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Hypertension treatment and implications of recent cardiovascular outcome trials. 高血压治疗和近期心血管结局试验的意义。
Michael A Weber

Clinical trials have shown that effective control of blood pressure reduces the risk of cardiovascular events in high-risk patients. For example, data from the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) study show significant reductions in the incidence of cardiac events, stroke and all-cause mortality in patients in whom blood pressure control was achieved compared with those in whom blood pressure remained uncontrolled. Although the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) demonstrated no significant difference in cardiovascular mortality and morbidity between patients receiving diuretics, calcium channel blockers or angiotensin-converting enzyme (ACE) inhibitors, this finding might have been confounded by differences in the blood pressure reductions achieved with the three treatments. Other studies have consistently shown that newer antihypertensive agents, such as ACE inhibitors and calcium channel blockers, reduce cardiovascular events to a similar, or possibly greater, extent as older therapies, such as diuretics and beta-blockers. In particular, ACE inhibitors appear to offer additional benefits beyond blood pressure reduction in terms of reducing cardiovascular events and producing renoprotective effects. Angiotensin II receptor blockers (ARBs) have been less extensively studied, but there is evidence already that they have heart failure, stroke and renoprotective benefits. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) is currently comparing the effects of the ARB telmisartan 80 mg and the ACE inhibitor ramipril 10 mg, alone and in combination, on cardiovascular events in high-risk patients.

临床试验表明,有效控制血压可降低高危患者发生心血管事件的风险。例如,缬沙坦抗高血压长期使用评估(VALUE)研究的数据显示,与血压不受控制的患者相比,血压得到控制的患者心脏事件、中风和全因死亡率显著降低。尽管降压降脂治疗预防心脏病发作试验(ALLHAT)显示,接受利尿剂、钙通道阻滞剂或血管紧张素转换酶(ACE)抑制剂治疗的患者在心血管死亡率和发病率方面没有显著差异,但这一发现可能与三种治疗方法在血压降低方面的差异相混淆。其他研究一致表明,新的降压药,如ACE抑制剂和钙通道阻滞剂,减少心血管事件的程度与利尿剂和受体阻滞剂等旧疗法相似,甚至可能更大。特别是,ACE抑制剂在减少心血管事件和产生肾保护作用方面,除了降低血压外,似乎还提供了额外的益处。血管紧张素II受体阻滞剂(ARBs)的研究较少,但已有证据表明它们具有心力衰竭、中风和肾保护作用。正在进行的替米沙坦单用和联合雷米普利全球终点试验(ONTARGET)目前正在比较ARB替米沙坦80mg和ACE抑制剂雷米普利10mg单用和联用对高危患者心血管事件的影响。
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引用次数: 14
Circadian rhythm of blood pressure and the relation to cardiovascular events. 血压的昼夜节律及其与心血管事件的关系。
Thomas D Giles

Incidences of potentially life-threatening cardiovascular events display a diurnal pattern, tending to be higher in the morning than at other times of day. The recording of blood pressure at pre-defined intervals under everyday circumstances is facilitated by ambulatory blood pressure monitoring (ABPM). This technique shows that systolic and diastolic blood pressures display a circadian rhythm in most individuals. Typically, at the end of the night on arousal, blood pressure surges. This surge coincides with increased cardiovascular events. A recent prospective study conducted in Japan, where the incidence of stroke is high, provides further evidence for the link between cardiovascular events and morning blood pressure surge. Prevalence of both silent ischaemic events and multiple cerebrovascular infarcts was highest among the elderly subjects studied, with the largest increase in blood pressure on awakening. An increased risk of cardiovascular morbidity and mortality is also seen in 'non-dippers' (i.e. individuals in whom the normal nocturnal fall in blood pressure is absent or blunted). ABPM is superior to clinic blood pressure in predicting cardiovascular morbidity and mortality, and this suggests that 24-h blood pressure control may be necessary to gain complete benefit from blood pressure-lowering therapy. Antihypertensive agents with a long duration of action have the potential to provide blood pressure control throughout the dosing interval and thus cover the critical early morning period when the blood pressure surges. Clinical studies that have compared telmisartan with shorter-acting angiotensin II receptor blockers and angiotensin-converting enzyme inhibitors demonstrate that telmisartan has a sustained duration of action, with proven efficacy over the entire 24-h period between doses, including the critical early morning period.

