Diagnosis and Management of Resistant Hypertension: A Review.

Approximately 19.7% of patients treated for hypertension have apparent resistant hypertension (blood pressure ≥130/80 mm Hg) despite using 3 or more antihypertensive medications, preferably a renin-angiotensin system blocker, a calcium channel blocker, and a thiazide-type diuretic, at maximally tolerated doses.

尽管使用了3种或更多抗高血压药物，包括首选的肾素-血管紧张素系统阻断剂、钙通道阻断剂和噻嗪类利尿剂，且剂量达到最大耐受量，但仍有大约19.7%的高血压治疗患者表现出明显的难治性高血压（血压≥130/80毫米汞柱）。

observations

Approximately 10% of patients treated for hypertension have true resistant hypertension confirmed with home or 24-hour ambulatory blood pressure monitoring to exclude white-coat hypertension (approximately 37.5% of apparent resistant hypertension) and after excluding medication nonadherence (approximately 50%) and secondary hypertension such as primary aldosteronism (approximately 5%-25%).

大约10%的高血压患者在接受治疗后被确认为真正的难治性高血压，通过家庭或24小时动态血压监测排除白大衣高血压（大约37.5%的表观难治性高血压），并排除药物不依从性（大约50%）以及继发性高血压如原发性醛固酮增多症（大约5%-25%）。

Conditions associated with resistant hypertension include obesity, diabetes, chronic kidney disease, and sleep apnea.

与难治性高血压相关的疾病包括肥胖、糖尿病、慢性肾脏病和睡眠呼吸暂停。

Resistant hypertension is associated with increased risk of cardiovascular death vs controlled blood pressure at 5 years to 10 years (absolute risk increase, 10.3% [95% CI, 8.7%-12.1%]).

难治性高血压与5至10年内心血管死亡风险增加相关（绝对风险增加10.3% [95% 置信区间, 8.7%-12.1%]），与控制血压相比。

Lifestyle modifications for resistant hypertension include a low-sodium diet (<1500 mg/d), reducing or avoiding alcohol, 150 min/wk or more of aerobic exercise, and weight loss.

难治性高血压的生活方式调整包括低钠饮食（<1500 mg/d）、减少或避免饮酒、每周150分钟或以上的有氧运动以及减重。

Illicit drugs (eg, cocaine) and medications that increase blood pressure (eg, nonsteroid anti-inflammatory drugs, serotonin-norepinephrine reuptake inhibitors) should be avoided.

应避免使用非法药物（例如可卡因）和增加血压的药物（例如非甾体抗炎药、血清素去甲肾上腺素再摄取抑制剂）。

Sleep apnea should be treated when diagnosis is confirmed.

一旦确诊，应治疗睡眠呼吸暂停。

Pharmacologic optimization includes use of combination tablets of antihypertensives; intensifying diuretic therapy by using chlorthalidone; and sequential addition of antihypertensive medications using evidence-based algorithms.

药物优化包括使用降压药的联合片剂；通过使用氯噻酮加强利尿治疗；以及使用基于证据的算法顺序添加降压药物。

In a meta-analysisof 20 studies (9 randomized clinical trials [RCTs] and 11 observational studies [331 participants]), use of antihypertensive therapies that combine 2 to 3 medications into a single formulation reduced SBP by -3.99 mm Hg (95% CI, -7.92 to -0.07) vs equivalent doses given separately.

在一项包含20项研究（9项随机临床试验[RCTs]和11项观察性研究[331名参与者]）的荟萃分析中，将2到3种降压药物组合成单一配方的治疗方案，与分别给予等效剂量相比，可使收缩压降低-3.99毫米汞柱（95%置信区间，-7.92至-0.07毫米汞柱）。

For patients with apparent or true resistant hypertension who have an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater and a serum potassium level of 4.5 mmol/L or less, adding spironolactone (25-50 mg/d) compared with placebo lowers office SBP by -13.3 mm Hg (95% CI, -17.89 to -8.72 [4 RCTs]) and 24-hour ambulatory SBP by -8.46 mm Hg (95% CI, -12.54 to -4.38 [2 RCTs]) in a network meta-analysisof 24 RCTs (3485 patients with resistant hypertension).

对于估计肾小球滤过率≥45 mL/min/1.73 m²且血清钾水平≤4.5 mmol/L的明显或真性难治性高血压患者，添加螺内酯（25-50 mg/d）与安慰剂相比，在24项随机对照试验（3485名难治性高血压患者）的网络荟萃分析中，可使诊室收缩压降低-13.3 mm Hg（95% CI, -17.89至-8.72）和24小时动态收缩压降低-8.46 mm Hg（95% CI, -12.54至-4.38）。

A meta-analysisof 10 RCTs (2478 participants) reported that compared with a sham procedure, catheter-based renal denervation, which disrupts the sympathetic nerves in the renal artery walls, decreased 24-hour ambulatory SBP by -4.4 mm Hg (95% CI, -6.1 to -2.7) and office SBP by -6.6 mm Hg (95% CI, -9.7 to -3.6).

10项随机对照试验（2478名参与者）的荟萃分析报告称，与假手术相比，破坏肾动脉壁交感神经的导管基础肾去神经术可使24小时动态收缩压降低-4.4 mm Hg（95% CI, -6.1至-2.7）和诊室收缩压降低-6.6 mm Hg（95% CI, -9.7至-3.6）。

conclusions_and_relevance

True resistant hypertension affects 10% of patients treated for hypertension and is diagnosed after excluding white-coat hypertension, medication nonadherence, and secondary hypertension such as primary aldosteronism.

真正的难治性高血压影响了10%接受高血压治疗的患者，并且在排除了白大褂高血压、药物不依从性以及包括原发性醛固酮增多症在内的继发性高血压后才能被诊断。

First-line treatment includes lifestyle modifications, diuretic therapy with chlorthalidone, and combination tablets of antihypertensives.

一线治疗包括生活方式的改变、使用氯噻嗪的利尿剂治疗以及联合使用降压药物的复方片剂。

Spironolactone and renal denervation decrease blood pressure in patients with true resistant hypertension.

螺内酯和肾脏去神经术能降低真正难治性高血压患者的血压。