【经验】难治性高血压的诊断与处理

关键信息

难治性高血压是指在使用3种或3种以上降压药物治疗后血压仍增高的状况，这篇报道对该情况的控制策略进行了综述。首先要考虑的药物为噻嗪类利尿剂。此外还可使用钙离子通道阻断剂和血管紧张素转换酶抑制剂。依普利酮和螺内酯等盐皮质激素受体拮抗剂也逐渐表现出其疗效。针对继发难治性高血压的病因，如阻塞性睡眠呼吸暂停或原发性醛固酮增多症进行治疗，也可改善患者血压。

难治性高血压的治疗方案选择不仅要关注疗效，还要顾全增量成本、药物不良作用和可能的心血管获益。

专家点评

加拿大心脏研究中心主管 Peter Lin 博士

有时患者并未达到其目标血压我们就放松了警惕。这篇文章提醒我们，应该让患者达到目标血压，未能达到降压目标的患者可能患有难治性高血压。难治性高血压是指使用3种或3种以上药物（其中包含一种利尿剂在内）治疗仍不能达到降压目标（140/90 mmHg）。我们当中有很多人均遇到过符合此定义的患者。

但在确诊患者为难治性高血压前，我们应确认患者是否具有不依从治疗、白大衣高血压和高盐摄入的情况。这些都可能导致患者表现出对治疗抵抗的情况，但实际上却并非如此。尽管在这篇文章中未提及，但一些研究者们已经指出仿制药可能是导致血压控制不佳的因素之一。当患者使用一种新的仿制药后血压上升时，这一因素最为明显。

一旦我们确定上述可能性均不存在，那么我们就需要考虑是否有继发高血压的病因存在。睡眠呼吸暂停在高血压患者中极为常见（30%），在难治性高血压患者中更甚（60%），我们应对这一现象进行研究。CPAP的使用对某些患者的血压有巨大影响。低钾预示患者可能具有醛固酮增多症，而肾动脉狭窄也在治疗抵抗的患者中更为常见。因此，面对真正治疗的难治性患者，我们应考虑到所有诸如此类的情况。

这篇文章还指出，ACE抑制剂、钙离子通道阻滞剂和利尿剂对患者而言是理想的治疗策略，当可能需第4种药物时，应考虑使用醛固酮阻断剂，如螺内酯。

如患者未能达到降压目标，则对治疗不依从等简单问题进行纠正、应用理想的联合用药方案、并进行适当研究以确定继发高血压的病因。

TAKE-HOME MESSAGE

This report reviews strategies for controlling resistant hypertension, when blood pressure remains elevated after treatment with three or more antihypertensive agents. Initial agents to consider are thiazide diuretics. Others are calcium channel blockers and angiotensin-converting enzyme inhibitors. Mineralocorticoid receptor antagonists, such as eplerenone and spironolactone, increasingly have shown effectiveness. Treating secondary causes of resistant hypertension, including obstructive sleep apnea or primary aldosteronism, can improve blood pressure.

Therapy choices for resistant hypertension should depend not only on efficacy, but also on incremental cost, drug adverse effects, and potential cardiovascular benefits.

Expert Comment

Often we get complacent with our patients who are not at their blood pressure target. This article reminds us that we should get patients to target and that those patients who cannot get to target might have resistant hypertension. Resistant hypertension is blood pressure that is not at target (140/90 mmHg) with treatment with three or more drugs, one of which is a diuretic. Many of us have patients who would fit this definition.

However before, determining that a patient has resistant hypertension, we should look for non-adherence, white coat hypertension, and high salt intake. Each of these may make patients seem resistant when, in fact, they are not. Although not mentioned in this article, some researchers have indicated that generic medications are a possible contributor to uncontrolled blood pressure. This is most obvious when patients’ blood pressure rises when they get a new generic medication.

Once we have convinced ourselves that none of those possibilities are at play, we need to look for secondary causes of hypertension. Sleep apnea is very common in hypertensive patients (30%) but is even more common in patients with resistant hypertension (60%), and this should be investigated. CPAP usage has had dramatic effects on some patients’ blood pressure. Low potassium would indicate possible hyperaldosteronism, and renal artery stenosis is more common in patients who are treatment-resistant as well. So, all of these conditions should be considered for the truly resistant patients.

The article also points out that ACE inhibitors, calcium channel blockers, and diuretics are good strategies for our patients, and, as a fourth possibility, an agent that blocks aldosterone, such as spironolactone, should be considered.

If your patient’s blood pressure is not at target, correct the simple things, like non-adherence issues, put patients on a good combination of medications, and do the appropriate investigations to look for secondary causes of hypertension.

JAMA : The Journal of the American Medical Association

Resistant Hypertension: A Review of Diagnosis and Management

JAMA 2014 Jun 04;311(21)2216-2224, W Vongpatanasin

This abstract is available on the publisher's site.

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Copyright © 2014 Elsevier Inc. All rights reserved.

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