潜在危及生命的心血管事件的发生率呈昼夜规律,早晨的发生率往往高于一天中的其他时间。动态血压监测(ABPM)有助于在日常情况下按预先设定的时间间隔记录血压。这项技术表明,大多数人的收缩压和舒张压都有昼夜节律。通常情况下,在夜间觉醒结束时,血压会飙升。这一激增与心血管事件的增加同时发生。最近在中风发病率高的日本进行的一项前瞻性研究为心血管事件和早晨血压飙升之间的联系提供了进一步的证据。无症状性缺血事件和多发性脑血管梗死的发生率在老年受试者中最高,醒来时血压升高幅度最大。在“非降血压者”(即夜间血压没有正常下降或下降迟钝的个体)中也可以看到心血管发病率和死亡率的增加。ABPM在预测心血管疾病发病率和死亡率方面优于临床血压,这表明24小时血压控制可能是获得降压治疗完全益处的必要条件。作用时间长的降压药有可能在整个给药间隔内控制血压,从而覆盖清晨血压飙升的关键时期。将替米沙坦与短效血管紧张素II受体阻滞剂和血管紧张素转换酶抑制剂进行比较的临床研究表明,替米沙坦具有持续的作用时间,在两次给药之间的整个24小时内均有效,包括关键的清晨时段。
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引用次数: 108
Total cardiovascular risk: a new treatment concept. 心血管总风险:一种新的治疗理念。
Giuseppe Mancia

Recognition that cardiovascular risk factors, such as hypertension, dyslipidaemia and diabetes mellitus, often cluster together has focused attention on the concept of total cardiovascular risk. Most current hypertension management guidelines emphasize the importance of assessing and managing the total risk in an individual patient. Due to the presence of additional risk factors, target-organ damage and associated clinical conditions, patients may be at high risk of cardiovascular events even when their blood pressure is normal or high-normal (systolic blood pressure 130-139 mmHg, diastolic blood pressure 80-89 mmHg). Such high-risk patients, although common in clinical practice, are often under-diagnosed. Intensive hypertensive therapy is recommended for high-risk patients. In most cases, this will necessitate combination therapy with two or more drugs. Moreover, antihypertensive therapy should form one component of a multifactorial approach aimed at treating all reversible risk factors. In the future, research should be aimed at controlling or reversing subclinical target-organ damage, the ultimate aim being to prevent the progression of cardiovascular risk in individuals at low or medium risk.

认识到心血管危险因素,如高血压、血脂异常和糖尿病,经常聚集在一起,使人们关注心血管总危险的概念。目前大多数高血压管理指南强调评估和管理个体患者总风险的重要性。由于其他危险因素、靶器官损伤和相关临床条件的存在,即使患者血压正常或高正常(收缩压130- 139mmhg,舒张压80- 89mmhg),心血管事件发生的风险也可能很高。这类高风险患者虽然在临床实践中很常见,但往往未得到充分诊断。高危患者建议强化高血压治疗。在大多数情况下,这将需要两种或两种以上药物的联合治疗。此外,降压治疗应成为旨在治疗所有可逆危险因素的多因素方法的一个组成部分。未来的研究应着眼于控制或逆转亚临床靶器官损伤,最终目的是防止低或中等风险个体心血管风险的恶化。
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引用次数: 31
Early intervention and prevention of myocardial infarction. 心肌梗死的早期干预和预防。
Prem S Pais

