Tian Zhejia, Vollmer Barbosa Clara, Lang Hannah, Bauersachs Johann, Melk Anette, Schmidt Bernhard M W
Department of Nephrology and Hypertension, Hannover Medical School, Carl-Neuberg-Straße 1, Hannover 30625, Germany.
Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
Cardiovasc Res. 2024 Feb 27;120(1):108-119. doi: 10.1093/cvr/cvad165.
Resistant hypertension is associated with a high risk of cardiovascular disease, chronic kidney disease, and mortality. Yet, its management is challenging. This study aims to establish the comparative effectiveness of pharmacologic and interventional treatments by conducting a network meta-analysis.
MEDLINE, Cochrane Register of Controlled Trials, and Web of Science Core Collection were systematically searched in March 2022. Randomized controlled trials comparing treatment options for management of resistant hypertension were included. Outcomes were blood pressure (BP) changes, measured in the office and in 24 h ambulatory BP measurement. We applied a frequentist random effects model to perform a network meta-analysis combining placebo medication and sham procedure as the reference comparator. From 4771 records, 24 studies met the inclusion criteria with 3458 included patients in total. Twelve active treatment alternatives [spironolactone, doxazosin, β-blocker, clonidine, darusentan, guanfacine, various types of renal sympathetic denervation, lifestyle intervention, continuous positive airway pressure, and baroreflex activation therapy (BAT)] were analysed. Among all comparators, spironolactone had the highest ranking probability and was considered the most effective treatment to reduce office systolic blood pressure (sBP) [-13.30 mmHg (-17.89; -8.72); P < 0.0001] and 24 h sBP [-8.46 mmHg (-12.54; -4.38); P < 0.0001] in patients with resistant hypertension. Lifestyle interventions were the most effective non-pharmacological treatment, lowering office sBP by -7.26 mmHg (-13.73; -0.8), whereas BAT lowered office sBP by -7.0 (-18.59; 4.59). Renal denervation lowered office sBP by -5.64 mmHg (-12.95; 1.66) and -3.79 mmHg (-11.39; 3.8) depending on the type of the procedure.
Among all pharmacologic and interventional treatments, spironolactone is the most effective treatment in reducing BP in patients with resistant hypertension. More comparative trials and especially trials with long-term follow-up are needed. In the meanwhile, we have to conclude that a combination of spironolactone and lifestyle modification are the most effective treatments in resistant hypertension.
顽固性高血压与心血管疾病、慢性肾病及死亡的高风险相关。然而，其治疗颇具挑战性。本研究旨在通过进行网状Meta分析来确定药物治疗和介入治疗的相对疗效。
2022年3月对MEDLINE、Cochrane对照试验注册库和科学网核心合集进行了系统检索。纳入了比较顽固性高血压治疗方案的随机对照试验。观察指标为诊室血压（BP）变化以及24小时动态血压监测中的血压变化。我们应用频率学派随机效应模型进行网状Meta分析，将安慰剂治疗和假手术作为对照比较对象。从4771条记录中，有24项研究符合纳入标准，共计3458例纳入患者。分析了12种积极治疗方案[螺内酯、多沙唑嗪、β受体阻滞剂、可乐定、达芦生坦、胍法辛、各种类型的肾交感神经去支配术、生活方式干预、持续气道正压通气和压力反射激活疗法（BAT）]。在所有比较对象中，螺内酯具有最高的排序概率，被认为是降低顽固性高血压患者诊室收缩压（sBP）[ -13.30 mmHg（-17.89；-8.72）；P < 0.0001]和24小时sBP[ -8.46 mmHg（-12.54；-4.38）；P < 0.0001]最有效的治疗方法。生活方式干预是最有效的非药物治疗方法，可使诊室sBP降低 -7.26 mmHg（-13.73；-0.8），而BAT使诊室sBP降低 -7.0（-18.59；4.59）。根据手术类型不同，肾去神经支配术使诊室sBP降低 -5.64 mmHg（-12.95；1.66）和 -3.79 mmHg（-11.39；3.8）。
在所有药物治疗和介入治疗中，螺内酯是降低顽固性高血压患者血压最有效的治疗方法。需要更多的比较试验，尤其是长期随访试验。同时，我们必须得出结论，螺内酯与生活方式改变相结合是治疗顽固性高血压最有效的方法。
