Lady Davis Institute for Medical Research and Department of Medicine, Sir Mortimer B. Davis-Jewish General Hospital, McGill University, Montréal, QC, Canada
Department of Medicine, Brigham and Women's Hospital, Harvard University, Boston, MA, USA.
BMJ. 2024 Jun 19;385:e079108. doi: 10.1136/bmj-2023-079108.
Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses. Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs. Assessment requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment. Resistant hypertension is associated with major cardiovascular events in the short and long term, including heart failure, ischemic heart disease, stroke, and renal failure. Guidelines from several professional organizations recommend lifestyle modification and antihypertensive drugs. Medications typically include an angiotensin converting enzyme inhibitor or angiotensin receptor blocker, a calcium channel blocker, and a long acting thiazide-type/like diuretic; if a fourth drug is needed, evidence supports addition of a mineralocorticoid receptor antagonist. After a long pause since 2007 when the last antihypertensive class was approved, several novel agents are now under active development. Some of these may provide potent blood pressure lowering in broad groups of patients, such as aldosterone synthase inhibitors and dual endothelin receptor antagonists, whereas others may provide benefit by allowing treatment of resistant hypertension in special populations, such as non-steroidal mineralocorticoid receptor antagonists in patients with chronic kidney disease. Several device based approaches have been tested, with renal denervation being the best supported and only approved interventional device treatment for resistant hypertension.
抗药性高血压定义为在同时使用至少三种不同类别的降压药物（包括利尿剂），且所有药物均以最大或最大耐受剂量给药的情况下，血压仍高于治疗目标。如果需要四种或更多种降压药物来控制血压，则也诊断为抗药性高血压。评估需要排除明显的治疗抵抗性高血压，这种高血压通常是由于不遵守治疗方案引起的。抗药性高血压与短期和长期的主要心血管事件有关，包括心力衰竭、缺血性心脏病、中风和肾衰竭。几个专业组织的指南建议进行生活方式改变和使用降压药物。药物治疗通常包括血管紧张素转换酶抑制剂或血管紧张素受体阻滞剂、钙通道阻滞剂和长效噻嗪类/类似利尿剂；如果需要第四种药物，则有证据支持添加盐皮质激素受体拮抗剂。自 2007 年最后一种降压药物获得批准以来，已经过去了很长时间，目前有几种新型药物正在积极开发中。其中一些药物可能会在广泛的患者群体中提供强大的降压效果，例如醛固酮合酶抑制剂和双重内皮素受体拮抗剂，而其他药物可能会通过允许在特殊人群中治疗抗药性高血压（例如在慢性肾脏病患者中使用非甾体类盐皮质激素受体拮抗剂）来提供获益。已经测试了几种基于器械的方法，其中肾去神经术是最有支持证据的，也是唯一批准用于抗药性高血压的介入治疗设备。