Although there has been a decline in the incidence of ischaemic heart disease in Western Europe, North America and Australia/New Zealand, it remains a major cause of morbidity and mortality worldwide due to rapidly increasing incidences in developing countries. Prevention is key to reducing the burden of this disease. The INTERHEART study performed in 52 countries around the world has shown that the major risk factors are tobacco smoking, elevated apolipoprotein A, hypertension, diabetes mellitus, abdominal obesity, psychosocial factors, low fruit and vegetable intake, physical inactivity and alcohol consumption. Strategies for prevention by reducing risk factors are applicable universally. Individual healthcare providers can implement primary and secondary preventive measures to individual patients. Primary prevention involves the avoidance of disease in high-risk subjects free of disease, whereas the purpose of secondary prevention is to avoid recurrence of myocardial infarction. The general principle is to encourage improved and proven lifestyle measures and to prescribe evidence-based effective medications. Primary prevention requires greater investment and planning to identify people at high risk, plus the implementation of life-style intervention and pharmacological prevention. In both situations, strategies will have to be tailored to suit individual countries and economies. Life-style measures (i.e. sensible diet, physical exercise and smoking cessation) are effective and need to be promoted. Compliance with preventive measures is achievable. Primordial prevention, which involves reducing the prevalence of risk factors, rests mainly on public education, media, legislation and government policy, and is very dependent on individual governments' commitment and determination. It requires promoting a healthier life-style in the population as a whole by encouraging people to seek alternatives and making them available.

尽管西欧、北美和澳大利亚/新西兰的缺血性心脏病发病率有所下降,但由于发展中国家的发病率迅速上升,它仍然是全世界发病率和死亡率的主要原因。预防是减轻这种疾病负担的关键。在全球52个国家进行的INTERHEART研究表明,主要风险因素是吸烟、载脂蛋白A升高、高血压、糖尿病、腹部肥胖、社会心理因素、水果和蔬菜摄入量低、缺乏体育活动和饮酒。通过减少危险因素进行预防的战略是普遍适用的。个别医疗保健提供者可针对个别患者实施初级和二级预防措施。一级预防的目的是避免无疾病的高危人群发病,而二级预防的目的是避免心肌梗死复发。总的原则是鼓励改善和证明的生活方式措施,并开出循证有效的药物。初级预防需要更多的投资和规划,以确定高危人群,并实施生活方式干预和药物预防。在这两种情况下,必须调整战略以适应各个国家和经济体。生活方式措施(即合理饮食、体育锻炼和戒烟)是有效的,需要加以推广。遵守预防措施是可以实现的。初级预防涉及减少风险因素的流行,主要依靠公共教育、媒体、立法和政府政策,并在很大程度上取决于各国政府的承诺和决心。它要求在全体人口中提倡一种更健康的生活方式,鼓励人们寻求替代办法并提供这些办法。
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引用次数: 18
Prospects for the prevention of stroke. 预防中风的前景。
Björn Dahlöf

We are currently fighting a battle against a stroke epidemic. Implementation of new treatment strategies could save many patients in the future. The control of blood pressure is a major objective; however, choosing specific antihypertensive therapy (e.g. an agent blocking the renin-angiotensin system) is also important. The Losartan Intervention For Endpoint reduction in hypertension (LIFE) study demonstrates potential benefits beyond blood pressure reduction of prescribing an angiotensin II receptor blocker (ARB) compared with more established therapy in patients with left ventricular hypertrophy (LVH). Losartan-based therapy brought about regression of LVH and reduced incidences of fatal and non-fatal stroke by 25%, new-onset diabetes by 25% and atrial fibrillation by 30% more than atenolol-based therapy for a similar blood pressure control and better tolerability. The Study on COgnition and Prognosis in the Elderly (SCOPE) study, although difficult to interpret, does not contradict an ARB benefit beyond blood pressure lowering in primary prevention linked to targeting the angiotensin type 1 receptor. The findings of the MOrbidity and mortality after Stroke, Eprosartan compared with nitrendipine in Secondary prevention (MOSES) trial suggest clear-cut ARB benefits independent of blood pressure lowering in secondary stroke prevention. Experimental findings and other clinical evidence further support the benefits of ARBs in stroke prevention. Telmisartan is an ARB with a particularly interesting profile for stroke; given the 24-hour efficacy with more pronounced protection against the morning blood pressure surge and peroxisome proliferator-activated receptor-gamma activity at clinical doses. The unique properties of telmisartan for secondary stroke prevention are being tested in the Prevention Regimen For Effectively avoiding Second Strokes (PRoFESS) study.

