给所有人服降压药
Give Blood Pressure Drugs to All
Fran Lowry
给所有人服降压药
Blood-pressure-lowering drugs should be offered to everyone, regardless of their blood pressure level, as a safeguard against coronary heart disease and stroke, researchers who conducted a meta-analysis of 147 randomized trials (comprising 958 000 people) conclude in the May 19 issue of BMJ [1].
BMJ第19期发表一篇荟萃分析（147个随机试验，958 000人），研究者认为不管血压水平如何，作为一项有助于冠心病和卒中保护的措施，所有人均应给与降压药。
“Guidelines on the use of blood-pressure-lowering drugs can be simplified so that drugs are offered to people with all levels of blood pressure,” write Drs Malcolm R Law and Nicholas Wald. “Our results indicate the importance of lowering blood pressure in everyone over a certain age, rather than measuring it in everyone and treating it in some.”
Drs Malcolm R Law and Nicholas Wald.认为，降压药使用指南应被简化，以便所有水平血压的人均可应用降压药。“我们的结果表明了超过某一年龄后每个人均应用降压药的重要性，而不是对每一个人测量血压，然后对某些人进行治疗。”
“Whatever your blood pressure, you benefit from lowering it further,” Law told heartwire . “Everyone benefits from taking blood-pressure-lowering drugs. There is no one who does not benefit because their blood pressure is so-called normal.”
Law说，不管你血压如何，你将来肯定会从降压中获益。每一个人均会从服用降压药中获益，而不管他们的血压处在所谓“正常范围”。
Six years ago, Law and Wald advocated the use of a polypill--containing a statin, three blood-pressure-lowering drugs (each at half the standard dose), folic acid, and aspirin--which they maintained could prevent heart attacks and stroke if taken by everyone 55 years and older and by everyone with existing cardiovascular disease [2].
6年前Law 和Wald即提倡使用一种polypill药丸（包含一种他丁，3种降压药，叶酸和阿司匹林）。如果≥55岁者或存在心血管疾病者坚持服用即能预防心脏病和卒中。
All Antihypertensives Prevent CHD and Stroke
所有抗高血压药均预防冠心病和卒中
Overall, the results of the meta-analysis showed that in people aged 60 to 69 with a diastolic blood pressure before treatment of 90 mm Hg or a systolic blood pressure of 150 mm Hg, three drugs at half standard dose in combination (as in the polypill) reduced the risk of CHD by approximately 46% and of stroke by 62%. However, when used individually, a single antihypertensive agent at standard dose had about half this effect.
荟萃分析表明年龄60-69岁、治疗前舒张压90mmHg;收缩压150mmHg者，三种降压药物半量组合后大约降低冠心病46%，降低卒中62%。一种降压药标准剂量单独应用仅有1/2的疗效。
The five main classes of blood-pressure-lowering drugs--thiazides, beta blockers, angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, and calcium-channel blockers--were similarly effective in preventing CHD events and strokes, with the exception of calcium-channel blockers, which had a greater preventive effect on stroke than the other four agents (relative risk, 0.92; 95% confidence interval, 0.85 to 0.98).
5种降压药---噻嗪类、beta阻滞剂、ACE抑制剂、血管紧张素受体阻滞剂、钙通道阻滞剂对于预防冠心病和卒中的效应相同，但钙通道阻滞剂对卒中的预防作用较其它4种更好。
People with and without cardiovascular disease derived equal benefit, with similar percentage reductions in CHD events and stroke, and regardless of what their blood pressure was before treatment. Even patients with blood pressures considered to be low--110 mm Hg systolic and 70 mm Hg diastolic--showed fewer CHD events and a reduced incidence of stroke when taking an antihypertensive.
不管治疗前血压为多少，有或无心血管病者均同等受益，心血管病事件和卒中的下降百分比相同。甚至在舒张压低于70mmHg，收缩压低于110 mmHg者服用降压药冠心病事件也较少，卒中发病率下降。
Law and Wald also report that calcium-channel blockers reduced the incidence of heart failure by 19%, and that the other antihypertensive agents reduced heart failure by 24%.
