An event that changed the history of medicine On April 12, 1945, two months after the end of World War II and the Yalta Conference, U.S. President Roosevelt suffered a cerebral hemorrhage and died after an ineffective resuscitation. Before his death, Roosevelt had been considered healthy and energetic, and his family doctors were optimistic about his health. The sudden death of the president was a “shock” that raised huge questions about his so-called “health,” prompting doctors to explore what had caused the president’s brain hemorrhage. In 1953, Stalin, the General Secretary of the Communist Party of the Soviet Union, also died of a cerebral hemorrhage due to high blood pressure. The death of this great man shocked the world and caused a great deal of concern about hypertension, and it was only then that people began to realize that hypertension can be fatal if left untreated. Because before that, it was widely believed that hypertension was a natural physiological phenomenon and a benign disease that could be cured by itself, doctors did not advocate active antihypertensive treatment, and at that time recommended a therapy called “Kempner diet”, which means eating boiled rice and fruits alone, prohibiting meat and eggs, consuming a small amount of salt, and strictly limiting drinking water. This is a very cruel treatment for a person who works and studies normally, which is equivalent to the “raw eggplant therapy”, “raw soybean juice therapy” and the “Nahna diet” that some “miracle doctors” boasted about some years ago. The “natto therapy”, which is still popular, is a replica of Kempner’s diet, and is undesirable at the expense of one’s quality of life and normal needs. For severe hypertension, surgical treatment, i.e. cutting off the sympathetic nerves in the chest, abdomen and pelvis, is an extremely risky operation that can lead to paraplegia and loss of ability to live. Second, the history of hypertension treatment from the 1950s, the medical profession began to pay attention to the treatment of hypertension, because hypertensive events are increasingly common, and hypertension caused by stroke, coronary heart disease is also increasingly common. early 1950s, the American pharmacologist Carl Beyer, invented the first safe and effective treatment. Beyer, invented the first safe and effective antihypertensive drug – chlorothiazide, which only made the treatment of hypertension a realistic and feasible thing, an epoch-making event that made it possible for hypertensive patients to effectively control their blood pressure in the long term. The above understanding of hypertension changed the history of medicine. For thousands of years, people had thought that only physical discomfort was a disease, and research on hypertension has made it known that some diseases are silent killers, such as diabetes, hyperlipidemia, obesity, and early stages of cancer, and we need to take the initiative to detect them. In fact, before the 1980s, there were few drugs that could be applied due to conditions, and various treatment options were not sufficient to control blood pressure and make it normal. The means to evaluate hypertension were equally limited, relying mainly on simple methods such as occasional blood pressure measurements, electrocardiograms, and urinary routines, so research on the relationship between hypertension and cardiovascular, renal, and other complications was very slow. Since the knowledge of hypertension is limited to increased blood volume and sympathetic excitation, high-dose thiazide diuretics, such as hydrochlorothiazide tablets at doses of 50 mg or more per day, and the non-selective beta-blocker ponerol, are advocated, and although effective in some hypertension, side effects are exposed, such as causing abnormal glucose tolerance, insulin resistance, induction of de novo diabetes, severe electrolyte disorders, making the blood sugar of diabetic patients become uncontrollable, and also causing abnormal lipid metabolism and increased hyperlipidemia, which in turn limited its application. It was not until the late 1970s and early 1980s that renin angiotensin converting enzyme inhibitors (ACEI), calcium antagonists (CCB), and highly selective β-blockers were introduced and used in the treatment of hypertension, and the spring in the field of hypertension really arrived. In 1977, experts and scholars in the field of hypertension in the United States published the world’s first comprehensive guidelines for the prevention, detection, evaluation and treatment of hypertension, called JNCI. III. The early guidelines set strict blood pressure target values for hypertension and complications, and set ideal blood pressure, normal blood pressure, and high blood pressure levels to be achieved, and the specific antihypertensive drugs to be used, such as what to choose first and what to choose second. The individualized treatment plan is easier to operate and implement in clinical practice, so that the majority of patients and friends really benefit. Is the lower the better for antihypertensive treatment? Evidence-based