我们目前正在与中风流行病作斗争。实施新的治疗策略可以在未来挽救许多患者。控制血压是一个主要目标;然而,选择特定的抗高血压疗法(如阻断肾素-血管紧张素系统的药物)也很重要。氯沙坦干预降低高血压终点(LIFE)研究表明,与更成熟的左心室肥厚(LVH)患者的治疗方法相比,处方血管紧张素II受体阻滞剂(ARB)的潜在益处不仅仅是降低血压。与以阿替洛尔为基础的治疗相比,以氯沙坦为基础的治疗使LVH消退,致死性和非致死性卒中发生率降低25%,新发糖尿病发生率降低25%,房颤发生率降低30%,血压控制相似,耐受性更好。老年人认知和预后研究(SCOPE)研究虽然难以解释,但并不与ARB的益处相矛盾,ARB的益处超出了针对血管紧张素1型受体的一级预防降压。卒中后发病率和死亡率,依普沙坦与尼群地平在二级预防(MOSES)试验中的比较结果表明,ARB在二级预防中具有独立于降血压的益处。实验结果和其他临床证据进一步支持arb在卒中预防中的益处。替米沙坦是一种ARB对中风有特别有趣的特征;考虑到24小时的功效,在临床剂量下对早晨血压激增和过氧化物酶体增殖激活受体γ活性有更明显的保护作用。替米沙坦用于二级卒中预防的独特特性正在有效避免二次卒中的预防方案(PRoFESS)研究中进行测试。
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引用次数: 9
Pathophysiological regulation of the AT1-receptor and implications for vascular disease. at1受体的病理生理调节及其对血管疾病的影响。
Sven Wassmann, Georg Nickenig

Background: Numerous studies have demonstrated that activation of the angiotensin II type 1 (AT1) receptor plays an important role in the pathogenesis of cardiovascular diseases.

Results: AT1-receptor activation by angiotensin II is not only involved in the regulation of blood pressure, water and sodium homeostasis, and control of other neurohumoral systems, but also leads to excessive production of reactive oxygen species and to hypertrophy, proliferation, migration, and apoptosis of vascular cells. AT1-receptor-induced oxidative stress may cause nitric oxide inactivation, lipid oxidation, and activation of redox-sensitive genes, such as chemotaxis and adhesion molecules, pro-inflammatory cytokines, and matrix metalloproteinases, all of which are involved in the initiation and progression of endothelial dysfunction and manifested atherosclerosis. The expression levels of the AT1-receptor define the biological efficacy of angiotensin II. Many agonists, such as, for example, angiotensin II, growth factors, low-density lipoprotein cholesterol, insulin, glucose, estrogen, progesterone, reactive oxygen species, cytokines, nitric oxide, and many others, are known to regulate AT1-receptor expression in vascular cells. The pathophysiological relevance of dysregulated AT1-receptor expression has been demonstrated in many cell culture and animal studies and interventional trials in humans. Hypercholesterolemia, estrogen deficiency, and diabetes mellitus are associated with enhanced vascular AT1-receptor expression, increased oxidative stress, and endothelial dysfunction. Importantly, treatment with AT1-receptor blockers may inhibit the onset and progression of vascular oxidative stress and inflammation, endothelial dysfunction, atherosclerosis, and related organ damage.

Conclusion: Inhibition of AT1-receptor activation is presumably a primary treatment goal in patients suffering from cardiovascular risk factors or manifested atherosclerotic diseases.

