Hypertension Section, Cardiology Division, University of Texas Southwestern Medical Center, Dallas.
JAMA. 2014 Jun 4;311(21):2216-24. doi: 10.1001/jama.2014.5180.
Resistant hypertension-uncontrolled hypertension with 3 or more antihypertensive agents-is increasingly common in clinical practice. Clinicians should exclude pseudoresistant hypertension, which results from nonadherence to medications or from elevated blood pressure related to the white coat syndrome. In patients with truly resistant hypertension, thiazide diuretics, particularly chlorthalidone, should be considered as one of the initial agents. The other 2 agents should include calcium channel blockers and angiotensin-converting enzyme inhibitors for cardiovascular protection. An increasing body of evidence has suggested benefits of mineralocorticoid receptor antagonists, such as eplerenone and spironolactone, in improving blood pressure control in patients with resistant hypertension, regardless of circulating aldosterone levels. Thus, this class of drugs should be considered for patients whose blood pressure remains elevated after treatment with a 3-drug regimen to maximal or near maximal doses. Resistant hypertension may be associated with secondary causes of hypertension including obstructive sleep apnea or primary aldosteronism. Treating these disorders can significantly improve blood pressure beyond medical therapy alone. The role of device therapy for treating the typical patient with resistant hypertension remains unclear.
耐药性高血压-即使用 3 种或更多种降压药物仍无法控制的高血压-在临床实践中越来越常见。临床医生应排除假性耐药性高血压，这种高血压是由于不遵医嘱服药或白大衣综合征导致的血压升高引起的。对于真正耐药性高血压的患者，噻嗪类利尿剂，特别是氯噻酮，应作为初始药物之一。其他 2 种药物应包括钙通道阻滞剂和血管紧张素转换酶抑制剂，以保护心血管。越来越多的证据表明，盐皮质激素受体拮抗剂（如依普利酮和螺内酯）可改善耐药性高血压患者的血压控制，无论循环醛固酮水平如何。因此，对于那些使用三联药物治疗方案将血压升高到最大或接近最大剂量后仍未得到控制的患者，应考虑使用这类药物。耐药性高血压可能与导致高血压的继发性原因有关，包括阻塞性睡眠呼吸暂停或原发性醛固酮增多症。治疗这些疾病可以在单独药物治疗的基础上显著改善血压。器械治疗对典型耐药性高血压患者的作用仍不清楚。
