Suzanne Oparil   美国伯明翰亚拉巴马大学医学院
　　<International Circulation>:  Is there a level of blood pressure that leads to better treatment?

　　《国际循环》：有没有一个更适宜治疗的血压阈值？
　　Prof. Oparil:  You could ask another question; is there a level of blood pressure where treatment provides harm?  A level associated with being too aggressive?  This is a big question.  If you look at the current situation of things it is something we are still struggling with.  There are about 75 million hypertensives in the United States defined as having a blood pressure greater than 140/90 mmHg.  If you change that level from what we have now you either treat a lot more people or treat fewer people， and having a higher blood pressure might not be good for people in a way that is not demonstrable.  There is concern.  If the recommendation is to backup then there would be a lot of concern.  It has been shown that over the years more and more people’s blood pressure has been treated， the average blood pressure of the population has gone down， and there are fewer strokes and heart attacks.  There is an association.  It is not the kind of evidence that we can use because there were not studies designed to look at that.

　　Oparil教授： 你可以以另一种形式来提这个问题：血压低于何种阈值，治疗是有害的？将血压限定于某个阈值是否过于激进？这是个很大的问题。倘若从目前的局势来看，这仍是我们正在努力解决的问题。在美国约有75万高血压患者（即血压> 140/90 mmHg）。若改变目前已有的血压阈值，不论是治疗更多人或是更少人，将血压保持在较高阈值水平可能并不利于人们，尽管未见明显的表现方式。值得注意，假若该建议仅是作为备份，那将产生许多影响。这些年来，越来越多的人接受降压治疗，人口的平均血压下降，卒中和心脏病的发生率下降，它们之中存在一种相关性。我们并不能利用这一证据，因为尚无针对这种现象的研究。
　　<International Circulation>:That does not necessarily say that lower than now is better.

　　《国际循环》：这么说来，不能肯定认为将血压阈值降低是更有益的？
　　Prof. Oparil: I’ve heard people say to take lower， to 90 even， or until the patient faints.  That may be not cost effective and dangerous for some people.

　　Oparil教授：  我曾听人建议将阈值降低，甚至降到90或直到患者晕倒。但这样一来，可能没有效果且对某些人造成危害。
　　<International Circulation>:The second question is， when treating how low should you go?  What is the goal for blood pressure?  And the third are there different classes of drugs that have more benefits or more harm than others?  How hard was it to get down to these three questions?

　　《国际循环》：第二个问题是，您认为血压的阈值应该降至多低？目标血压值是多少？第三个问题是，不同的药物之间 是否有的效果更强或危害更大？解决这三个问题有多难？
　　Prof. Oparil: We talked about it for a few weeks through conference calls but there was consensus in the end.

　　Oparil教授：我们已经通过几周的电话会议就上述问题进行讨论，最终达成一致意见。
　　<International Circulation>: Regarding international guidelines， what guidelines are doing a really good job?  Why?

　　《国际循环》：纵观国际上高血压治疗的指导原则，哪项指导原则是真正有效的？为什么？
　　Prof. Oparil: That is hard to say.  They are all good in different ways.  They all have different patient populations and different health systems， so I can’t really say one is good and another isn’t.  The European guidelines， dominated by the Italians， use a lot more personal opinion and meta-analyses.  We probably wouldn’t agree with some of the things they say.  That is not to say that what they are not doing the right thing in the absence of evidence and that the evidence will emerge and they will turn out to be right.  It certainly isn’t my intention to trash anyone’s guidelines， nor JNC-7， nor any previous JNC guidelines.  I was on JNC-7 and JNC-5 expert panels.  The experts coming together know the literature well but this process is more rigorous and goes through everything.  It has other expertise， including nurses and people who are really experts in the evidence-based methodology.  They say that some of these papers everyone likes because they are coauthors on them don’t prove what they say they prove.  For instance， some of the derivatives and post-hoc analysis of studies.  Like a study that was designed to look at one variable but turned out to show something else.  At times it is decided to hone in on that other thing.  This way of doing things is not fair and can be misleading.  The other thing is that people are human.  If people are experts in an area they are inclined to boast that area.  If you did the study there is motivation to hype the study and draw conclusions that are very firm.  The same thing applies to the federal government.  Some of the studies they do the try to force into guidelines because it is they that did them.

　　Oparil教授：这很难回答。它们各有各的优点。他们适用于不同的人群和不同的卫生系统，因此，我不能明确哪条原则好，哪条原则不好。欧洲指导原则主要是意大利人在执行，使用了很多 个人观点和荟萃分析。我们可能不同意他们的某些观点，但是，在没有证据的情况下，不能说他们所做的事是错误的；也有可能出现证据表明他们是正确的。当然，我并不想抨击任一个指导原则，即不是JNC-7，也不是JNC以前的指导原则。我曾是JNC-7和JNC-5专家小组的成员。所有的专家都熟读研究文献，但制定的过程是非常严格且对所有条例均进行了审查，还包括其它专家的评价，如护士和循证医学的方法学专家。他们指出，有些论文大家都喜欢是因为他们是共同作者，但这并不代表他们拥护它，例如，某些研究的事后分析及其后继研究。就像一项研究原来是想考察一个变量，但却得到其它结果。这种处理方式是不公平的，可能会产生误导。值得一提的是，人是利已的，就像某个区域的专家倾向于吹嘘区域性，就像你的研究动机只是炒作这个研究，这样你的研究结果就会很明确。同样的道理也适用于美国联邦政府。他们所进行的一些研究旨在推动指导原则，因为是他们执行这些原则。

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