背景:大量研究表明,血管紧张素II型1 (angiotensin II type 1, AT1)受体的激活在心血管疾病的发病机制中起着重要作用。结果:血管紧张素II激活at1受体,不仅参与血压、水、钠稳态的调节和其他神经体液系统的调控,还可导致活性氧的过量产生和血管细胞的肥大、增殖、迁移和凋亡。at1受体诱导的氧化应激可引起一氧化氮失活、脂质氧化和氧化还原敏感基因的激活,如趋化和粘附分子、促炎细胞因子、基质金属蛋白酶等,这些都参与内皮功能障碍的发生和发展,并表现为动脉粥样硬化。at1受体的表达水平决定了血管紧张素II的生物学功效。许多激动剂,如血管紧张素II、生长因子、低密度脂蛋白胆固醇、胰岛素、葡萄糖、雌激素、黄体酮、活性氧、细胞因子、一氧化氮等,都可以调节血管细胞中at1受体的表达。at1受体表达失调的病理生理学相关性已经在许多细胞培养和动物研究以及人类的介入性试验中得到证实。高胆固醇血症、雌激素缺乏和糖尿病与血管at1受体表达增强、氧化应激增加和内皮功能障碍有关。重要的是,使用at1受体阻滞剂治疗可以抑制血管氧化应激和炎症、内皮功能障碍、动脉粥样硬化和相关器官损伤的发生和进展。结论:抑制at1受体激活可能是患有心血管危险因素或表现为动脉粥样硬化疾病的患者的主要治疗目标。
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引用次数: 112
Angiotensin receptor blockade with candesartan in heart failure: findings from the Candesartan in Heart failure--assessment of reduction in mortality and morbidity (CHARM) programme. 血管紧张素受体阻断坎地沙坦治疗心力衰竭:坎地沙坦治疗心力衰竭的结果——死亡率和发病率降低评估(CHARM)项目
Jan B Ostergren

Background: Randomized clinical trials in patients with chronic heart failure and reduced left ventricular ejection fraction (LVEF) have demonstrated the life-saving and symptomatic benefits of angiotensin-converting enzyme (ACE) inhibitors, beta-blockers, and, in more selected patients, spironolactone. Despite these major advancements, the prevalence of heart failure continues to increase mainly as a consequence of aging populations. The development of angiotensin II type 1 receptor blockers (ARBs) provides a pharmacologically distinct mechanism of inhibiting the renin-angiotensin-aldosterone system. ARBs offer the potential to produce further clinical improvements for patients with heart failure above and beyond ACE inhibitors, as well as an alternative for those intolerant to an ACE inhibitor.

Methods: The Candesartan in Heart failure--Assessment of Reduction in Mortality and morbidity (CHARM) programme was designed as three parallel, randomized, double-blind, placebo-controlled clinical trials comparing candesartan with placebo in three different but complementary populations of patients with symptomatic heart failure.

Results: In patients with intolerance to an ACE inhibitor and an LVEF of 40% or less (the CHARM-Alternative trial), candesartan reduced cardiovascular mortality and hospitalizations for heart failure by 23% (P < 0.001). In patients with an LVEF of 40% or less treated with an ACE inhibitor (the CHARM-Added trial), candesartan reduced cardiovascular death and hospitalization for chronic heart failure by 15% (P = 0.011). In patients with a LVEF greater than 40% (the CHARM-Preserved trial), hospitalizations for heart failure and new-onset diabetes were significantly reduced.

Conclusion: The CHARM programme, together with evidence from mechanistic studies and from other large trials with ARBs, constitutes a firm basis for including an ARB in the therapeutic arsenal in the treatment for chronic heart failure.

背景:慢性心力衰竭和左心室射血分数降低(LVEF)患者的随机临床试验表明,血管紧张素转换酶(ACE)抑制剂、β受体阻滞剂以及在更多选定的患者中使用螺内酯可以挽救生命和缓解症状。尽管取得了这些重大进展,但由于人口老龄化,心力衰竭的患病率仍在继续增加。血管紧张素II型受体阻滞剂(ARBs)的发展提供了一种独特的抑制肾素-血管紧张素-醛固酮系统的药理学机制。arb为ACE抑制剂以外的心力衰竭患者提供了进一步临床改善的潜力,也为ACE抑制剂不耐受的患者提供了一种替代方案。方法:坎地沙坦治疗心力衰竭——降低死亡率和发病率评估(CHARM)项目设计为三个平行、随机、双盲、安慰剂对照临床试验,在三个不同但互补的有症状心力衰竭患者群体中比较坎地沙坦和安慰剂。结果:在对ACE抑制剂不耐受且LVEF为40%或更低的患者(CHARM-Alternative试验)中,坎地沙坦使心血管死亡率和心力衰竭住院率降低23% (P < 0.001)。在接受ACE抑制剂治疗的LVEF为40%或更低的患者中(CHARM-Added试验),坎地沙坦使心血管死亡和慢性心力衰竭住院率降低了15% (P = 0.011)。在LVEF大于40%的患者(CHARM-Preserved试验)中,因心力衰竭和新发糖尿病住院的患者显著减少。结论:CHARM项目,以及来自ARB机制研究和其他大型试验的证据,构成了将ARB纳入慢性心力衰竭治疗药物库的坚实基础。
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引用次数: 8
The Study on COgnition and Prognosis in the Elderly (SCOPE)--recent analyses. 老年人认知与预后的研究(SCOPE)——近期分析。
Peter Trenkwalder

