Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana, USA.
Am J Hypertens. 2021 Apr 20;34(4):318-326. doi: 10.1093/ajh/hpaa209.
Blood pressure (BP) in the office is often recorded without standardization of the technique of measurement. When office BP measurement is performed with a research-grade methodology, it can inform better therapeutic decisions. The reference-standard method of ambulatory BP monitoring (ABPM) together with the assessment of BP in the office enables the identification of white-coat and masked hypertension, facilitating the stratification of cardiorenal risk. Compared with general population, the prevalence of resistant hypertension is 2- to 3-fold higher among patients with chronic kidney disease (CKD). The use of ABPM is mandatory in order to exclude the white-coat effect, a common cause of pseudoresistance, and confirm the diagnosis of true-resistant hypertension. After the premature termination of Systolic Blood Pressure Intervention Trial due to an impressive cardioprotective benefit of intensive BP-lowering, the 2017 American Heart Association/American College of Cardiology guideline reappraised the definition of hypertension and recommended a tighter BP target of <130/80 mm Hg for the majority of adults with a high cardiovascular risk profile, inclusive of patients with CKD. However, the benefit/risk ratio of intensive BP-lowering in particular subsets of patients with CKD (i.e., those with diabetes or more advanced CKD) continues to be debated. We explore the controversial issue of BP targets in CKD, providing a critical evaluation of the available clinical-trial evidence and guideline recommendations. We argue that the systolic BP target in CKD, if BP is measured correctly, should be <120 mm Hg.
诊室血压（BP）的测量往往没有标准化技术。当采用研究级方法进行诊室 BP 测量时，它可以为更好的治疗决策提供信息。动态血压监测（ABPM）的参考标准方法以及诊室 BP 的评估可以识别白大衣高血压和隐匿性高血压，从而有利于心血管和肾脏风险的分层。与普通人群相比，慢性肾脏病（CKD）患者中难治性高血压的患病率高出 2-3 倍。为了排除白大衣效应（假性抵抗的常见原因）并确认真正难治性高血压的诊断，必须使用 ABPM。由于强化降压对心脏有明显的保护作用，收缩压干预试验提前终止，2017 年美国心脏协会/美国心脏病学会指南重新评估了高血压的定义，并建议大多数心血管风险较高的成年人（包括 CKD 患者）的血压目标值<130/80mmHg。然而，强化降压在 CKD 特定患者亚组（即患有糖尿病或更严重 CKD 的患者）中的获益/风险比仍存在争议。我们探讨了 CKD 中血压目标的争议问题，对现有临床试验证据和指南建议进行了批判性评估。我们认为，如果正确测量 BP，CKD 的收缩压目标应该<120mmHg。
