《International Circulation》: Thank you very much， Prof. De Backer. I represent International Circulation in China. My first question is: It was reported by an article of Britain Medical Magazine in 2004 that angiotensin antagonists （ARBs） might increase the risk of Myocardial Infarction. From then on， the safety of ARBs has been received increasing attention. However， the result of JIKEI HEART study showed that there was no mortality benefit， including cardiovascular mortality， nor was there a reduction in the risk of MI by conventional therapy plus ARB (valsartan) last year. How to evaluate the relationship of between ARBs and myocardial infarction in new guidelines? Do you think that ARBs may increase the risk of myocardial infarction? How to explain the possible mechanism within?

Prof. De Backer: Well， let me say that with the new guidelines of ESH/ESC on the management of arterial hypertension ，we are not entering in the details of the question that you asked. The update of the guidelines  are first of all the result of a  joint effort of two important societies-society of hypertension and society of cardiology.These societies have assigned a group of experts . And these experts came up with the best scientific evidence we have today， so that means that within our task force， we have asked our experts to cover the whole of available scientific information until now. Now I come to your question more in particular. The guidelines do not  recommend actions  based on just one  study;   we are trying to oversee what we know today and based on that knowledge we are trying to give a good recommendation to the clinician and to the practitioner. And  on the particular issue of ARBs and myocardial infarction， I think that at this moment， even when there are some studies suggesting something in one particular direction， that the whole of the picture that we leads to the conclusion that we are recommending ARBs as one of the different options that we have in terms of different classes of hypertension control today， and that there is no reason to select out ARBs separately from other families that we have.

《International Circulation》: So this guideline should be more balanced for the drugs in different classes.

Prof.De Backer: That’s what we are planning to do in the task forces. We need to have a good balance， to have evidence-based guidelines ， based on the whole scientific knowledge that we have， not only one or another study.

《International Circulation》: Thank you. And another question is: For patients with diabetes and hypertension who haven’t proteinuria， which one provides more benefits， ARBs versus ACE inhibitors? Are there any difference between ACE inhibitors and ARBs for patients with diabetic nephropathy? Does ARBs have a priority for management of nephropathy in patients with type 2 diabetes?

Prof.De Backer: Again， I’m a cardiologist， even more in epidemiology. I’m not a endocrinologist， not a nephrologist. I can only say that the patients with diabetes have a very high risk for developing cardiovascular disease， so we have to do everything we can in preventing that disease. That means that blood pressure control is extremely important and that our goals in diabetes are lower than in other subjects for blood pressure. Also I would like to remind that in patients with diabetes， that we have something to do with the diabetes itself， good glycemic control is crucial， with the lipids， good cholesterol control is crucial， with the weight， with the body mass index， and when it comes to blood pressure， again， we should try to achieve the goals by whatever means we have and I accept that there is some discussion between ACE inhibitors and ARBs， but I cannot answer your question directly， I would like to refer that to an endocrinologist， or a nephrologists， they know these recent studies much better and I think these studies are mainly based on mechanistic thinking， not on clinical trials with good hard endpoints.

《International Circulation》: Thank you. In recent years， the limitation of brachial blood pressure for BP-lowing evaluation has been known， while the obvious relationship between pressure gradient and cardiovascular events is found according to recent studies， some scholars have suggested that the Arterial Hardness Value should be one of important index for high pressure evaluation and medicine selection. How to view this opinion? Which objective standards can be used to evaluate high pressure and anti-hypertension drugs?

Prof.De Backer: Don’t know if I got your question correctly. Your question is?

《International Circulation》: Compare with the BP-lowering evaluation with brachial blood pressure or with the arterial hardness value.

Prof.De Backer: Yes. OK. Again， the new information comes from clinical studies and from experimental animal studies showing that the blood pressure is on its own is important， but also   markers of hardness of the arterial wall could  be important . At this moment， in my view， that information is not ready for daily clinical practice. I think that the idea of using both pulse  pressure on top of the blood pressure， I think this is already OK for practice， but arterial stiffness or arterial hardness measurements are still， I think， something that is scientifically important but not yet ready for the daily practice.

《International Circulation》: Another question is: It was mentioned for the first time that ß-blockers are no longer preferred as a routine initial therapy for hypertension in British Hypertensive Society Guidelines 2006. How to comment the current status of ß blockers in hypertension treatment? How to use ß blocker? When to use? Who to use? Are ß blockers still the initial therapy for hypertension?

Prof.De Backer: I think that there has been indeed a lot of controversial publications in LANCET and other papers. Again， there are two points. First of all， ß blockers are definitely of great preventive value in patients after myocardial infarction. So in patients who suffered from myocardial infarction and have hypertension， they still should be treated with ß blockers. Now in the other hand， we also know that in the large majority of our patients with hypertension， that we’ll never reach the goals that we accept now with one drug. So the question whether we start with one and then add another one is， I think， not so relevant. Anyhow， we’ll have to use different classes in most of our patients， and then to decide if we start with a ß blocker and then we add a diuretic or start with a diuretic and then add a ß blockers， I think it’s not so relevant， so for the clinician， it is not such an important question. I think that indeed， some classes of  drugs， like in the elderly，  are preferred. In diabetic patients we’ll use  more  ACEI and ARBs than ß blockers . So we always have to think at the whole picture of the patient and think of the co-morbidities. Most of our patients are elderly patients not with one disease， not only with hypertension， with a lot of co-morbidities and dependent of these co-morbidities we have to make the choice of the drug we are using.

《International Circulation》: Thank you. My last question is: according to the new issued updated guideline of hypertension， what are the major differences between this version and the previous one. And also the positioning change of different drugs， classes like ARB， CCB. What do you