In clinical work, we often encounter patients who ask this question: How should I use so many antihypertensive drugs? Not only patients do not know how to use, some non-specialist doctors may not know the rational use of antihypertensive drugs. An elderly patient came back for review after the Chinese New Year and complained that his blood pressure was particularly high during and after the Chinese New Year and could not be controlled no matter what. This old man is less than 70 years old, hypertension for more than 20 years, the last two years the blood pressure is maintained at about 180 mmHg, a little excitement to 200 mmHg. Last year, due to double lower limb edema, blood creatinine elevation hospitalization, diagnosed as hypertensive nephropathy, chronic renal failure, renal hypertension, renal anemia. Amlodipine benzenesulfonate + candesartan + hydrochlorothiazide combination of antihypertensive treatment, as well as correction of anemia, renal preservation and other treatments, the blood pressure gradually dropped to 140/90 mmHg below, and observation for a few days is very stable, good discharge. After returning home, he ran out of the medication he had brought with him from the hospital and went to a nearby clinic to get a prescription. The doctor at the clinic told him that he could not use “Sartan” anymore because of kidney failure, so he was given nifedipine controlled-release tablets. After two days, his blood pressure started to rise gradually, with a high pressure of 160~180 mmHg. He went to see the doctor again, who prescribed him nifedipine tablets and told him to take one tablet if he was high, but in less than half a day, his blood pressure went up again, and might be higher. So for a few days, it felt very hard on his head. Because of the Chinese New Year, it is not convenient to come to the hospital to see the doctor, so it has been until after the holiday work to come to the clinic. The patient was hypertensive caused by renal disease, renal disease caused renal hypertension, primary hypertension and secondary hypertension entangled together, it is very difficult to control, often need more than 3 antihypertensive drugs, and to use large doses. His elevated and fluctuating blood pressure after being discharged from the hospital was a result of irrational use of medication. Then how exactly to choose antihypertensive drugs? At present, clinically used antihypertensive drugs are roughly divided into six categories, and a new class of drugs is invented almost 10 years. According to the time of listing, antihypertensive drugs are divided into: First, α-blocker 1940s listing, the representative drug for terazosin. By blocking the adrenergic α-receptor, it directly dilates blood vessels and lowers blood pressure. The antihypertensive effect is relatively strong, but the decline in blood pressure reflexively causes an increase in heart rate, which induces angina pectoris in individual patients. The biggest side effect is postural hypotension (hypotension or even collapse when changing positions such as lying down or squatting and suddenly standing up). Because of its side effects, it is not used as the first-line antihypertensive drug in clinical practice and is seldom used. But for renal hypertension and other refractory hypertension, can also be used. Second, diuretics 1950s on the market, representing the drug hydrochlorothiazide. Diuretics are roughly divided into 4 kinds: 1, thiazides: representative drug hydrochlorothiazide; 2, tabular diuretics: furosemide, torasemide, etc.; 3, aldosterone antagonists: also known as potassium-preserving diuretics, representative drug spironolactone; 4, osmotic diuretics: mannitol. Excessive sodium intake is a major cause of hypertension, and excessive sodium in the body inhibits the efficacy of certain antihypertensive drugs. Diuretics for hypertension are not for urination, but for sodium elimination. Diuretics are the basic medication for antihypertensive treatment and can be used in combination with almost any other antihypertensive medication. 1, hydrochlorothiazide’s diuretic effect is slower, but the effect of sodium excretion is not bad, so it is the first choice of antihypertensive diuretics. The dosage of hydrochlorothiazide is 12.5 mg~25 mg (half tablet~1 tablet) per day. If the dosage is increased, the antihypertensive effect is not increased, but the risk of hypokalemia will be increased. Some ARB antihypertensive drugs such as Irbesartan Hydrochlorothiazide Tablets and Valsartan Hydrochlorothiazide Tablets are made by adding 12.5 mg of Hydrochlorothiazide Tablets to increase the antihypertensive effect. 2, the second type of tabs diuretic diuretic effect is very strong, used for severe edema, heart failure, etc. Diuretic treatment, often cause hypokalemia, so generally not used for antihypertensive treatment. 3, the third diuretic spironolactone’s diuretic effect is also relatively slow, is aldosteronism caused by secondary hypertension of special treatment drugs. Because it reduces the excretion of potassium, it can offset the low blood potassium caused by other diuretics, often used in combination with thiazide diuretics, which can increase the effect of diuresis, but also to avoid blood potassium disorders. Long-term use alone may cause hyperkalemia. Note: spironolactone can cause gynecological tendencies such as gynecomastia, so it should be used with caution in young male hypertensive patients. 4, The fourth osmotic diuretic cannot be used for antihypertensive treatment. 