Principal results of the Study on COgnition and Prognosis in the Elderly (SCOPE) were published in 2003. Blood pressure reduction was pronounced in both the candesartan and control groups, with little difference. With candesartan-based treatment, compared with control, the relative risk of non-fatal stroke was 0.72 (P = 0.04) and of major cardiovascular events 0.89 (P = 0.19). There were no significant differences in cognitive outcomes. We have reviewed recent subgroup analyses in SCOPE. Cardiovascular endpoints were analysed in patients who did not receive add-on treatment after random allocation to groups (post hoc) and in patients with certain characteristics at baseline, such as age, sex, diabetes, isolated systolic hypertension, or a history of stroke. Cognitive endpoints were analysed in patients with baseline Mini Mental State Examination (MMSE) score 24-28, and in those examined with more extensive investigations than the MMSE. In patients without add-on treatment, there were significant risk reductions in the candesartan group in major cardiovascular events [relative risk (RR) 0.68, 95% confidence interval (CI) 0.51 to 0.92] and mortality (RR 0.73, 95% CI 0.57 to 0.95). In other subgroups, the relative risks for major cardiovascular events and stroke were generally consistent with those in the entire study population. However, risk reductions in the candesartan group were particularly marked in patients with a history of stroke. In patients with MMSE score 24-28 at baseline, the score declined significantly less in the candesartan group (between-group difference 0.49, 95% CI 0.02 to 0.97). Cardiovascular outcome benefit of candesartan-based treatment was most evident in patients without add-on treatment and in those with a history of stroke. Results in other subgroups were generally consistent with those in the entire SCOPE study population. In patients with slightly low cognitive function at baseline, the MMSE score declined less in the candesartan group.

老年人认知与预后研究(SCOPE)的主要结果发表于2003年。坎地沙坦组和对照组血压均明显降低,差异不大。以坎地沙坦为基础的治疗组与对照组相比,非致死性卒中的相对风险为0.72 (P = 0.04),主要心血管事件的相对风险为0.89 (P = 0.19)。在认知结果上没有显著差异。我们在SCOPE中回顾了最近的亚组分析。在随机分组后(事后)未接受附加治疗的患者,以及在基线时具有某些特征(如年龄、性别、糖尿病、孤立性收缩期高血压或卒中史)的患者中,对心血管终点进行分析。认知终点分析了基线迷你精神状态检查(MMSE)评分为24-28分的患者,以及那些接受了比MMSE更广泛调查的患者。在没有附加治疗的患者中,坎地沙坦组在主要心血管事件[相对危险度(RR) 0.68, 95%可信区间(CI) 0.51至0.92]和死亡率(RR 0.73, 95% CI 0.57至0.95)方面的风险显著降低。在其他亚组中,主要心血管事件和中风的相对风险总体上与整个研究人群一致。然而,坎地沙坦组的风险降低在有中风史的患者中尤为明显。在基线时MMSE评分为24-28的患者中,坎地沙坦组的评分下降明显更少(组间差异0.49,95% CI 0.02至0.97)。以坎地沙坦为基础的治疗在没有附加治疗的患者和有中风史的患者中心血管结局获益最为明显。其他亚组的结果与整个SCOPE研究人群的结果基本一致。在基线时认知功能稍低的患者中,坎地沙坦组的MMSE评分下降较少。
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引用次数: 39
Diabetes, nephropathy, and the renin system. 糖尿病,肾病和肾素系统。
Norman K Hollenberg

Blockade of the renin-angiotensin system has become crucial in the management of type 1 (insulin-dependent) and type 2 (non-insulin-dependent) diabetes mellitus, especially in patients who are at risk of nephropathy. In this review, we address the issue of why the renin system and its blockade are so important. As in many complex processes, diabetic nephropathy reflects an interaction between genetic factors and environmental factors. Recent research has uncovered a number of environmental factors; control of these factors should contribute to improved management. The renin system is important in patients with diabetes mellitus because so many relevant factors converge on the intrarenal renin system.