Law and Wald报道钙通道阻滞剂降低心衰发生率19%，其它种类制剂降低心衰24%。
In an accompanying editorial [3], Dr Richard McManus (University of Birmingham, UK) and Dr Jonathan Mant (University of Cambridge, UK) write that the findings of Law and Wald will contribute to debate on the management of hypertension in several areas. “Taken at face value, these findings provide tacit support for the use of a ‘polypill’ to lower the risk of cardiovascular disease in people likely to be at high risk (such as all people over the age of 55) without first checking their blood pressure.”
Dr Richard McManus认为Law and Wald的发现将加剧有关高血压控制的几个方面的争论。“初步来看，这些发现不言而喻支持在不先行血压测量的情况下使用polypill药丸，以便降低可能高危的人群(例如所有超过55岁者)的心血管病危险。”
In a comment to heartwire , McManus added that he believes that the findings reinforce the view that treatment to lower blood pressure should be offered on the basis of risk, regardless of blood pressure.
McManus在写于heartwire的评论中认为，他相信这些发现将强化下列认识：降压治疗应依据危险性大小，而不是血压。
Throwing the Baby Out With the Bath Water
把孩子随水泼掉
On the other side of the Atlantic, hypertension experts were not so sanguine in their opinion of Law and Wald’s conclusions.
在大西洋的彼岸，高血压病专家对Law and Wald的结论并不乐观。
Commenting on this study for heartwire , Dr James Elliott (Rush Medical College, Chicago, IL) said he took issue with the authors’ suggestion that the measuring of blood pressure was unnecessary.
“Professors Wald and Law made the revolutionary comment some years ago that we should abandon blood pressure and simply treat everyone at high CVD risk with their magic polypill, which they claimed reduced heart disease and stroke by 90%.This meta-analysis is an unusual compilation of data that supports that hypothesis.”
Dr James Elliott对作者提议不必测量血压表示异议。“Professors Wald and Law数年前即发出革命性的倡议，我们应该放弃血压而对高危心血管病者使用他们的魔幻般的polypill药丸治疗即可，该药丸据他们说降低心脏病和卒中90%。本荟萃分析不过是支持该假设的有关文献的一种高级汇编。”
Abandoning blood pressure measuring is like throwing the baby out with the bath water, Elliott said.
Elliott说，放弃血压测量就像把孩子随水泼掉。
Elliott also took issue with the meta-analysis, which he called “old-fashioned.”
Elliott也不同意荟萃分析，他认为是“过时了”。“我认为Wald and Law已经变成了最大的主合派。”
A Meta-Analysis Is Like a Sausage
荟萃分析像香肠
Adding his opinion, Dr Franz Messerli (St Luke’s-Roosevelt Hospital Center, New York City) said that by including 147 trials in their meta-analysis, the authors had to make numerous assumptions, “some possibly valid, others clearly not.”
Dr Franz Messerli认为，荟萃分析147各试验，作者必须做多种假设。“有些可能有效，而另一些则否。”
Because the “blood pressure fall was not reported in patients with a history of coronary heart disease, they estimated this fall from a meta-analysis of blood pressure trials. This is clearly inappropriate since the fall in blood pressure depends on the pretreatment level, and patients with coronary heart disease who often are hypotensive (particularly post MI) will not respond the same way as do patients with hypertension,” he told heartwire.
因为“有冠心病病史者并未报告血压的下降，他们从关于血压试验的荟萃分析中对这种下降进行了估计。这非常不合适，因为血压下降依赖于治疗前水平，常常伴有低血压的冠心病病人（特别是心肌梗塞后）对同样方法的反应不会与高血压病人一样。”
It is little surprise that beta blockers now, all of a sudden, look better than in any other review ever done, Messerli added. “Numerous meta-analyses have clearly demonstrated that beta blockers do not reduce the risk of coronary heart disease in hypertension, despite the fact that they lower blood pressure. Thus, despite its appearance of being bigger and better, this study is yet another example of my dictum: A meta-analysis is like a sausage, only God and the butcher know what goes in it and neither would ever eat any.”
