Michael A. Weber:曾任ASH主席，ACCOMPLISH研究执行委员会委员

International Circulation:  As late breaking clinical trials， ACCOMPLISH findings challenge the JNC 7 guidelines， especially in terms of starting with a one drug strategy and the use of diuretics in combination with ACE inhibitors.  Do you think that the results of ACCOMPLISH will change or effect the recommendations of JNC 8?
Prof. Michael A. Weber:  I think there is a good probability that guidelines around the world will be affected by the results of the ACCOMPLISH trial.  We studied high risk hypertensive patients and what was very interesting is that when we use either a diuretic or amlodipine in combination with a blocker of the renin angiotensin system we got very similar blood pressure effects but the patients getting amlodipine in combination with the blocker of the renin angiotensin system had significant fewer major events; fatal or near fatal heart attacks， strokes， the need for revascularization， and other critical endpoints.  So I imagine both in the United States， Europe， and in Asian countries there will now be a strong trend towards recommending the use of amlodipine to be taken in combination with angiotensin receptor blockers or ACE inhibitors. 

《国际循环》： 作为一项最新突破性研究，ACCOMPLISH结果向JNC7指南挑战，特别是由单药开始治疗策略和适用利尿剂联合ACEI。您认为ACCOMPLISH试验结果能否改变JNC8的建议或影响其建议？
Weber教授： 我想世界各地的指南很可能会受ACCOMPLISH试验结果的影响。在我们研究高危高血压患者时，让人很感兴趣的是当我们使用利尿剂或氨氯地平联合一种肾素血管紧张素系统阻滞剂时，虽然可获得很接近的降压疗效，但氨氯地平联合肾素血管紧张素系统阻滞剂组的主要事件、致死性或接近致死性心脏事件、卒中、血运重建率和其他关键终点明显更少。因此，我想美国、欧洲和亚洲各国极有可能推荐氨氯地平与ACEI或ARB联用。

International Circulation:  What should be the status of diuretic being the initial therapy for hypertension?
Prof. Michael A. Weber:  Diuretics as intial therapy for hypertension have had a very mixed success.  They may be useful for a number of patients of African ancestry and maybe in some older people but by and large as single drugs， they have not been highly effective for reducing blood pressure and as we know they may also have some metabolic concerns as well.  Where diuretics seem to fit in best are as low dose adjuncts to other types of therapy where they now bring useful additional blood pressure reduction with only relatively minimal unwanted metabolic effects.  I think diuretics will continue to be useful and certainly for many patients who require more than two drugs， let us say three drugs， then it is easy to argue that these patients will in general be treated with a blocker of the renin angiotensin system， a drug like amlodipine， and one of the thiazide-like diuretics.  So the diuretics will have an important future. 

《国际循环》： 利尿剂作为高血压初始治疗药物的地位会怎样改变？
Weber教授： 利尿剂作为高血压的初始治疗，好坏参半。利尿剂对部分非洲裔患者、老年患者可能有用，但单药使用时，降低血压并非高效，如我们所知，还可能带来代谢方面的问题。利尿剂最适合低剂量时与其他类型的治疗联合使用，这样会使血压进一步降低，并且对代谢的负面影响相对较小。我想，利尿剂仍然有用，并且对许多需2种以上降压药的患者作用肯定，比如三种药物联合，患者一般会选用一种肾素血管紧张素阻滞剂、一种氨氯地平等药物和一种噻嗪类利尿剂。因此，未来利尿剂仍很重要。

International Circulation:  What advice do you give， when and how， combination therapy should begin?
Prof. Michael A. Weber:  It is popular now with recent guidelines to recommend that combination therapy be used relatively early in the management of hypertension particularly in those patients whose baseline blood pressures are a reasonable distance away from the intended blood pressure goal， for instance， 20/10 is seen in the United States as a reason to start treatment with a fixed combination.  So I do see an increase in use of combination treatment， we know that people that start with combination therapy are more likely to obtain blood pressure goals and to do it more quickly.  It may be more cost effective and more likely to give us good results so I do see combination therapy as growing.  It is not for everybody and many physicians would still like to titrate drugs individually and slowly and carefully get to their desired endpoint but never the less for many doctors and many patients combination treatment does seem to be part of the future.

《国际循环》： 您认为初始联合治疗应由什么开始，何时及如何进行？
Weber教授： 当前指南的推荐对高血压管理相对早期的联合治疗仍然适用，特别对那些基础血压与预期血压目标相差不远的患者——如美国将20/10mmHg作为启动固定联合治疗的一个标准。因此，我想联合治疗还会更广泛应用，我们知道开始联合治疗的患者更容易达到目标血压，并且实现得更快，可能更具有费用-获益比，更易获得良好的结果。因此，我认为联合治疗将会增多。并非每个患者和医生都喜欢个体化、缓慢、认真滴定药物，以期达到预期的终点，不过看来许多医生和患者都将会喜欢采用联合治疗。

International Circulation:  We often hear that ‘lower is better’， which is commonly used to describe therapeutic objectives for various cardiovascular markers of risk including blood pressure， lipids， and glucose.  Is aggressive blood pressure lowering needed in stage one hypertension? 
Prof. Michael A. Weber:  Stage one hypertension still represents meaningful risks for patients and since there is so much stage one hypertension to be found， we have to focus on people with stage one hypertension and make sure they are being well treated in order to give optimal protection to those sorts of patients.  I do see that we need to be careful in our treatment of stage one hypertension.  I am not sure if the word aggressive is the correct term but certainly we need to be forceful in making sure we achieve the recommended treatment goals; less than 140/90 and for people who have had any sort of complexity such as kidney diabetes or diabetes， even less than that.

《国际循环》： 我们经常听到“越低越好”，常用来形容控制各种心血管危险因素如血压、血脂和血糖。高血压1期是否也需要“积极降压”？
Weber教授： 1期高血压对患者而言，仍存在有意义的风险，这已在许多1期高血压患者中发现。我们必须关注1期高血压的患者，确保其得到良好治疗，以能实现对患者的最佳保护。我认为我们需要认真治疗1期高血压。我不知道“积极”的正确内涵，但很明显，在确保实现所推荐的治疗目标上，我们必须措施得力，以使血压低于140/90mmHg；对于合并其他复杂疾病如糖尿病肾病或糖尿病的患者，甚至要达到更低血压目标。