The 2006 China Chronic Disease Report shows that among the diseases with an increasing mortality trend from 1991 to 2000, the mortality rate of cardiovascular and cerebrovascular diseases is not only high in absolute terms, but also in the “leading position”. Every 12 seconds, one person dies of cardiovascular disease in China. The “China Cardiovascular Disease Report” published in the same year pointed out that the incidence of hypertension in China is extremely serious, with a prevalence rate of 18.8%, and the number of hypertensive patients in China is expected to reach 200 million in 2006, and 10 million new hypertensive patients are added every year.
A large number of epidemiological studies have shown that hypertension is the No. 1 risk factor for cardiovascular and cerebrovascular diseases. A large, prospective cohort study published by Andersson in 1998, which spanned more than 20 years, showed that the mortality rate of coronary heart disease was higher in patients with hypertension than in those without hypertension, even after blood pressure control. Further analysis found that overall mortality was 1.6 times higher in hypertensive patients than in the non-hypertensive population, with a predominant increase in coronary heart disease mortality (20.1% vs. 10.3%). Total mortality and coronary heart disease mortality were similar in the two groups during the first 10 years of the study; however, coronary heart disease mortality increased steeply thereafter, even with good blood pressure control. The authors suggest that this may be because atherosclerosis is already present in hypertensive patients and that blood pressure control alone is an inadequate intervention for atherosclerosis. A recent review of seven hypertension studies published in JAMA noted that intensive blood pressure lowering, compared with standard treatment, failed to reduce the incidence of all-cause mortality, heart attack, stroke, and congestive heart failure.ASCOT-LLA was a multicenter, randomized study in which all enrolled hypertensive patients with a combination of at least three cardiovascular risk factors and total cholesterol ≤6.5 mmol/ L (250 mg/dL). These patients were randomized to atorvastatin 10 mg/day or placebo on the basis of strict blood pressure control with nonfatal myocardial infarction and fatal coronary artery disease as the primary endpoint. The results showed that the addition of atorvastatin to blood pressure lowering reduced LDL-C by 90 mg/dL (2.32 mmol/L) from 133 mg/dL (3.44 mmol/L), and LDL-C decreased by only 5% in the group with antihypertensive drugs alone. Analysis of the primary endpoint found that the addition of atorvastatin to antihypertensive therapy further significantly reduced coronary events by 36% compared with antihypertensive therapy alone (P=0.0005). Because of the significant benefit, the study was closed almost 2 years earlier. Therefore, various hypertension treatment guidelines are beginning to emphasize that hypertension treatment should progress from simple control of blood pressure levels to integrated control of cardiovascular risk factors and anti-atherosclerosis, especially combined antihypertensive and lipid-lowering synergistic therapy to delay or reverse the onset and progression of atherosclerotic lesions, thereby minimizing the overall risk of cardiovascular disease.
In the trend of establishing an anti-atherosclerosis-focused treatment strategy for hypertension, China published the Clinical Guideline Recommendations for Cholesterol Management in Hypertensive Patients in 2010. It is emphasized that hypertensive patients should be risk stratified according to combined risk factors and target organ damage, and different LDL-C target values should be established and statin interventions should be given.
Hypertensive target organ damage is defined as the following 4 items.
1. Left ventricular hypertrophy on ECG or echocardiogram
2, carotid ultrasound showed IMT ≥ 0.9 mm or atherosclerotic plaque
3, serum creatinine is mildly elevated (115-133 umol/L in men, 107-124 umoL/L in women)
4, urinary microalbumin 30 to 300 mg/24 h
Cardiovascular risk factors include.
1, age (male >45 years, female >55 years)
2, smoking
3, dyslipidemia
4, impaired glucose tolerance or fasting glucose 5.6-6.9 mmol/L
5, abdominal obesity (waist circumference: men I>85 cm, women ≥ 80 cm)
6, family history of early onset of cardiovascular disease (first-degree relatives onset age <50 years)
7, high-sensitivity c-reactive protein (hsCRP) ≥ 3 mg / L
8, physical inactivity
According to different situations to determine the lipid intervention goals
1, hypertension combined with coronary artery disease or coronary artery disease and other critical conditions: in addition to lifestyle changes, where there are no contraindications and patients who can tolerate treatment. Regardless of whether the LDL-C level is elevated, intensive treatment with statins should be combined, and the dose should be adjusted gradually according to whether the target value is reached, with LDL-C control daily standard value of 2.1 mmol/L or lower.
2, hypertension combined with ≥ 1 target organ damage, or combined with ≥ 3 cardiovascular risk factors other than elevated blood pressure: In addition to lifestyle changes, all patients without contraindications and who can tolerate treatment, regardless of whether LDL-C levels are elevated, should be combined with statin therapy, LDL-C control target value of 2.6 mmol/L or lower, or in the baseline LDL C level by 30%-40%.
3, hypertension combined with 1-2 cardiovascular risk factors other than elevated blood pressure: In addition to lifestyle changes, patients who are not contraindicated and can tolerate treatment are recommended to combine statin therapy with a target LDL-C control value of 3.4 mmol/L or lower, or a 20%-30% reduction in baseline LDL-C level. .
The Recommendation is highly operational, taking into account the Chinese context. For example, it is not necessary to have a blood cholesterol test result to decide whether to initiate statin therapy, taking into account the clinical situation and risk factors. Chinese patients with hypertension often have low lipid levels, and the addition of “cholesterol reduction margin” as a target value makes lipid-lowering therapy more evidence-based. It is also emphasized that cholesterol management in hypertensive patients should be initiated as early as possible, with long-term adherence and lifelong treatment.