ß阻滞剂较其它制剂目前突显更好效果并不令人吃惊，Messerli说，“一些荟萃分析清楚表明ß阻滞剂并不降低高血压病人冠心病的危险，尽管它确实降低血压。因此，尽管本研究看起来更大更好，但它只不过是我有关声明的另一个样本：荟萃分析就像一个香肠，只有上帝和屠夫知道它内含何物，但决不会去吃它。”
给所有人服降压药
BMJ第19期发表一篇荟萃分析（147个随机试验，958 000人），研究者认为不管血压水平如何，作为一项有助于冠心病和卒中保护的措施，所有人均应给与降压药。
Drs Malcolm R Law and Nicholas Wald.认为，降压药使用指南应被简化，以便所有水平血压的人均可应用降压药。“我们的结果表明了超过某一年龄后每个人均应用降压药的重要性，而不是对每一个人测量血压，然后对某些人进行治疗。”
Law说，不管你血压如何，你将来肯定会从降压中获益。每一个人均会从服用降压药中获益，而不管他们的血压处在所谓“正常范围”。
6年前Law 和Wald即提倡使用一种polypill药丸（包含一种他丁，3种降压药，叶酸和阿司匹林）。如果≥55岁者或存在心血管疾病者坚持服用即能预防心脏病和卒中。
所有抗高血压药均预防冠心病和卒中
荟萃分析表明年龄60-69岁、治疗前舒张压90mmHg;收缩压150mmHg者，三种降压药物半量组合后大约降低冠心病46%，降低卒中62%。一种降压药标准剂量单独应用仅有1/2的疗效。
5种降压药---噻嗪类、beta阻滞剂、ACE抑制剂、血管紧张素受体阻滞剂、钙通道阻滞剂对于预防冠心病和卒中的效应相同，但钙通道阻滞剂对卒中的预防作用较其它4种更好
不管治疗前血压为多少，有或无心血管病者均同等受益，心血管病事件和卒中的下降百分比相同。甚至在舒张压低于70mmHg，收缩压低于110 mmHg者服用降压药冠心病事件也较少，卒中发病率下降。
Law and Wald报道钙通道阻滞剂降低心衰发生率19%，其它种类制剂降低心衰24%。
Dr Richard McManus认为Law and Wald的发现将加剧有关高血压控制的几个方面的争论。“初步来看，这些发现不言而喻支持在不先行血压测量的情况下使用polypill药丸，以便降低可能高危的人群(例如所有超过55岁者)的心血管病危险。”
McManus在写于heartwire的评论中认为，他相信这些发现将强化下列认识：降压治疗应依据危险性大小，而不是血压。
把孩子随水泼掉
在大西洋的彼岸，高血压病专家对Law and Wald的结论并不乐观。
Dr James Elliott对作者提议不必测量血压表示异议。“Professors Wald and Law数年前即发出革命性的倡议，我们应该放弃血压而对高危心血管病者使用他们的魔幻般的polypill药丸治疗即可，该药丸据他们说降低心脏病和卒中90%。本荟萃分析不过是支持该假设的有关文献的一种高级汇编。”
Elliott说，放弃血压测量就像把孩子随水泼掉。
Elliott也不同意荟萃分析，他认为是“过时了”。“我认为Wald and Law已经变成了最大的主合派。”
荟萃分析像香肠
Dr Franz Messerli认为，荟萃分析147个试验，作者必须做多种假设。“有些可能有效，而另一些则否。
因为“有冠心病病史者并未报告血压的下降，他们从关于血压试验的荟萃分析中对这种下降进行了估计。这非常不合适，因为血压下降依赖于治疗前水平，常常伴有低血压的冠心病病人（特别是心肌梗塞后）对同样方法的反应不会与高血压病人一样。”
ß阻滞剂较其它制剂目前突显更好效果并不令人吃惊，Messerli说，“一些荟萃分析清楚表明ß阻滞剂并不降低高血压病人冠心病的危险，尽管它确实降低血压。因此，尽管本研究看起来更大更好，但它只不过是我有关声明的另一个样本：荟萃分析就像一个香肠，只有上帝和屠夫知道它内含何物，但决不会去吃它。”
