用于治疗但未控制的高血压患者校正的血浆肾素检测指导药物治疗算法：一项随机对照试验。

Plasma Renin test-guided drug treatment algorithm for correcting patients with treated but uncontrolled hypertension: a randomized controlled trial.

作者信息

Egan Brent M, Basile Jan N, Rehman Shakaib U, Davis Phillip B, Grob Curt H, Riehle Jessica Flynn, Walters Christine A, Lackland Daniel T, Merali Carmen, Sealey Jean E, Laragh John H

机构信息

Department of Medicine, Medical University of South Carolina, Charleston, South Carolina, USA.

出版信息

Am J Hypertens. 2009 Jul;22(7):792-801. doi: 10.1038/ajh.2009.63. Epub 2009 Apr 16.

DOI:10.1038/ajh.2009.63

PMID:19373213

Abstract

BACKGROUND

Undefined pathophysiologic mechanisms likely contribute to unsuccessful antihypertensive drug therapy. The renin test-guided therapeutic (RTGT) algorithm is based on the concept that, irrespective of current drug treatments, subnormal plasma renin activity (PRA) (<0.65 ng/ml/h) indicates sodium-volume excess "V" hypertension, whereas values >or=0.65 indicate renin-angiotensin vasoconstriction excess "R" hypertension.

METHODS

The RTGT algorithm was applied to treated, uncontrolled hypertensives and compared to clinical hypertension specialists' care (CHSC) without access to PRA. RTGT protocol: "V" patients received natriuretic anti-"V" drugs (diuretics, spironolactone, calcium antagonists, or alpha(1)-blockers) while withdrawing antirenin "R" drugs (converting enzyme inhibitors, angiotensin receptor antagonists, or beta-blockers). Converse strategies were applied to "R" patients. Eighty-four ambulatory hypertensives were randomized and 77 qualified for the intention-to-treat analysis including 38 in RTGT (63.9 +/- 1.8 years; baseline blood pressure (BP) 157.0 +/- 2.6/87.1 +/- 2.0 mm Hg; PRA 5.8 +/- 1.6; 3.1 +/- 0.3 antihypertensive drugs) and 39 in CHSC (58.0 +/- 2.0 years; BP 153.6 +/- 2.3/91.9 +/- 2.0; PRA 4.6 +/- 1.1; 2.7 +/- 0.2 drugs).

RESULTS

BP was controlled in 28/38 (74% (RTGT)) vs. 23/39 (59% (CHSC)), P = 0.17, falling to 127.9 +/- 2.3/73.1 +/- 1.8 vs. 134.0 +/- 2.8/79.8 +/- 1.9 mm Hg, respectively. Systolic BP (SBP) fell more with RTGT (-29.1 +/- 3.2 vs. -19.2 +/- 3.2 mm Hg, P = 0.03), whereas diastolic BP (DBP) declined similarly (P = 0.32). Although final antihypertensive drug numbers were similar (3.1 +/- 0.2 (RTGT) vs. 3.0 +/- 0.3 (CHSC), P = 0.73) in "V" patients, 60% (RTGT) vs. 11% (CHSC) of "R" drugs were withdrawn and BP medications were reduced (-0.5 +/- 0.3 vs. +0.7 +/- 0.3, P = 0.01).

CONCLUSIONS

In treated but uncontrolled hypertension, RTGT improves control and lowers BP equally well or better than CHSC, indicating that RTGT provides a reasonable strategy for correcting treated but uncontrolled hypertension.

摘要

背景

尚不明确的病理生理机制可能导致抗高血压药物治疗失败。肾素检测指导治疗（RTGT）算法基于这样一种概念，即无论当前的药物治疗如何，血浆肾素活性（PRA）低于正常水平（<0.65 ng/ml/h）表明存在钠容量过多的“V”型高血压，而PRA值≥0.65表明存在肾素 - 血管紧张素血管收缩过度的“R”型高血压。

方法

将RTGT算法应用于接受治疗但血压未得到控制的高血压患者，并与无法获取PRA的临床高血压专家的治疗（CHSC）进行比较。RTGT方案：“V”型患者接受利钠抗“V”药物（利尿剂、螺内酯、钙拮抗剂或α1受体阻滞剂），同时停用抗肾素“R”药物（转换酶抑制剂、血管紧张素受体拮抗剂或β受体阻滞剂）。对“R”型患者采用相反的策略。84例门诊高血压患者被随机分组，77例符合意向性分析，其中38例接受RTGT治疗（年龄63.9±1.8岁；基线血压（BP）157.0±2.6/87.1±2.0 mmHg；PRA 5.8±1.6；使用3.1±0.3种抗高血压药物），39例接受CHSC治疗（年龄58.0±2.0岁；BP 153.6±2.3/91.9±2.0；PRA 4.6±1.1；使用2.7±0.2种药物）。

结果

38例中的28例（74%（RTGT））血压得到控制，而39例中的23例（59%（CHSC））血压得到控制，P = 0.17，血压分别降至127.9±2.3/73.1±1.8 mmHg和134.0±2.8/79.8±1.9 mmHg。收缩压（SBP）下降幅度RTGT组更大（-29.1±3.2 vs. -19.2±3.2 mmHg，P = 0.03），而舒张压（DBP）下降幅度相似（P = 0.32）。在“V”型患者中，尽管最终使用的抗高血压药物数量相似（3.1±0.2（RTGT） vs. 3.0±0.3（CHSC），P = 0.73），但“R”药物的停用率RTGT组为60%，CHSC组为11%，且降压药物用量减少（-0.5±0.3 vs. +0.7±0.3，P = 0.01）。