Department of Medicine, University of Alabama at Birmingham, 35294-2041, USA.
Cardiol Clin. 2010 Nov;28(4):639-54. doi: 10.1016/j.ccl.2010.07.002.
Hypertension is a very common modifiable risk factor for cardiovascular morbidity and mortality. Patients with hypertension represent a diverse group. In addition to those with primary hypertension, there are patients whose hypertension is attributable to secondary causes, those with resistant hypertension, and patients who present with a hypertensive crisis. Secondary causes of hypertension account for less than 10% of cases of elevated blood pressure (BP), and screening for these causes is warranted if clinically indicated. Patients with resistant hypertension, whose BP remains uncontrolled in spite of use of 3 or more antihypertensive agents, are at increased cardiovascular risk compared with the general hypertensive population. After potentially correctible causes of uncontrolled BP (pseudoresistance, secondary causes, and intake of interfering substances) are eliminated, patients with true resistant hypertension are managed by encouraging therapeutic lifestyle changes and optimizing the antihypertensive regimen, whereby the clinician ensures that the medications are prescribed at optimal doses using drugs with complementary mechanisms of action, while adding an appropriate diuretic if there are no contraindications. Mineralocorticoid receptor antagonists are formidable add-on agents to the antihypertensive regimen, usually as a fourth drug, and are effective in reducing BP even in patients without biochemical evidence of aldosterone excess. In the setting of a hypertensive crisis, the BP has to be reduced within hours in the case of a hypertensive emergency (elevated BP with evidence of target organ damage) using parenteral agents, and within a few days if there is hypertensive urgency, using oral antihypertensive agents.
高血压是心血管发病率和死亡率的一个非常常见的可改变危险因素。高血压患者是一个多样化的群体。除了原发性高血压患者，还有一些高血压是由继发性原因引起的，一些是难治性高血压患者，还有一些是高血压急症患者。继发性高血压占血压升高（BP）病例的比例不到 10%，如果临床需要，应进行这些原因的筛查。与一般高血压人群相比，血压控制不佳的难治性高血压患者（尽管使用了 3 种或更多种降压药物）发生心血管风险增加。在消除了未控制 BP 的潜在可纠正原因（假性抵抗、继发性原因和摄入干扰物质）后，通过鼓励治疗性生活方式改变和优化降压方案来管理真正的难治性高血压患者，在此过程中，临床医生确保以最佳剂量开具具有互补作用机制的药物，同时在没有禁忌症的情况下添加适当的利尿剂。盐皮质激素受体拮抗剂是降压方案的有力附加药物，通常作为第四种药物，即使在没有醛固酮过多生化证据的患者中，也能有效降低血压。在高血压急症的情况下，需要在数小时内使用静脉药物降低血压，对于高血压紧急情况（血压升高并伴有靶器官损伤证据）；如果是高血压亚急症，需要在数天内使用口服降压药物降低血压。