阻断肾素-血管紧张素系统在1型(胰岛素依赖型)和2型(非胰岛素依赖型)糖尿病的治疗中变得至关重要,特别是在有肾病风险的患者中。在这篇综述中,我们讨论了肾素系统及其阻断如此重要的原因。在许多复杂的过程中,糖尿病肾病反映了遗传因素和环境因素之间的相互作用。最近的研究发现了一些环境因素;控制这些因素应该有助于改进管理。肾素系统在糖尿病患者中非常重要,因为许多相关因素都集中在肾内肾素系统上。
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引用次数: 16
Vascular and metabolic effects of candesartan: insights from therapeutic interventions. 坎地沙坦对血管和代谢的影响:来自治疗干预的见解。
Kwang Kon Koh, Michael J Quon, Seung Hwan Han, Wook-Jin Chung, Jeong-A Kim, Eak Kyun Shin

Background: Effects of angiotensin II type 1 receptor blockers (ARBs) to improve endothelial dysfunction may be due to mechanisms in addition to the reduction of high blood pressure per se. Endothelial dysfunction is characterized by vascular inflammation that contributes to clinically significant atherosclerosis and by an increased tendency for thrombus formation. Hypertensive patients have impaired endothelial functions that have positive predictive power with respect to future cardiovascular events.

Objectives: The present review will focus on multiple mechanisms underlying vascular and metabolic effects of ARBs that may synergize to prevent or regress atherosclerosis, onset of diabetes, and coronary heart disease.

Conclusions: Angiotensin II accelerates the development of atherosclerosis by activating angiotensin II type 1 receptors that then promote superoxide anion generation and oxidative stress, leading to activation of nuclear transcription factor and endothelial dysfunction. Activation of angiotensin II type 1 receptors also stimulates increased expression of plasminogen activator inhibitor type 1 and tissue factor. Endothelial dysfunction associated with the metabolic syndrome and other insulin-resistant states is characterized by impaired insulin-stimulated production of nitric oxide from the endothelium and decreased blood flow to skeletal muscle. Increasing insulin sensitivity therefore improves endothelial function, and this may be an additional mechanism whereby ARBs decrease the incidence of coronary heart disease and the onset of diabetes. Adiponectin serves to link obesity with insulin resistance. In addition, adiponectin has anti-atherogenic properties.

背景:血管紧张素II型1受体阻滞剂(ARBs)改善内皮功能障碍的作用可能是由于除了降低高血压本身之外的机制。内皮功能障碍的特征是血管炎症,可导致临床上显著的动脉粥样硬化,并增加血栓形成的倾向。高血压患者内皮功能受损,对未来心血管事件有积极的预测作用。目的:本综述将聚焦于arb的血管和代谢作用的多种机制,这些机制可能协同预防或逆转动脉粥样硬化、糖尿病和冠心病的发生。结论:血管紧张素II通过激活血管紧张素II型1受体加速动脉粥样硬化的发展,从而促进超氧阴离子的产生和氧化应激,导致核转录因子的激活和内皮功能障碍。血管紧张素II型1受体的激活也刺激纤溶酶原激活物抑制剂1型和组织因子的表达增加。与代谢综合征和其他胰岛素抵抗状态相关的内皮功能障碍的特征是胰岛素刺激内皮产生一氧化氮受损和骨骼肌血流量减少。因此,增加胰岛素敏感性可改善内皮功能,这可能是arb降低冠心病发病率和糖尿病发病的另一种机制。脂联素将肥胖与胰岛素抵抗联系起来。此外,脂联素具有抗动脉粥样硬化的特性。
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引用次数: 23
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Journal of hypertension. Supplement : official journal of the International Society of Hypertension
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