their guidelines for hypertension management， and China and the United States are also in the process of updating their hypertension guidelines. From your perspective， why are organizations updating their hypertension guidelines now in the last couple of years?
《国际循环》：我们知道ESH/ESC和日本JSH刚刚更新了高血压治疗指南，现在，中国和美国也正在更新高血压指南。在您看来，为什么这些年来，这些组织都在不断地更新指南？
Prof Oparil: We are working very hard on this. The reason is that there is a lot of new evidence in the literature based on randomized controlled trials of antihypertensive treatment. We believe very strongly that every piece of guidance that is given to physicians should be based on evidence in the form of randomized controlled trials as randomization eliminates bias and eliminates expert opinion. Because there have been so many new trials， there are many new guidelines being constructed.
Prof Oparil：我们一直在致力于指南的修订是因为：这几年有很多新的抗高血压治疗方面的临床随机数据出台。对临床医生进行指导的指南中，任何一项决策都应以随机临床对照试验的证据为基础，去除其片面性和专家个人意见，这一点我们深信不移。因为已经有许多新的临床试验结果，所以相应的，指南也有许多方面需要更新修订。
International Circulation: In your opinion， what’s the role of guidelines in the prevention， treatment and control of hypertension – the world’s major cardiovascular disease， and how can we maximize the value of the guidelines?
《国际循环》：在您看来，指南在高血压（世界主要的心血管疾病）的预防和治疗中发挥着什么作用？我们怎样才能最有效地发挥指南的这些作用？
Prof Oparil: Guidelines， in fact， are only guidelines. We do respect the judgment of physicians who are well-trained and concerned about the welfare of their patients， and patient A is not the same as patient B. I am not the same as you with respect to my cardiovascular system. But primary care physicians and family physicians， certainly in the United States， and it is these physicians who take care of most patients with hypertension， are very busy. They see many patients every day， maybe forty， fifty， sixty patients. They cannot think through a long series of papers or clinical studies， they can’t digest a hundred pages of advice. They have to have simple advice about the things that work best at lowering blood pressure and protecting the patient. So we are trying to construct simple guidance for them about what is effective and what is safe in， firstly， lowering blood pressure， and secondly， preventing cardiovascular disease and preventing cardiovascular disease death. It is simple but it is complicated.
Prof Oparil：实际上，指南仅仅是指南。我们尊重接受过良好训练并且关心患者利益的临床医生的判断，同时我们也明白患者存在个体差异。但是初级内科医生和家庭医生是非常忙碌的，尤其是在美国，因为他们需要面对很多高血压患者，每天接诊40、50甚至60位患者。他们没有时间阅读长篇大论的文献、临床研究报告，以及长达100多页的建议，他们需要的是关于降低血压和保护患者的简单的建议方案。所以我们试图为他们制定简单的指南，例如哪些药物更有效，哪些方案更安全；首先降低血压，然后预防心血管事件的发生和由此导致的死亡等。因此，指南是简单的但同时又是复杂的 。
International Circulation: The recommended combination therapy in the new version of the ESH/ESC guidelines changed from ‘hexagonal’ to ‘quadrilateral’ – the importance of beta-blockers and alpha-blockers has been reduced. The new JSH guidelines still emphasize that the five classes of antihypertensives are equal. What are your comments on this and will the JNC8 be more like the ESH/ESC’s guidelines?
《国际循环》：在新版的ESH/ESC指南中，联合治疗方案得到推荐，并且药物从之前的“六角形”转变为“四边形”——β受体阻滞剂和α受体阻滞剂的重要性降低。新的JSH指南却还是强调五种降压药的作用是平等的。您对此怎么看呢？JNC 8会更倾向于ESH/ESC指南么？
Prof Oparil: I have no comment as our group is in the process of evaluating the evidence supporting one decision or another and we are taking an evidence based approach， which means a very rigorous evaluation of all the published randomized controlled trials since 1966. So we have a lot of evidence to sift through. We have to weigh the strength of the evidence and then based on the strength of the evidence we will give a recommendation which is either strong， weak or negative. In other words， you must do this， maybe you can do this， or you must not do this. So I have no recommendation with respect to any particular drug or treatment approach， but we hope that once we have finished this process， we will have the best possible advice given the evidence that was evaluated and given our patient population. We don’t have many Asian people in our studies， so we will be looking at Caucasians， Hispanics， who may be either black or white， and African-Americans. So things may be different in Asia versus North America versus UK.
Prof Oparil：目前，我们正在评估从1966年以来所有发布的随机对照试验结果，所以我现在还不便发表评论。我们必须对这些证据进行综合分析，然后我们将在此基础上给出不同级别的建议。所以我对于任何特殊药物或者治疗方案不作评论，但是希望一旦完成这项研究，就将有最好的建议方案出台。我们的研究中亚洲患者人群所占比例不是很大，因此将来我们会更加关注高加索人种、西班牙人种等，无论是黑人或白人，还是非裔美国人。亚洲人群的结果可能会与北美和英国有所不同。
International Circulation: Cardiovascular risk assessment and its incorporation into treatment decisions is a clear strategy in hypertension management. What are your thoughts on this?
《国际循环》：对心血管危险因素进行评估，并且将其应用于高血压治疗方案的制定中已经作为一种例行的手段。您对此怎么看呢？
Prof Oparil: JNC7 did not do formal risk assessment at all. The National Heart， Lung and Blood Institute of the US National Institutes of Health has launched an effort at cardiovascular disease prevention and treatment guidelines which will include JNC8， our favorite， as well as ATP4， which deals with lipid management and another guideline which deals with obesity management which is a horrible thing in the United States， and then there are cross-cutting committees. One deals with risk assessment， one deals with lifestyle modifications and another deals with implementation， how you get all of these recommendations into practice. How we will integrate what the risk assessment group says with the JNC8 recommendations is yet to be determined.
Prof Oparil：JNC 7并没有做过正式的风险评估。美国健康研究中心的国家心肺血液研究所关于心血管疾病预防和治疗指导方面做出了一定的努力，这些将会收入JNC 8。我们更关注关于血脂以及肥胖处理的推荐，因为肥胖在美国是一个非常危险的因素。另外还有cross-cutting 委员会，一方面是关于危险因素评估，一方面关于生活方式调整，另外一方面是关于这些推荐方案的实施：如何将建议用于临床实践。JNC 8中我们如何整合危险因素评估仍然在决议中。
International Circulation: We know the FDA approved the indication of several so-called single pill combinations or fixed-dose-combinations as a first line treatment for moderate to severe hypertension， and the updated ESH/ESC guidelines are also moving in the direction of earlier control of blood pressure especially for high risk patients. What’s your opinion regarding the earlier and broader use of combination therapies， such as fixed-drug-combinations， in hyp
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