Hypertension Unit, Renal Division, University of Sao Paulo Medical School, São Paulo, Brazil.
Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical School, São Paulo, Brazil.
Curr Hypertens Rep. 2018 Jun 16;20(8):67. doi: 10.1007/s11906-018-0866-y.
Resistant hypertension (RH) is a growing clinical condition worldwide associated with target-organ damage and poor prognosis compared to non-resistant counterparts. The purpose of this review is to perform a critical evaluation of preferable drug choices for managing RH highlighting the evidence that significant proportion of patients remained uncontrolled despite using four anti-hypertensive drugs.
Until recently, the fourth drug therapy was main derived from personal opinion or small interventional studies. The recent data derived from two multicentric randomized trials, namely PATHWAY-2 and ReHOT, pointed spironolactone as the preferable fourth drug therapy in patients with confirmed RH as compared to bisoprolol and doxazosin (PATHWAY-2) as well as clonidine (ReHOT). However, significant proportion of patients (especially observed in ReHOT trial that used 24-h ambulatory blood pressure monitoring) did not achieve optimal blood pressure with the fourth drug. This finding underscores the need of new approaches and treatment options in this important research area. The current evidence pointed that significant proportion of RH patients are requiring more than four drugs for controlling BP. This statement is particularly true considering the new criteria proposed by the 2017 Guidelines for diagnosing RH (> 130 × 80 mmHg). New combinations, drugs, or treatments should be tested aiming to reduce the RH burden. Based on the aforementioned multicentric trials, we proposed the first five preferable anti-hypertensive classes in the overall context of RH.
与非耐药性高血压相比，耐药性高血压（RH）是一种在全球范围内不断增加的临床病症，与靶器官损伤和预后不良相关。本综述的目的是对管理 RH 的首选药物进行批判性评估，重点介绍尽管使用了四种抗高血压药物，仍有相当一部分患者血压控制不佳的证据。
直到最近，第四种药物治疗主要来自个人意见或小型干预性研究。最近两项多中心随机试验（PATHWAY-2 和 ReHOT）的数据表明，与比索洛尔和多沙唑嗪（PATHWAY-2）以及可乐定（ReHOT）相比，螺内酯是确诊 RH 患者的首选第四种药物治疗。然而，相当一部分患者（尤其是在使用 24 小时动态血压监测的 ReHOT 试验中观察到）未通过第四种药物达到最佳血压。这一发现强调了在这一重要研究领域需要新的方法和治疗选择。目前的证据表明，相当一部分 RH 患者需要四种以上的药物来控制血压。考虑到 2017 年 RH 诊断指南（>130×80mmHg）提出的新标准，这一说法尤其正确。应测试新的组合、药物或治疗方法，以减轻 RH 的负担。基于上述多中心试验，我们提出了在 RH 整体背景下的前五种首选抗高血压药物类别。
