1/4高血压患者不依从治疗

《心脏》杂志(Heart)4月3日在线发表的一项研究发现，高血压患者的尿液检查结果显示25%的患者部分或完全不依从治疗。此外，不依从治疗与门诊时收缩压和舒张压升高及24-h平均日间舒张压升高呈线性相关(所有P < 0.006) (Heart 2014 April 3 [doi: 10.1136/heartjnl-2013-305063])。

在这项研究中，英国莱斯特大学的Maciej Tomaszewski医生及其同事通过高效液相色谱-串联质谱法对208例患者的现场尿样进行检查，评估40种最常见的降压药及其代谢产物。一部分患者为新近转诊(n = 125)，一部分因血压控制不佳被随访(66)，还有一部分转诊拟接受肾脏去神经支配治疗(17)。

不依从治疗的情况尤其常见于高血压控制不佳的患者(28.8%)或转诊拟接受肾脏去神经支配治疗的患者(23.5%)。研究者表示，在无常规尿液筛查的情况下，不依从治疗的患者可能因认为治疗无效而进行不必要的检查或治疗。

Tomaszewski医生和5名研究者声明从英国心脏基金会和英国国立卫生研究所获得研究支持和其他支持。

随刊述评

检查符合伦理吗？是过度治疗吗？

英国剑桥大学临床药理学教授Morris J. Brown医生表示，难治性高血压究竟是高血压的一种发病形式，还是医生对不服药患者想象出来的一种疾病，目前对此仍存争议。另一方面，目前有大量证据表明20%~25%真正的治疗抵抗可归因于原发性醛固酮增多症。但Tomaszewski医生的研究表明不依从治疗的患者比例与所谓难治性高血压的患者比例几乎一样高。此外，该研究发现通过尿液检查这种简单廉价的手段即可找出不依从治疗的患者。不过，研究者巧妙回避了一些问题，如检查是否符合伦理以及根据检查结果接下来应该采取何种措施等。不能强制进行或强制患者同意进行尿液检查。对于良性的可治愈原因引起的难治性高血压，在未事先证明存在治疗抵抗的情况下，不可进行昂贵检查。Brown 医生声明无经济利益冲突(Heart 2014 April 3 [doi: 10.1136/heartjnl-2013-305063])。

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Urine testing of patients with hypertension revealed that 25% were partially or totally nonadherent to treatment, researchers reported online April 3 in the journal Heart.

Furthermore, nonadherence was linearly related to increased systolic and diastolic blood pressures during clinic visits and 24-hour mean daytime diastolic blood pressure (P < .006 for all), reported Dr. Maciej Tomaszewski of the University of Leicester, England, and his associates.

Using a urine test available to commercial labs, the investigators tested 208 patients for 40 of the most common antihypertensive medications and their metabolites by performing high-performance liquid chromatography–tandem mass spectrometry of spot urine samples. Patients were either newly referred (n = 125), followed up for inadequately controlled blood pressure (66), or referred for renal denervation (17), the investigators reported (Heart 2014 April 3 [doi: 10.1136/heartjnl-2013-305063]).

Nonadherence was particularly common among patients whose hypertension was inadequately controlled (28.8%) or who were referred for renal denervation (23.5%), the investigators said. Without routine urine screening, nonadherent patients might receive or undergo unnecessary tests, procedures, or treatments for perceived nonresponse to treatment, said Dr. Tomaszewski, who is also with the National Institute for Health Research (NIHR) Leicester Biomedical Research Unit in Cardiovascular Disease, and his colleagues.

Larger, multicenter studies should directly estimate biochemical nonadherence in other populations and assess the cost-effectiveness of screening for nonadherence compared with the overall cost of managing resistant hypertension, the investigators said.

Dr. Tomaszewski and five of his associates reported receiving research and other support from the British Heart Foundation and the NIHR.

Commentary – Is the test ethical? Is overtreatment?

Dr. Morris J. Brown commented: "A contentious question has been whether resistant hypertension is a pathogenetic subset of hypertension, justifying a search for ‘stratified medicines’; or is it an imaginary condition caused by doctors in white coats and patients who do not take their tablets?"

"On the one hand, there is abundant evidence that primary aldosteronism causes 20%-25% of true treatment resistance," Dr. Brown added. But Tomaszewski et al. show that nonadherent patients "account for an almost identical, high proportion of supposed resistant hypertension. Furthermore, the authors answer not only the question ‘Is my patient taking his/her tablets,’ but also ‘How can I simply and cheaply find out?’ "

The authors "deftly side-stepped" questions related to the ethics of the test and what to do about the findings, Dr. Brown said. "Neither completion nor assent to urine testing could be compulsory," he emphasized. "But then, nor is progression to expensive tests for benign, curable causes of resistant hypertension – without resistance to treatment being first demonstrated."

Dr. Brown is a professor of clinical pharmacology at the University of Cambridge, England. He reported that he had no conflicts of interest. These remarks were taken from his editorial accompanying Dr. Tomaszewski’s report (Heart 2014 April 3 [doi: 10.1136/heartjnl-2013-305063]).

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Is the test ethical? Is overtreatment?

"A contentious question has been whether resistant hypertension is a pathogenetic subset of hypertension, justifying a search for ‘stratified medicines’; or is it an imaginary condition caused by doctors in white coats and patients who do not take their tablets?" commented Dr. Morris J. Brown.

"On the one hand, there is abundant evidence that primary aldosteronism causes 20%-25% of true treatment resistance," he added. But Tomaszewski et al. show that nonadherent patients "account for an almost identical, high proportion of supposed resistant hypertension. Furthermore, the authors answer not only the question ‘Is my patient taking his/her tablets,’ but also ‘How can I simply and cheaply find out?’ "

The authors "deftly side-stepped" questions related to the ethics of the test and what to do about the findings, said Dr. Brown. "Neither completion nor assent to urine testing could be compulsory," he emphasized. "But then, nor is progression to expensive tests for benign, curable causes of resistant hypertension – without resistance to treatment being first demonstrated."

Dr. Brown is a professor of clinical pharmacology at the University of Cambridge, England. He reported that he had no conflicts of interest. These remarks were taken from his editorial accompanying Dr. Tomaszewski’s report (Heart 2014 April 3 [doi: 10.1136/heartjnl-2013-305063]).