难治性高血压

ResistantHypertension:Diagnosis,Evaluation,andTreatmentJENNY(AScientificStatementFromtheAmericanHeartAssociationProfessionalEducationCommitteeoftheCouncilforHighBloodPressureResearch)难治性高血压Objective

Expandingourunderstandingofthecausesofresistanthypertensionandtherebypotentiallyallowingformoreeffectivepreventionand/ortreatmentwillbeessentialtoimprovethelong-termclinicalmanagementofthisdisorder.难治性高血压1Contents23DiagnosisEvaluationTreatment难治性高血压Definition

bloodpressureremainsabovegoalthreeanti-hypertensiveagentsofdifferentclassesoneofthe3agentsshouldbeadiureticallagentsshouldbeprescribedatoptimaldoseamounts.Resistanthypertension难治性高血压Prevalence1NHANES53%FraminghamHeartStudy48%ALLHAT250%难治性高血压PatientCharacteristicsPatientCharacteristicsAssociatedWithResistantHypertensionOlderageHighbaselinebloodpressureObesityExcessivedietarysaltingestionChronickidneydiseaseDiabetesLeftventricularhypertrophyBlackraceFemalesexResidenceinsoutheasternUnitedStates难治性高血压PseudoresistancePoorBloodPressureTechniquePoorAdherenceLifestyleFactorsWhite-CoatEffectSecondaryCauses难治性高血压measuringthebloodpressurebeforelettingthepatientsitquietlyuseoftoosmallacuffPoorBloodPressureTechnique难治性高血压amajorcauseoflackofbloodpressurecontrolPoorAdherencelessthan40%ofpatients40%ofpatientsthefirstyearoftreatment45to10yearsoffollow-up3难治性高血压White-CoatEffectStudiesindicatethatasignificantwhite-coateffect(whenclinicbloodpressuresarepersistentlyelevatedwhileout-of-officevaluesarenormalorsignificantlylower)isascommoninpatientswithresistanthypertensionasinthemoregeneralhypertensivepopulation,withaprevalenceintherangeof20%to30%.5难治性高血压LifestyleFactorsObesityisacommonfeatureofpatientswithresistanthypertension.ExcessivedietarysodiumintakeHeavyalcoholintakeisassociatedwithbothanincreasedriskofhypertension,aswellastreatment-resistanthypertension.难治性高血压Non-narcoticanalgesicsNon-steroidalanti-inflammatoryagents,includingaspirin,selectiveCOX-2inhibitorsSympathomimeticagents(decongestants,dietpills,cocaine)Stimulants(methylphenidate,dexmethylphenidate,dextroamphetamine,amphetamine,methamphetamine,modafinil)AlcoholOralcontraceptivesCyclosporineEPONaturallicoriceHerbalcompounds(ephedraormahuang)Drug-RelatedCauses难治性高血压RenalarterystenosisPrimaryaldosteronismRenalparenchymaldiseaseHyperparathyroidismCushing’sdiseasePheochromocytomaSecondaryCausesObstructiveSleepApneaAorticcoarctation难治性高血压EvaluationMedicalHistory:

duration,severity,progressionofthehypertension;treatmentadherence;responsetopriormedicationsAssessmentofAdherenceBloodPressureMeasurementsitquietlycorrectcuffsize;supportthearmatheartleveltheaverageof2readingssupineanduprightbloodpressuresPhysicalExamination难治性高血压Ameanambulatorydaytimebloodpressureof<135/85mmHgisconsideredelevated.EvaluationAmbulatoryBloodPressureMonitoringBiochemicalEvaluationAroutinemetabolicprofileUrinalysisApaired,morningplasmaaldosteronePlasmareninactivityNoninvasiveImaging难治性高血压TreatmentMaximizeAdherence

theuseofalong-actingcombinationofproducts

2.NonpharmacologicalRecommendationsWeightLossDietarySaltRestriction

ModerationofAlcoholIntakeIncreasedPhysicalActivityIngestionofaHigh-Fiber,Low-FatDiet3.TreatmentofSecondaryCausesofHypertension4.PharmacologicalTreatment难治性高血压AliskirenEffectsofaliskirenandvalsartanonplasmaANGIandIIlevels.Aliskirenaloneorincombinationwithvalsartanwastestedin120mildlysodiumdepleted,Nor-motensiveadults(age,18to35years)inadouble-dummy,doubleblind,randomized,placebo-controlled,4-periodcrossoverstudy.Subjectsreceivedsingledosesofaliskiren300mgalone,aliskiren150mgincombinationwithvalsartan80mg,valsartan160mgalone,andplaceboseparatedby2-weekwashoutperiods难治性高血压Thereisnodoubtthataliskirenisaneffectiveantihypertensiveagentandthatateffectivedosesitiswelltolerated.Itappearstobesafe,butthisstatementismadewiththeobviousqualificationforanynoveldrugorclassthatrareorlong-termadverseeventsmaytaketimetobecomeapparent.7AliskirenDOSE:75mg-300mgqdp.o难治性高血压Darusentan

Darusentanprovidesadditionalreductioninbloodpressureinpatientswhohavenotattainedtheirtreatmentgoalswiththreeormoreantihypertensivedrugs.Aswithothervasodilatordrugs,fluidmanagementwitheffectivediuretictherapymightbeneeded.难治性高血压aVaccineAgainstHypertensionTargetingAngiotensinII,ReducesEarly-MorningandDay-TimeBloodPressureCYT006-AngQb

avirus-like-particlebasedconjugatevaccinetargeting(AngII)72mild-to-moderatehypertensivepatients.thevaccinewithanoptimizeddoseregimeninjectionsofeither100or300µg难治性高血压CYT006-AngQbreducedbloodpressureinsituationswheretherenin-angiotensin-aldosteronesystemisstimulated,andwaspar