| 摘要: | 背景 WHO/ISH高血壓最新治療指引認為；除某些特定適應症外，六大類降壓藥均可作為高血壓治療第一線用藥。然而，如何根據臨床症狀選擇最有效的降壓藥，目前仍無研究。 目的 我們嘗試利用傳統醫學之辨證分型，對原發性高血壓患者比較其胰島素阻抗、左心室心肌質量、血液動力學和左心室舒張功能之差異，同時觀察其對Angiotension II blocker治療之療效。 方法 2001年12月到2003年1月期間在高雄市健仁醫院心臟科就診之原發性高血壓病患者，年齡30-80歲，從未接受治療，或近三個月未服用過降血壓藥物者，均被納入此一研究。依傳統中醫學證型分為陽亢型與痰濕壅盛型，測定胰島素與C-peptide濃度，所有病人一律接受心臟超音波之檢查。病人每天早晨均給予Valsartan治療，採用居家血壓自我測量的方法，來評估病人對治療之反應。 結果 陽亢型高血壓病人有較低的胰島素值(7.98 ±4.27 vs 11.39 ±9.54, P=0.033)及胰島素阻抗，較小的左心室質量(187.78±56.82 vs 220.59±74.74, P=0.02)、收縮末期容量(91.62±26.42 vs 104.21±31.79, P=0.03)與舒張末期容量(28.99±10.66 vs 35.55±14.35, P=0.01)，較低的收縮期心室壁張力(2839.61±456.27 vs 3123.66±608.09, P=0.01)，較短的E wave deceleration time(0.19±0.04 vs 0.20±0.04, P=0.04)。治療四週後，陽亢型病人與痰濕壅盛型相比，收縮壓(137.02 ± 14.62 mmHg vs 147.43 ± 12.63 mmHg, P=0.001)與舒張壓(137.02 ± 14.62 mmHg vs 147.43 ± 12.63 mmHg, P=0.001)間有顯著差異(P= 0.012)。且隨年齡增加，陽亢型病人出現isolated systolic hypertension的可能性較大。 結論 根據傳統醫學體質分類，原發性高血壓病人至少可被分為陽亢型與痰濕中阻型兩類，他們具有不同之胰島素值、胰島素阻抗、左心室質量、收縮末期容量、舒張末期容量、收縮期心室壁張力和E wave deceleration time。同時對Valsartan治療陽亢型高血壓病人有較好的反應。故陽亢型高血壓病人可以Valsartan作為第一線治療首選藥物；相對的，痰濕中阻型高血壓病人則需另選其他類之降血壓藥。; Background Drugs from all six main classes of anti-hypertensive agents are effective in lowering blood pressure, with no substantive differences between drug classes in effects on blood pressure. However, how to choice the best effective drug for hypertensive patients according clinic symptoms are not available. Objectives We tried to research the relativity of the different phenotypes and the traditional Chinese medicine constitution classification of essential hypertensive patients from the viewpoint of the insulin resistance、LV hypertrophy、LV diastolic dysfunction and response to treatment.We also tried to find the most effective anti-hypertensive drug for hypertensive patients according to the traditional Chinese medicine constitution classification of essential hypertensive patients. Subjects and methods A total of 99 never or at least three months un-treatment essential hypertensive patients from Jiannren Hospital were classified into two types, the syndrome of the Yin-Deficiency and Yang-Excess type (type A) and the syndrome of the Phlegm-Dampness abundant type (type B), according traditional Chinese medicine constitution classification and evaluated by recording home blood pressure during the study periods. LV mass and performance were measured by M-mode echocardiography and mitral flow in diastole did by pulsed-wave Doppler. Insulin and C-peptide were assessed for determination of insulin resistance. We also assessed the anti-hypertensive efficacy of valsartan between the two types. Results Type A patients had lower insulin level (7.98 ±4.27 vs 11.39 ±9.54, P=0.033), less insulin resistance, smaller LV mass (187.78±56.82 vs 220.59±74.74, P=0.02), smaller end diastolic (28.99±10.66 vs 35.55±14.35, P=0.01) and end systolic volume (91.62±26.42 vs 104.21±31.79, P=0.03), lower systolic wall tension (2839.61±456.27 vs 3123.66±608.09, P=0.01), shorter E wave deceleration time (0.19±0.04 vs 0.20±0.04, P=0.04), less percentage of diastolic dysfunction, with good control and response rates to valsartan therapy than type B patients. On the other hand, with aging, the possibility of isolated systolic hypertension in type A group was noted more frequently than in type B group. Valsartan therapy for type A hypertensive patients is associated with profound and significant systolic BP (137.02 ± 14.62 mmHg vs 147.43 ± 12.63 mmHg, P=0.001) and diastolic BP (85.88 ± 8.99 mmHg vs 91.29 ± 10.43 mmHg, P=0.012) reduction at 4 weeks treatment. Conclusions We concluded that according to the traditional Chinese medicine constitution classification, hypetensive patients can be divided into two groups. They have different insulin level, LV mass, hemodynamic pattens, and even have different control and response rates of valsartan therapy. Valsartan therapy for type A hypertensive patient |