5, In addition, indapamide tablets are also a kind of diuretic, lowering blood pressure by excreting sodium and relieving vasospasm. Note: Diuretics can interfere with the excretion of uric acid and thus can induce gouty attacks. Third, beta-blockers 1960s marketed, representative drug metoprolol. Adrenergic receptors are divided into 3 types, i.e. β1 receptor, β2 receptor and β3 receptor. β1 receptor is mainly distributed in cardiac muscle, and agitation can cause heart rate to increase and cardiac muscle contraction force to increase; β2 receptor is distributed in the bronchial tube, and agitation can cause bronchial dilatation; β3 receptor is mainly distributed in the adipocytes, and agitation can cause lipolysis. β Receptor blockers are to block the above mentioned effects, and cause effects contrary to agitation, such as slowing down of heart rate, and increase of blood pressure, which can cause gout attacks. β-blockers block these effects, causing the opposite of agonism, such as slowing the heart rate, decreasing myocardial contractility, and bronchospasm. Beta-blockers are currently divided into three generations: 1. First generation, non-selective beta-blockers. This class of drugs unselectively block the three receptors, not only cause heart rate slowing, blood pressure drop, but also cause bronchospasm, induced asthma, but also interferes with glucose metabolism, resulting in elevated blood glucose. The ability to lower blood pressure is not strong, but there are many side effects, so this class of drugs has basically been eliminated. 2, the second generation, selective blockade of β1 receptors, representative of the drug for metoprolol, and other atenolol, bisoprolol and so on. It can reduce blood pressure, slow down the heart rate, and has no effect on the airways and blood sugar. It is the main force of β-blockers at present, and can be preferred. 3, the third generation, is also non-selective β-blocker, but added α-blocker, antagonizing the side effects of the first generation of drugs, and better antihypertensive effect, is a rising star in the class of drugs β-blocker. The representative drugs are Aroclor and Carvedilol. Beta-blockers have an additional protective effect on the heart, and are preferred for hypertension, which is mainly characterized by high diastolic blood pressure (low blood pressure). In addition, they may be preferred for hypertension caused by anxiety disorders, as well as hypertension in which psychiatric factors play a major role. The absolute contraindication to beta-blockers is atrioventricular block of degree II or higher. Calcium channel blocker 1970s market, also called calcium antagonist, because of this kind of drugs in the name of the drug have the word “diphenhydramine”, so commonly known as diphenhydramine class, the representative drug amlodipine. Amlodipine, the representative drug, directly dilates blood vessels and lowers blood pressure by blocking calcium channels on the cell membranes of cardiac muscle and smooth muscle cells of blood vessel walls. CCB is a large family, with many members of different “genders, ages, and personalities”. To summarize, it is currently divided into three generations. The first generation: the representative drug nifedipine. This type of drug has a fast onset of action and a short duration of efficacy, and needs to be taken three times a day. After taking the drug, the blood pressure will be lowered very quickly, but due to the rapid expansion of blood vessels, patients often feel headache and dizziness, redness and rapid heartbeat. Nifedipine is difficult to stabilize blood pressure even if it is taken three times a day due to its rapid onset of action and rapid expiration. Moreover, long-term use of nifedipine alone to lower blood pressure is prone to cause sudden death, so nifedipine has been banned for long-term antihypertensive use. It is now mostly used for temporary antihypertensive use in malignant hypertension and exceptionally high blood pressure, but it is now considered to be unsafe even in this way, so it should be avoided as much as possible. Second generation: In order to overcome the shortcomings of nifedipine, some pharmaceutical companies have put nifedipine in a special coat to prolong the release of the drug to achieve a longer duration of action and fewer side effects. This is the second generation of the drug, including nifedipine controlled release tablets, nifedipine extended release tablets. It is taken 1 to 2 times a day. The side effects of sudden death are gone, but side effects such as redness of the face and ears are still present, and long-term use can also result in gingival hyperplasia and mild edema of the lower extremities. Such drugs can not be broken in half to take. The third generation: the representative drug amlodipine, with a half-life of 35 to 50 hours, is the longest maintenance time of all the current antihypertensive drugs. Therefore, there is no need for slow or controlled release, it can be taken once a day, and it controls blood pressure smoothly for 24 hours. Its absorption and efficacy are not affected by the patient’s gastrointestinal function or food, and it can also be taken with most medications, as well as broken in half. In addition, due to its long duration of action, patients who occasionally miss a dose will not cause an increase in blood pressure. Therefore, it is the most commonly used CCB, and is also one of the most commonly used antihypertensive drugs. V. Angiotensin converting enzyme inhibitors 1980s marketed. Because of this kind of drugs have the word “Puli” in the drug name, so it is commonly called Puli class, the representative drug Benadryl, Fosinopril, and other captopril, enalapril, lynopril, ramipril, perindopril, etc. Angiotensin