Giuseppe Mancia教授 意大利米兰比可卡大学
<International Circulation>: There are many issues about the latest European hypertension guidelines on the ESC congress. Compared with the previous guidelines， what would you like to tell readers about the update of combination therapy?
Prof. Mancia: Well， I think one important thing to highlight is confirmation， because already in the 2007 guidelines， it was said that combination treatment is extremely important for the treatment of hypertension， because blood pressure reduction can be much greater with the combination of two drugs as compared to mono-therapy， for a variety of reasons， including the fact that several factors are involved， and mechanisms are involved in the blood pressure elevation and the more mechanisms one can recruit， the greater the chance for blood pressure to be controlled. So confirmation is important.
Of course， there are some differences in terms of which combinations should be preferred. Guidelines emphasize that only a few studies look at the combination in a randomized trial fashion. Most studies randomization involved just the first step， mono-therapy， and then the other combinations were just added. What has been done has been to look at the combinations that have been successfully used in successful trials. So， this has resulted in an update of the very famous geometrical figures. They are， what are called preferred combinations， and mainly they are a blocker of the rennin angiotensin system together with the diuretic or calcium channel blocker. But even a calcium channel blocker and a diuretic have been used as a combination in a number of trials. And then there are combinations that can be used， but are of less priority. One of them is， for example， the old time combination of the diuretic and the beta blocker， which has been used in many trials， but of course is not given priority because of the increased risk of developing diabetes. And then another combination， which is not to be preferred， is a double blockade of the system， an ACE inhibitor together with a angiotensin receptor blocker， or a renal inhibitor together with a ACE inhibitor or angiotensin receptor blocker. So， a revised version of the geometrical figure.
《国际循环》：ESC大会上有许多最新欧洲高血压指南的相关议题。与既往指南相比，新指南对联合治疗更新有哪些？
Mancia教授：我认为最突出的是新指南重申2007年指南提出的联合治疗对高血压治疗的重要性，因为与单药治疗相比，双药联用能更显着地降低血压。多种因素及机制参与了血压升高，一种治疗方法如能改善多种机制，其控制血压可能性越大。因此，重申和强调联合治疗非常重要。
当然，联合治疗可选择不同的组合。指南强调，在联合治疗的相关研究中，随机试验数量相对较少。大多数研究仅仅在第一阶段单药治疗时进行了随机化，然后再加用另一种药物进行联合治疗。我们只是从成功的试验中发现那些成功的联合治疗方案，并根据这些结果对联合治疗方案推荐的几何图形进行更新。其中，肾素血管紧张素系统（RAS）抑制剂与利尿剂、钙离子拮抗剂的联合应用是优选的联合治疗组合，有些试验也采用了利尿剂与钙离子拮抗剂的组合。其他联合治疗方案也可应用，但不优先考虑。例如，之前所用的利尿剂与β受体阻滞剂的组合，曾被多种试验所应用，但因其会增加糖尿病发病风险而不被优先考虑。还有另一个不被优先考虑的是两种RAS抑制剂即ACEI与ARB联用、肾素抑制剂与ACEI或ARB联用。因此，新指南对联合治疗组合方案的推荐几何图进行了修订。
<International Circulation>: Hypertension， with mono-therapy， is often difficult for effective blood pressure control. Usually， again， combination therapy is used， but this can lead to difficulty with medical compliance， which again， is one reason why incidence of hypertension remains high. So， how would you opine in terms of effectively improving patients’ compliance?
Prof. Mancia: That’s very difficult， of course. First of all， it is difficult for the individual physician， in clinical practice， to know which is the adherence of the patient to treatment. There are not good means to detect adherence or non-adherence in clinical practice: pill counting， questioning the patient， psychological profile of the patient. Of course， doctor-physician experience can help， but sometimes one can make bad mistakes.
Secondly， how to improve adherence. There are no clear recipes， unfortunately. What is clear， however， that a factor of paramount importance is a good physician-patient relationship. If there is a good relationship， then patients probably are more likely to take drugs. A good relation means， however， that the physician is involved in a greater amount of work， because he has to talk to the patient， see the patient often， to be a good psychologist， know about the patient without interfering with his or her privacy. So many many subtle things， which are not easy in daily life practice， are really qualities of good physicians， and require work， because the patient cannot be left alone， in a way.
《国际循环》：高血压单药治疗通常难以实现有效的血压控制，往往需要进一步加用药物实施联合治疗，但这会导致依从性差。而依从性差是高血压发病率居高不下的原因之一。您认为应如何有效提高患者的依从性？
Mancia教授：提高患者依从性是非常困难的。首先，在临床实践中医生很难知道患者对治疗的依从性怎样。目前尚无很好的方法评估或检测临床实践中患者依从与否，只能通过计数药片、询问患者和患者心理学特征来粗略评估。当然，医生的经验在这种评估中发挥了重要作用，但值得一提的是，有时凭经验会犯严重错误。其次，如何改善依从性？非常遗憾的是，目前还没有特别明确的措施。唯一明确的是，良好的医患关系对改善患者的依从性至关重要。如果能建立良好的医患关系，患者将更可能坚持服药。而要想建立这种良好的关系，医生就需要做更多的工作，经常与患者见面和交流，还需要拥有心理学家的技能——在不触犯患者隐私的情况下对患者进行了解。所以说建立良好的医患关系时，有很多东西都是非常微妙的，日常临床实践中并不容易做到，但这些却是一个好医生必须具备的。而这些都需要做大量的工作，而不能让患者独立面对。
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