review Stewart found in his clinical work that the risk of myocardial infarction increased fivefold when the diastolic blood pressure of hypertensive patients fell below 90 mmHg. Studies have shown that a too-low drop in blood pressure can affect blood perfusion to the heart and cause ischemic damage to the myocardium, so Stewart first proposed in 1979 that there is a “In 1987, the famous Dr. Craickshank also found in a group of comparative studies of hypertension that the lowest cardiovascular death rate was observed when the diastolic blood pressure was maintained at 85-90 mmHg, and the death rate was on the rise when the diastolic blood pressure was less than 85 mmHg or higher than 90 mmHg, which once again This is another proof of the “J-shaped curve” in the treatment of hypertension. The “J-shaped curve” in clinical practice has attracted widespread attention and lively discussions about its practical significance and value. In the late 1980s and early 1990s, evidence-based medicine was in full swing and rapidly spreading around the world, and any new theory had to be validated by evidence-based medicine. In the SHEP study, cardiovascular adverse events increased in the treated group with diastolic blood pressure below 60 mmHg, and the risk of stroke increased by 14% in 1736 hypertensive patients with a mean blood pressure of 177/77 mmHg who received aggressive antihypertensive therapy to reduce diastolic blood pressure by more than 5 mmHg. The INVEST study is a large, multicenter, prospective clinical trial of hypertension combined with coronary artery disease, with a total of 22,576 patients participating in the trial study. The American Heart Association announced the results of the INVEST study at the 2004 American Medical Congress, which showed that excessive reduction of both systolic and diastolic blood pressure increased the incidence of coronary heart disease events and that there was a “J-shaped curve” for both systolic and diastolic blood pressure in antihypertensive treatment. However, the above tests did not fully explain whether the “J-shaped curve” existed in all hypertensive patients, and in response to this controversial issue, a larger study of optimal treatment of hypertension, the HOT study, was conducted in 1998, led by Mansson. The purpose of this trial was to look at the correlation between different blood pressure levels and major cardiovascular events by setting different target blood pressures in the treatment of hypertension. ), comparing the incidence of cardiovascular disease in the 3 groups. The actual diastolic blood pressure in the three groups was 85.2 mmHg, 83.2 mmHg, and 81.1 mmHg, respectively, resulting in the most significant decrease in major cardiovascular events at a mean blood pressure of 138.5/82.7 mmHg, and no increase in major cardiovascular events below this level. However, it was difficult to conclusively determine whether a J-shaped curve existed because the blood pressure levels after antihypertensive treatment in these 3 groups were too close to each other without significant differences. Then there are also a large number of clinical studies that do not support a J-shaped curve. For example, the Prevention of Recurrent Stroke with Antihypertensive Therapy Study (PROGRESS), a multicenter, randomized, placebo-controlled study with 172 clinical centers in 10 countries, enrolled 6105 patients who had had a transient ischemic attack or stroke, some with hypertension and some with normal blood pressure, and observed them for 4 years, showing a 28% reduction in the risk of recurrent stroke in the treatment group. Further analysis showed that the risk of recurrent stroke was reduced by 28% in the treatment group, and further analysis revealed that the risk of recurrent stroke was reduced by 43% when the blood pressure was lowered to 132/79 mmHg compared with 141/83 mmHg. We cannot follow the evidence-based medical conclusions blindly. The age, underlying disease, and drug selection of the enrolled cases are all things we need to understand carefully, and the older we are, the more likely we are to have a positive result. The risk of cardiovascular disease is greater in elderly patients, just like an engine that has been used for many years, overloaded or running for a long time, it may strike at any time, and if it has to be repaired, most of the time it will be a major replacement of parts or do scrap treatment, can you say that the repairman is poor or give you broken? The same disease enrolled in a comparative study of older people over 60 years old and young people at 40 years old may get completely different conclusions. But to get the same results for cardiovascular accidents, the 40 year old age group may need to be observed for 10-20 years or even longer, and no government or corporation has the funds and time to do such studies. Therefore, we should not just tout the findings of large clinical studies, let alone follow them blindly, but should make a prudent scientific assessment with a rational eye. No study can be perfect, and the true scientific