Hwang Andrew Y, Dietrich Eric, Pepine Carl J, Smith Steven M
Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, PO Box 100486, Gainesville, FL, 32610-0486, USA.
Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA.
Curr Hypertens Rep. 2017 Jul;19(7):56. doi: 10.1007/s11906-017-0754-x.
Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment-resistant hypertension (TRH). This review aims to summarize recent data on potential mechanisms of resistance and discuss current pharmacotherapeutic options available in the management of TRH.
Excess sodium and fluid retention, increased activation of the renin-angiotensin-aldosterone system, and heightened activity of the sympathetic nervous system appear to play an important role in development of TRH. Emerging evidence also suggests a role for arterial stiffness and, potentially, gut dysbiosis. Therapeutic approaches for TRH should include diuretic optimization and the addition of aldosterone antagonists as the preferred fourth agent in most patients. Further therapeutic approaches may be guided by the suspected underlying mechanism of TRH in conjunction with other patient-specific factors. The pathophysiology of TRH is multifaceted; however, increasing evidence supports several mechanisms that may be targeted to improve blood pressure control among patients with TRH. Further studies are needed to determine whether such approaches may be more effective than usual care.
新出现的证据表明，多种机制可能导致难治性高血压（TRH）的发生。本综述旨在总结关于抵抗潜在机制的最新数据，并讨论TRH管理中目前可用的药物治疗选择。
钠和液体潴留过多、肾素-血管紧张素-醛固酮系统激活增加以及交感神经系统活性增强似乎在TRH的发生中起重要作用。新出现的证据还表明动脉僵硬度以及可能的肠道菌群失调也发挥了作用。TRH的治疗方法应包括优化利尿剂，并在大多数患者中添加醛固酮拮抗剂作为首选的第四种药物。进一步的治疗方法可能由TRH可疑的潜在机制结合其他患者特异性因素来指导。TRH的病理生理学是多方面的；然而，越来越多的证据支持几种可能针对改善TRH患者血压控制的机制。需要进一步研究以确定这些方法是否可能比常规治疗更有效。
