Arterial Hypertension Program, University Hospital Clementino Fraga Filho, Faculty of Medicine, Internal Medicine Department, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil.
J Hum Hypertens. 2013 Nov;27(11):657-62. doi: 10.1038/jhh.2013.34. Epub 2013 May 2.
Resistant hypertension (RH) is defined as an uncontrolled office blood pressure (BP) despite the use of at least three antihypertensive drugs. With an increasing prevalence, RH implies in a very high cardiovascular risk and needs a careful clinical approach, aiming to control BP and to reduce its morbidity and mortality. The initial diagnostic approach involves drug adherence checking and the evaluation of antihypertensive scheme, emphasizing the use of diuretics and adequate combination and dosages of the two other drugs, which preferentially reduces cardiovascular risk and promotes prevention/regression of target organ damages. Because of an exaggerated white-coat effect, ambulatory BP monitoring (ABPM) at baseline is mandatory to classify patients into true RH (uncontrolled ambulatory BPs) and white-coat RH (controlled ambulatory BPs), and define initial therapeutic approach. Ideally, the objective is ambulatory BP control, so the treatment follow-up shall be based on ABPM measurements. The treatment involves lifestyle changes and use of adequate combinations of antihypertensive agents from different classes. In this way, patients with true RH need to intensify antihypertensive treatment by adding aldosterone antagonists as the fourth drug and also changing antihypertensive treatment to bedtime. Otherwise, in patients with controlled ambulatory BP, the therapeutic scheme should be maintained and ABPM or home BP monitoring repeated serially. Despite pharmacological interventions, ambulatory BP control in RH patients remains challenging and new interventional procedures have been recently proposed, as renal denervation and baroreflex activation therapy. Currently, these procedures shall be reserved to true RH patients in whom other alternatives have failed.
抗药性高血压（RH）定义为在使用至少三种降压药物的情况下仍无法控制的诊室血压（BP）。随着 RH 发病率的增加，这意味着存在极高的心血管风险，需要采取谨慎的临床方法，旨在控制血压并降低其发病率和死亡率。初始诊断方法包括药物依从性检查和评估降压方案，强调使用利尿剂和适当的联合用药以及其他两种药物的剂量，这优先降低心血管风险并促进预防/逆转靶器官损伤。由于存在明显的“白大衣效应”，因此在基线时进行动态血压监测（ABPM）是必需的，以便将患者分为真正的 RH（未控制的动态血压）和“白大衣”RH（控制的动态血压），并确定初始治疗方法。理想情况下，目标是控制动态血压，因此治疗随访应基于 ABPM 测量。治疗包括生活方式改变和使用不同类别的降压药物的适当联合用药。通过这种方式，真正的 RH 患者需要通过添加醛固酮拮抗剂作为第四种药物来强化降压治疗，并且还需要将降压治疗改为睡前。否则，对于动态血压得到控制的患者，应维持治疗方案，并连续重复进行 ABPM 或家庭血压监测。尽管进行了药物干预，但 RH 患者的动态血压控制仍然具有挑战性，最近提出了新的介入性治疗方法，如肾去神经术和压力反射激活疗法。目前，这些治疗方法应保留给其他替代方法失败的真正 RH 患者。
