The role of selective imidazoline receptor agonists in modern hypertension management - an international real-world survey (STRAIGHT)

<b>Background</b>: Multiple pharmacologic strategies are currently available to lower blood pressure (BP). Renin-angiotensin system (RAS)-inhibitors, calcium channel blockers and diuretics are widely recommended as first line therapies. Sympathetic activation is an important contributor to BP elevation but remains unopposed or is even increased by some of these drug classes. Selective imidazoline receptor agonists (SIRAs) reduce increased central sympathetic outflow and are considered as add-on therapy in most guidelines. We conducted an international survey to evaluate contemporary hypertension management strategies in countries with high prescription rates of SIRAs to better understand the rationale and practical indications for their use in a real-world setting. <b>Methods:</b> Physicians from seven countries (India, Jordan, Lebanon, Russia, Saudi Arabia, South Africa, United Arab Emirates) were asked to complete a web-based questionnaire and comment on clinical case scenarios to provide information on their current practice regarding antihypertension strategies, underlying rationale for their choices, and adherence to relevant guidelines. <b>Results:</b> 281 physicians completed the questionnaire including mainly cardiologists (35%) and general practitioners (32%). 96% reported using European (60%) or local (56%) guidelines in their daily practices. The majority of responding physicians (83%) had knowledge of SIRAs and 70% prescribed SIRAs regularly typically as a third line antihypertensive strategy (63%). The preferred combination partners for SIRAs were RAS-inhibitors (72%). <b>Conclusions:</b> Contemporary hypertension management varies between countries and therapeutic approaches in a real-world setting are not always in line with recommendations from available guidelines. In the countries selected for this survey prescription of SIRAs was common and appeared to be guided predominantly by considerations relating to the underlying pathophysiologic mechanism of sympathetic inhibition.

**背景**：当前临床已有多种降压药物治疗方案用于降低血压（blood pressure, BP）。肾素-血管紧张素系统（renin-angiotensin system, RAS）抑制剂、钙通道阻滞剂与利尿剂均被广泛推荐为一线降压治疗方案。交感神经激活是血压升高的重要致病因素，但部分上述降压药物不仅无法拮抗交感神经激活，甚至可能加重该过程。选择性咪唑啉受体激动剂（selective imidazoline receptor agonists, SIRAs）可降低过度激活的中枢交感神经传出冲动，多数临床指南将其列为辅助治疗药物。本研究开展一项国际性调查，旨在在选择性咪唑啉受体激动剂处方率较高的国家中评估当前高血压管理策略，以深入了解该类药物在真实世界临床场景中的使用理论依据与实际适用指征。
**方法**：研究邀请来自印度、约旦、黎巴嫩、俄罗斯、沙特阿拉伯、南非及阿拉伯联合酋长国7个国家的医师完成线上问卷，并对临床病例场景发表评论，以收集其当前高血压治疗策略、选择策略的内在理论依据，以及对相关指南的依从性相关信息。
**结果**：共计281名医师完成问卷，其中以心脏科医师（35%）与全科医师（32%）占比最高。96%的受访者表示，日常临床工作中会参考欧洲指南（60%）或本国指南（56%）。多数受访医师（83%）了解选择性咪唑啉受体激动剂，其中70%会常规处方该类药物，且63%将其作为三线降压治疗方案。选择性咪唑啉受体激动剂的首选联合用药为肾素-血管紧张素系统抑制剂（72%）。
**结论**：当前各国的高血压管理策略存在差异，真实世界临床场景中的治疗方案并非始终与现有指南推荐一致。本次调查纳入的国家中，选择性咪唑啉受体激动剂的处方较为普遍，其使用主要以交感神经抑制的潜在病理生理机制为依据。