attitude is to remove the bad and extract the good, and to remove the false and keep the true. The emphasis on lowering blood pressure is only part of the evidence in clinical studies of hypertension, and cannot be extended to all hypertensive patients. It is certainly not a scientific attitude to over-emphasize guidelines and to use the same target blood pressure value for all people regardless of age, duration of disease, or concomitant diseases, and practice has shown that excessive lowering of blood pressure, lipids, and blood glucose is detrimental. Therefore, individualized treatment needs to take into account the patient’s age, weight, disease duration, condition, occupation, family history, and many other aspects. In 2013, the European Society of Cardiology (ESC)/European Society of Hypertension (ESH), Canada and other countries’ guidelines pointed out that the target blood pressure for hypertensive patients younger than 80 years old is less than 140/90 mmHg, and the target blood pressure for older adults older than or equal to 80 years old is set at 150/90 mmHg. The 2014 US guidelines for adult hypertension (JNC 8) recommend a blood pressure target of 150/90 mmHg for hypertensive patients older than 60 years, and the five randomized controlled studies he relied on, namely SHEP, Syst-Enr, HYVET,JATOS and VALISH, had the lowest incidence of major cardiovascular events when systolic blood pressure was controlled at 140-150 mmHg lowest. As the risk of renal and cardiovascular and atherosclerosis increases with age in the elderly, it is more meaningful to ensure effective blood perfusion to all organs than to simply set a rigid target value. JNC 8, ESC/ESH, American Diabetes Association (ADA), and European Society of Anesthesiology (ESA) guidelines have all revised the systolic blood pressure target for hypertensive patients with diabetes upward from less than 130 mmHg to 140 mmHg. This conclusion comes from several recent large clinical studies, particularly the ACCORD study, which found that systolic blood pressure controlled at less than The results of this study found that diabetic patients with systolic blood pressure control below 120 mmHg had increased cardiovascular mortality and all-cause mortality, while those with systolic blood pressure above 133 mmHg had reduced cardiovascular mortality, so the lower the diabetic blood pressure control, the better. Fourth, individualized antihypertensive treatment strategy Medicine can not be considered a purely scientific category, there are social, humanistic, economic and other factors, and sometimes need philosophical thinking, a specific patient should be dialectical, if he (she) is a simple hypertensive young patients, no other comorbidities, 10-20 years may not have cardiovascular events, blood pressure lowered a little on his prognosis may not produce If an elderly patient has hypertension combined with multiple diseases, especially diabetes, stroke, coronary heart disease, etc., then he is a high-risk patient and may have a cardiovascular event at any time, and a poorly managed blood pressure that drops too low will affect the perfusion of the heart, kidneys and other important organs and accelerate the occurrence of adverse prognosis, so a J-shaped curve definitely exists in this part of the patient. Our ancestors proposed thousands of years ago that everything has a degree, and overkill or excess will break the balance of the human body. Chinese medicine believes that the balance of yin and yang is the basis for us not to get sick, and that yin and yang is the best state of peace for the human body. Once yin and yang are out of balance, disease is born. Therefore, a dogmatic and mechanical understanding of the guidelines, excessive lowering of blood pressure, including excessive lowering of sugar and excessive lowering of lipids are all causes of the imbalance, which in turn increases the rate of death and illness. For the elderly or patients with more comorbidities, the clinical concept of dialectical thinking should be used to formulate treatment plans. The prescriptions should be based on the Chinese medicine rules of ruler, minister, adjuvant and ambassador, and the main contradiction should be seized. Evidence-based medicine sometimes does not apply to all patients, and overly based on evidence-based medicine, causing some doctors to mechanically copy the recommended drugs for each disease according to A, B, C, D, E, etc., which makes some elderly patients take dozens of drugs for a long time, resulting in long-term overload of liver and kidneys and other organs, and even functional insufficiency. Evidence-based medicine is the greatest progress in the history of medicine, which has broadened our horizons and re-evaluated whether the treatment means we take are useful or useless, whether they are harmful, whether they help prognosis, and what the adverse effects are, and has a great guiding effect on our treatment activities. When the guidelines are appropriate, the antihypertensive regimen should be developed in accordance with the guidelines.