International Circulation: The ASCOT-LLA trial demonstrated the significant benefits of adding atorvastatin to hypertension treatment in adults with three or more risk factors for heart disease. For the hypertensive patient with three or more risk factors for heart disease， or hypertension with target organ damage without CVD， what is the most appropriate time to start statin therapy? What is the greatest benefit with combined statin therapy?

    国际循环：ASCOT-LLA 试验证明阿托伐他汀在高血压伴有三个以上心血管危险因素的患者成效显著。对于高血压伴有三个以上心血管危险因素，但不伴有冠心病的患者，开始他汀治疗最合适的时间是什么？他汀治疗最大的优势是什么？

Professor Williams: I think in the ASCOT trial that we did， the issue there was we were trying to find out that if you take high-risk patients whose cholesterol value is not at a level that would normally be treated， simply adding a statin routinely to their treatment in a relatively low dose-atorvastatin 10mg， would that make any difference to outcomes. What we found was a 35-36% reduction in coronary events and a 27% reduction in stroke， even in people with well-controlled blood pressure. The importance of that is to emphasize that you don’t need high cholesterol to benefit from statins， you just need high risk， at least in the hypertensive population. Therefore， what we should be doing is that when we make the decision to treat blood pressure， we should also be considering initiation of statin treatment. The other interesting thing was that when we looked at how rapid that benefit was， within 90 days we were already seeing significant differences in the primary endpoint. It was clear by 90 days. The effects were very rapid. I think what generally happens is people start blood pressure treatment and they think you can come back and we will sort that out and we might put you on something for your cholesterol. The reality is that the two approaches combined are incredibly effective. Calculating the baseline risk of our population and the risk reduction， we saw about a 78% risk reduction by the combination of the most effective blood pressure lowering and statins. That is really impressive and it’s going to have a huge impact on the high-risk population.

    Williams教授： ASCOT研究的目的是尝试了解胆固醇未达到需要治疗水平的高风险患者常规给予相对低剂量的他汀治疗，阿伐他汀10mg，疗效是否会有所不同。结果提示即便是血压控制良好的患者，加用阿托伐他汀10mg，冠心病事件减少35%~36%，脑卒中减少27%。这一发现强调，不单是高胆固醇患者会从他汀治疗中获益，高危高血压患者也可从他汀治疗中获益。因此，我们不但需要治疗高血压本身，也应该开始加用他汀治疗。另一个有趣的现象是当我们观察他汀获益有多快时，我们观察到，90天内已经出现主要终点事件的显著性差异，仅仅90天，获益非常快速。通常人们认为，降压治疗可以使高血压恢复健康，我们应当纠正这种思想，而关注对胆固醇的管理。事实是，降压联合降胆固醇非常有效。我们发现有效的降压加上他汀治疗可以使人群的风险与基线相比降低78%。这一点令人印象深刻，它将会对高风险人群产生巨大的影响。

Professor Shephard: It’s clear that when you discover a patient who has a cardiovascular risk factor problem， the sooner you get that patient onto therapy， the better. There’s no point in waiting until the patient develops a particular profile of risk， or a particular blood pressure， or particular cholesterol level before you start treatment. If they have a total global risk of an event that you think is actionable， you should get them started on treatment right away and that treatment does not necessarily have to target only the risk factor that seems to be the one that is causing the problem， but any management strategy that will lower global risk， whether it be lowering blood pressure or lowering cholesterol， will actually benefit that patient. So， you can have a patient who is hypertensive， perhaps whose hypertension is resistant to intervention， who would benefit from added statin as well.

    Shephard教授: 对于有心血管危险因素的患者，他汀治疗越早越好，无需等到患者出现特征表现，或血压、血胆固醇升至某个特定值。如果你认为他们有心血管事件发病的危险，应立即让他们开始接受治疗，并且该治疗不仅仅针对导致该疾病的可能因素，任何能够降低心血管危险的治疗措施，无论降低血压或降低胆固醇，对患者都是有利的。所以，对单纯降压治疗疗效不佳的高血压患者，加用他汀治疗也会获益。

关注多效药片 提高患者依从性

International Circulation: Currently， hypertension control is less than satisfactory in much of the population and patient compliance is an important cause of this less than satisfactory control of blood pressure. When we consider the management of multiple risk factors for hypertensive patients， how can we effectively improve patient compliance? Does a polypill have more benefits?

    国际循环：目前，很多患者高血压控制得不是很满意，依从性是导致血压控制不满意的主要原因之一。治疗高血压合并多种危险因素的患者时，如何有效提高患者的依从性？多效药片是否更具优势？

Professor Shephard: One of the difficulties of treating patients who have risk of cardiovascular disease is that you can treat multiple risk factors all at one time. That means， in general terms， giving multiple drugs. If you give multiple drugs to a patient， the rate at which that patient will drop out of therapy rises with the increment and number of drugs used. If you could package these drugs into a single pill， you would save the problem of that patient requiring to compartment his day in order to take half a dozen pills over the course of the 16 hours that he is awake. Polypills are a great idea in theory. There is a practical difficulty with polypills， and that is that sometimes it’s very difficult to actually produce a pill that contains multiple drugs， which may interact with each other in an adverse way. So， a polypill with 6 elements in it， which was suggested sometime back， is probably a million miles away， but pills with 2 components are on the market right now and are effective and will minimize the patients’ problems in terms of compliance.

    Shephard教授: 治疗有心血管病危险患者的难点之一是需要同时处理多个危险因素，这意味着患者需要同时服用多种药物。此时，患者退出治疗的风险会随着使用药物的数量增加而增加。如果这些药物被制成一粒药，患者就不必在他醒着的12或16小时内为服用半打药片而忙碌一天。多效药片是一个很好的治疗方法。但制作多效药片存在困难，有时很难真的制成一片药包含多种药物，有可能产生相互作用而发生不良反应。所以，一片包含6种药物的多效药片距离实现还很遥远，但含有2种成分的多效药片在市场上已经有售并且很有效，它将会最大程度减少患者依从性问题。

International Circulation: Do you feel the new data coming out for atorvastatin and amlodipine is encouraging that this combination in a polypill will be helpful?

    国际循环：您认为应用阿托伐他汀和氨氯地平的多效药片是否对患者有帮助？

Professor Shephard: The atorvastatin and amlodipine combination is a particular case in point. There you are dealing with two of the major elements of cardiovascular risk and you are dealing with them by combining effectively these two treatment strategies which makes it a lot easier for the patient to comply. I think that kind of combination where you are looking at the major elements of risk is the one that drug companies should tackling， and amlodipine and atorvastatin is clearly a good combination.

    Shephard教授：阿托伐他汀和氨氯地平的联合应用确实是一个特别的例子。在处理心血管危险的两个主要危险因素时，将降压与降胆固醇两种治疗策略有效结合，这种方法使患者更容易依从。我认为，能够将主要危险因素的治疗方案相结合的药物是制药公司应该研发的，而阿托伐他汀和氨氯地平的联合方案无疑是一<