<International Circulation>: For my next question， in the 2009 version of the European guidelines， they canceled traditional classification of five kinds of antihypertensive drugs to line 1 or 2 in the drug application. Then the drug application should be based on evidence based medical evidence with treatment for individual patients. Dr. Morgan， in the guidelines published this year， is there any changes for the recommendation for the drugs and are there new treatment strategies for common problems?

　　Professor Morgan: It is strange what has happened. Due to the requirement for objective based evidence， they have gone back to saying you could use any of the five drug classes first and they have not ranked them in order. However， when you look at the other pattern， they have 19 different situations with associate conditions， and in many of these， beta blockers are not recommended. Also they indicate you rapidly go to two drug therapy and beta blockers are not apart from diuretics， not associated with combination so if you read it in one way， they have said we cannot decide between the overall on the objective evidence. But when you actually look at what they say to do， in general， using an ACE inhibitor， a diuretic， or a calcium channel block as the first line therapy.

　　Dr. Yan: I agree with Professor Morgan. In my opinion， I feel the new guideline maybe over emphasize the qualities of different kinds of the drugs. Actually I think the five kinds of antihypertensive drugs do have their properties， for example you just mentioned the beta blocker， maybe not so good for the prevention of the stroke， especially for Chinese population. ??

　　Professor Morgan: I absolutely agree. I think this becomes important in China because the reason of beta blockers is being left in because in Europe so many people have coronary artery diseases and in that situation with cardiac disease， beta blockers might have different indication. Going on to combinations， they really have said that combinations in many situations should always include ACE inhibitors or an ARB. Whether that is used with a diuretic or whether that is used with a calcium channel blocking drug， they have not come down firmly. They have not followed the NICE guidelines， which says the combinations of the ACE inhibitors with a calcium channel blocking drug dihydropyridine， I should emphasize， is the best way to go. They in actual fact recommend either a diuretic with an ACE or an ARB or a calcium channel blocker.

　　Dr. Yan: I have noticed that in this new guidelines in the secondary prevention of stroke. The new guidelines still take the 5 kinds of anti hypertensive drugs for the prevention of stroke.

　　Professor Morgan: I do not accept that as a correct theory. My reading of the literature， base on abstracts is probably diuretics and calcium channel blocking drugs and that is because stroke is so more common in the elderly and those drugs work very well in the elderly. ACE inhibitors also work but there are some studies say that calcium channel blocking drugs may be more effective.

　　Dr. Yan: The PROGRESS trial is a combination of diuretics and ACE inhibitors should also be recommended， I think this is in front of beta blocker.

　　Professor Morgan: I have no doubt whatsoever. The PROGRESS study with a diuretic was very clear.

　　《国际循环》：2009年欧洲高血压指南取消了传统的对于降压药物的一二线分类。药物应用应当基于对个体患者治疗的循证医学证据。Morgan教授，在今年发布的指南中，是否有药物推荐方面的改变，以及常见问题的治疗新策略？

　　Prof. Morgan：由于有客观证据的要求，指南说可以首先使用五类药物中任何一种，而且也没有将这些药物排序。然而，指南中共有19种不同的相关情况。在很多情况下β受体阻滞剂都不被推荐。而且指南推荐早期使用双药联合治疗，β受体阻滞剂应当和利尿剂联合使用。从一个方面来看，指南说我们不能在整体的客观证据之间做决定。但是如果去查看指南的具体推荐，总体上来说，ACEI、利尿剂和钙通道阻滞剂是一线治疗。

　　严晓伟教授：我同意Morgan教授的观点。我认为指南应当强调药物的性质。的确，五种降压药都各有特点，例如刚才提到的β受体阻滞剂可能不一定在预防卒中方面表现良好，尤其是对于中国患者。

　　Prof. Morgan：我同意。我认为这在中国非常重要。因为β受体阻滞剂的使用原因被忽略了。在欧洲，很多人患有冠心病，在这种情况下，β受体阻滞剂可能有其他适应证。关于联合用药，指南的确指出许多情况下联合用药都应当包括ACEI或者ARB。是否和利尿剂或者钙通道阻滞剂联用并没有硬性规定。欧洲新指南没有和NICE指南保持一致。NICE指南中指出ACEI和二氢吡啶类钙通道阻滞剂是最佳组合。而本次指南推荐利尿剂和ACEI或ARB或钙通道阻滞剂联合使用。

　　严晓伟教授：我注意到指南中关于卒中二级预防的内容。指南中仍然推荐5类降压药用于卒中预防。

　　Prof. Morgan：我认为这个理论并不正确。我阅读的文献中，利尿剂和钙通道阻滞剂对预防卒中效果最好，因为卒中在老年人中更常见，而这两种药物对老年人效果良好。ACEI也有作用，但是钙通道阻滞剂可能更有效。

　　严晓伟教授：PROGRESS试验联合使用利尿剂和ACEI也证明了这点，我认为优于β受体阻滞剂。

　　Prof. Morgan：我也不怀疑这一点。PROGRESS使用利尿剂的结果非常清楚。