II is a kind of strong blood pressure inhibitor, so it is the most commonly used CCB. Angiotensin II is a strong vasoconstrictor and is one of the “main characters” that cause high blood pressure. ACEI can lower blood pressure by inhibiting the production of angiotensin II. In addition, ACEI can dilate the small glomerular arteries and inhibit angiotensin II in renal tissues. Therefore, in addition to lowering blood pressure, ACEI has two other independent effects: lowering urinary proteins and slowing down renal damage (renal preservation). Because of these two effects, ACEIs are the drug of choice for hypertension in patients with kidney disease and diabetes. Side effects of ACEIs include dry cough, elevated blood potassium, and elevated blood creatinine. The incidence of dry cough is particularly high in East Asians, and some people often have to stop taking their medication because of dry cough. This is the reason why this type of drug was very popular at the beginning of the market and then gradually fell out of favor. The incidence of elevated blood potassium and elevated blood creatinine is not high, but when it happens it is more dangerous, so it is more of a concern. Angiotensin receptor blockers were introduced in the 1990s. Because of this kind of drugs in the name of the drug have “sartan” two words, so commonly known as sartan class, representative of the drug valsartan, candesartan, irbesartan, and other chlorosartan, timosartan, olmesartan and so on. This class of drugs is the latest listed antihypertensive drugs, it can be said that each is a fine product. They also target angiotensin II, so the hypertension guidelines are all about comparing the two and using either one. However, the difference between the two is that ACEIs inhibit the production of angiotensin II, while ARBs block the action of angiotensin II as a way to lower blood pressure. Like ACEI, ARB also has the three main effects of lowering blood pressure, lowering urinary protein, and preserving kidneys, and the indications are the same as those of ACEI, but ARB is much safer than ACEI, with no side effects of dry cough, and much milder side effects of elevated potassium and creatinine in the blood. So it makes sense that ARBs are gradually replacing ACEIs. Initially, it was thought that ACEIs could not be used if blood creatinine was >265 umol/L and ARBs could not be used if blood creatinine was >350 umol/L, and it was even mistakenly believed that both types of drugs could not be used as long as blood creatinine was elevated. This is the reason why the community doctor at the beginning of the story told the patient to stop using candesartan. A great deal of information has since confirmed that these fears were unwarranted. Blood creatinine values are no longer contraindicated, but it is important to monitor changes in blood creatinine and to reduce the dosage if the blood creatinine rises >30% during use, and to discontinue the drug if the rise is >50%. Other conditions, such as blood potassium > 5.5 mmol / L, or pregnant women, or bilateral renal artery stenosis, can not use ACEI and ARB. In addition, ACEI and ARB can not be used in combination. Summarize I. Highest state of blood pressure control 1. Smooth blood pressure lowering: It means that the blood pressure should be lowered smoothly, and the blood pressure should not be allowed to fluctuate. Only long-acting drugs have this effect, so it is necessary to use long-acting drugs to lower blood pressure; 2, control up to the standard: the average person’s blood pressure down to 140/90 mmHg or less, nephropathy, diabetes, etc. down to 130/80 mmHg or less to be called up to the standard. If the standard is not reached, complications will be difficult to control; 3, organ protection: for the treatment of hypertension, it is not enough just to lower the blood pressure, but also to protect the heart, brain, kidneys and other important organs to avoid complications. It is generally believed that CCB, ACEI, ARB and β-blockers have organ-protective effects. Second, several principles of antihypertensive drug use 1, individualized medication: can not friends, neighbors, in-laws with what drugs are good, you choose what drugs. According to each person’s physical condition and medical condition, the use of antihypertensive drugs should be selected under the guidance of the doctor; 2, choose long-acting drugs: the third generation of CCB, ACEI, ARB are long-acting drugs. Long-acting drugs are simple to use, once a day medication can be used, not easy to miss the phenomenon, so patients are more likely to accept. Moreover, long-acting drugs have a long duration of efficacy and can maintain stable blood pressure control. 3.Combination of drugs: Unless early hypertension single drug, generally advocate the joint use of 2~3 antihypertensive drugs. The side effects are small and the curative effect is good. If a drug blood pressure control is not good, should be added varieties do not increase the amount of a flavor of the increase in the amount of efficacy may not increase how much, but the side effects have increased significantly; 4, take medication on time: the maintenance time of the drug are fixed, take medication on time to enable the concentration of drugs in the blood to remain stable, of course, the blood pressure can also remain stable. Do not take medication on demand – take medication when your blood pressure is high, and do not eat when your blood pressure is normal. If this is the case, blood pressure is always in fluctuation, and complications mostly occur when blood pressure fluctuates.