Hospital Clínico San Carlos, Madrid, Spain.
J Hypertens. 2010 Nov;28(11):2329-35. doi: 10.1097/HJH.0b013e32833d4c99.
Currently there is no consensus regarding which add-on therapy to use in resistant hypertension. This study was designed to compare two treatment options, spironolactone (SPR) versus dual blockade of the renin-angiotensin-aldosterone system (RAAS).
Forty-two patients with true resistant hypertension were included in the study. An open-label prospective crossover design was used to add a second RAAS blocker to previous treatment and then SPR following 1 month of wash-out. BP was measured in the office and by ambulatory blood pressure monitoring (ABPM). Changes in laboratory tests were also studied for both treatments. The predictive values of aldosterone-renin ratio (ARR) and serum potassium of determining the antihypertensive response were analyzed for both arms.
Following the first stage of dual blockade, SBP dropped significantly both in office (reduction of 12.9 ± 19.2 mmHg)) and by ABPM (reduction of 7.1 ± 13.4 mmHg). Office DBP was unchanged but was significantly reduced as measured by ABPM (3.4 ± 6.2 mmHg). On SPR treatment, office BP was reduced 32.2 ± 20.6/10.9 ± 11.6 mmHg. By ABPM the reduction was 20.8 ± 14.6/8.8 ± 7.3 mmHg (P < 0.001). The BP control was achieved by 25.6% of patients in dual blockade and 53.8% in SPR with office blood pressure. By ABPM, 20.5% were controlled on dual blockade and up to 56.4% with SPR. Serum potassium was a weak inverse predictor of the blood pressure-lowering effect of SPR.
SPR has a greater antihypertensive effect than dual blockade of the RAAS in resistant hypertension. SPR at daily doses of 25-50 mg shows a potent antihypertensive effect when added to prior regimes of single RAAS axis blockade in patients with resistant arterial hypertension.
目前对于难治性高血压患者，哪种附加治疗方案更有效还没有达成共识。本研究旨在对比螺内酯（SPR）和肾素-血管紧张素-醛固酮系统（RAAS）双重阻断两种治疗方案。
42 名真正的难治性高血压患者参与了本研究。采用开放标签前瞻性交叉设计，在洗脱期 1 个月后，在先前的治疗基础上加用第二种 RAAS 阻滞剂，然后添加 SPR。诊室血压和动态血压监测（ABPM）均可测量血压。两种治疗方案还检测了实验室检查的变化。对两种治疗方案的醛固酮-肾素比值（ARR）和血清钾预测降压反应的价值进行了分析。
在双重阻断的第一阶段后，诊室收缩压（SBP）和 ABPM 均显著下降（诊室 SBP 降低 12.9 ± 19.2 mmHg，ABPM 降低 7.1 ± 13.4 mmHg）。诊室舒张压（DBP）无变化，但 ABPM 测量的 DBP 显著降低（3.4 ± 6.2 mmHg）。SPR 治疗时，诊室 BP 降低 32.2 ± 20.6/10.9 ± 11.6 mmHg。ABPM 显示，BP 降低 20.8 ± 14.6/8.8 ± 7.3 mmHg（P < 0.001）。诊室血压控制在双重阻断治疗中为 25.6%，在 SPR 治疗中为 53.8%。ABPM 显示，双重阻断治疗的血压控制率为 20.5%，SPR 治疗的血压控制率为 56.4%。血清钾是 SPR 降压效果的弱负预测指标。
在难治性高血压中，SPR 的降压效果优于 RAAS 双重阻断。在难治性动脉性高血压患者先前的单一 RAAS 轴阻断治疗方案中，每日加用 25-50mg 的 SPR 可产生较强的降压效果。
