McAlister F A, Lewanczuk R Z, Teo K K
Division of General Internal Medicine, University of Alberta Hospital, Edmonton.
Can J Cardiol. 1996 Sep;12(9):822-8.
To review the factors contributing to treatment resistance in hypertensive patients and assess the evidence from therapeutic trials in these patients.
A MEDLINE search using the words 'resistant hypertension', 'refractory hypertension' and 'treatment resistance, hypertension' was carried out to identify relevant articles. The bibliographies of articles were used to screen for other relevant articles. All available English-language articles on the epidemiology, prognosis and management of hypertension resistant to standard treatment were reviewed.
Resistant hypertension is an important public health problem and a common reason for referral of patients to specialized hypertension clinics. Patients with uncontrolled hypertension are at increased risk of stroke, myocardial infarction, congestive heart failure and renal failure. Many factors may play a role in the development of resistant hypertension, including misdiagnosis (pseudoresistance), noncompliance, occult secondary causes for hypertension, volume overload, obesity, cigarette smoking, excess alcohol intake, sleep apnea, interfering medications and suboptimal combinations of antihypertensives. Only beta-blockers and thiazide diuretics have been demonstrated to reduce cardiovascular morbidity and mortality in hypertension. The trials evaluating third-line agents in patients with resistant hypertension have demonstrated additional blood pressure lowering with all classes of agents, and the randomized controlled trials have not demonstrated any statistically significant differences between the agents in either efficacy or tolerability.
Evaluation of the patient with resistant hypertension should include 24 h ambulatory blood pressure monitoring and an extensive search for hypertensive end organ damage. Contributing factors should be sought and stepped care should still form the basis for treatment decisions. The choice of third-line agent should be dictated by the patient's renin profile, current medication and any concomitant diseases.
回顾导致高血压患者治疗抵抗的因素，并评估这些患者治疗试验的证据。
利用“顽固性高血压”“难治性高血压”和“治疗抵抗，高血压”等词汇在医学文献数据库（MEDLINE）中进行检索，以识别相关文章。通过文章的参考文献筛选其他相关文章。对所有关于标准治疗抵抗性高血压的流行病学、预后和管理的英文文章进行了综述。
顽固性高血压是一个重要的公共卫生问题，也是患者转诊至高血压专科诊所的常见原因。血压控制不佳的患者发生中风、心肌梗死、充血性心力衰竭和肾衰竭的风险增加。许多因素可能在顽固性高血压的发生中起作用，包括误诊（假性抵抗）、不依从、隐匿性高血压继发原因、容量超负荷、肥胖、吸烟、过量饮酒、睡眠呼吸暂停、干扰药物以及降压药联合使用不当。只有β受体阻滞剂和噻嗪类利尿剂已被证明可降低高血压患者的心血管发病率和死亡率。评估顽固性高血压患者三线药物的试验表明，各类药物均可进一步降低血压，随机对照试验未显示这些药物在疗效或耐受性方面有任何统计学上的显著差异。
对顽固性高血压患者的评估应包括24小时动态血压监测，并广泛寻找高血压靶器官损害。应寻找促成因素，逐步治疗仍应作为治疗决策的基础。三线药物的选择应根据患者的肾素水平、当前用药情况和任何合并疾病来决定。
