Department of Internal Medicine School of Medicine University Hospital Clementino Fraga Filho Universidade Federal do Rio de Janeiro Brazil.
J Am Heart Assoc. 2020 Sep;9(17):e017634. doi: 10.1161/JAHA.120.017634. Epub 2020 Aug 27.
Background The long-term prognosis of refractory hypertension (RfHT), defined as failure to control blood pressure (BP) levels despite an antihypertensive treatment with ≥5 medications including a diuretic and mineraloreceptor antagonist, has never been evaluated. Methods and Results In a prospective cohort study with 1576 patients with resistant hypertension, patients were classified as refractory or nonrefractory based on uncontrolled clinic (or office) and ambulatory BPs during the first 2 years of follow-up. Multivariate Cox analyses examined the associations between the diagnosis of RfHT and the occurrence of total cardiovascular events (CVEs), major adverse CVEs, and cardiovascular and all-cause mortality, after adjustments for other risk factors. In total, 135 patients (8.6%) had RfHT by uncontrolled ambulatory BPs and 167 (10.6%) by uncontrolled clinic BPs. Over a median Follow-Up of 8.9 years, 338 total CVEs occurred (288 major adverse CVEs, including 124 myocardial infarctions, and 96 strokes), and 331 patients died, 196 from cardiovascular causes. The diagnosis of RfHT, using either classification by clinic or ambulatory BPs, was associated with significantly higher risks of major adverse CVEs, cardiovascular mortality, and stroke incidence, with hazard ratios varying from 1.54 to 2.14 in relation to patients with resistant nonrefractory hypertension; however, the classification based on ambulatory BPs was better in identifying higher risk patients than the classification based on clinic BP levels. Conclusions Patients with RfHT, particularly when defined by uncontrolled ambulatory BP levels, had higher risks of major adverse CVEs and mortality in relation to patients with resistant but nonrefractory hypertension, supporting the concept of refractory hypertension as a true extreme phenotype of antihypertensive treatment failure.
难治性高血压（RfHT）的长期预后，定义为尽管使用了≥5 种药物进行降压治疗，包括利尿剂和盐皮质激素受体拮抗剂，但仍无法控制血压（BP）水平，从未得到过评估。
在一项前瞻性队列研究中，纳入了 1576 例难治性高血压患者，根据前 2 年随访期间的诊室（或诊室）和动态血压未得到控制的情况，将患者分为难治性或非难治性。多变量 Cox 分析检查了 RfHT 诊断与总心血管事件（CVE）、主要不良 CVE、心血管和全因死亡率之间的关联，调整了其他危险因素。总共 135 例（8.6%）患者通过未控制的动态血压和 167 例（10.6%）患者通过未控制的诊室血压诊断为 RfHT。中位随访 8.9 年后，共发生 338 例总 CVE（288 例主要不良 CVE，包括 124 例心肌梗死和 96 例卒中），331 例患者死亡，其中 196 例死于心血管原因。无论是通过诊室血压还是动态血压分类，RfHT 的诊断均与更高的主要不良 CVE、心血管死亡率和卒中发生率风险显著相关，与难治性非难治性高血压患者相比，危险比在 1.54 到 2.14 之间变化；然而，与基于诊室 BP 水平的分类相比，基于动态 BP 水平的分类更能识别出高危患者。
与难治性但非难治性高血压患者相比，RfHT 患者，尤其是当根据未控制的动态血压水平定义时，发生主要不良 CVE 和死亡的风险更高，支持难治性高血压是降压治疗失败的一种真实极端表型的概念。
