難治性高血壓

Objective

Expandingourunderstandingofthecausesofresistanthypertensionandtherebypotentiallyallowingformoreeffectivepreventionand/ortreatmentwillbeessentialtoimprovethelong-termclinicalmanagementofthisdisorder.難治性高血壓第1頁(yè)1Contents23DiagnosisEvaluationTreatment難治性高血壓第2頁(yè)Definition

bloodpressureremainsabovegoalthreeanti-hypertensiveagentsofdifferentclassesoneofthe3agentsshouldbeadiureticallagentsshouldbeprescribedatoptimaldoseamounts.Resistanthypertension難治性高血壓第3頁(yè)P(yáng)revalence1NHANES53%FraminghamHeartStudy48%ALLHAT250%難治性高血壓第4頁(yè)P(yáng)atientCharacteristicsPatientCharacteristicsAssociatedWithResistantHypertensionOlderageHighbaselinebloodpressureObesityExcessivedietarysaltingestionChronickidneydiseaseDiabetesLeftventricularhypertrophyBlackraceFemalesexResidenceinsoutheasternUnitedStates難治性高血壓第5頁(yè)P(yáng)seudoresistancePoorBloodPressureTechniquePoorAdherenceLifestyleFactorsWhite-CoatEffectSecondaryCauses難治性高血壓第6頁(yè)measuringthebloodpressurebeforelettingthepatientsitquietlyuseoftoosmallacuffPoorBloodPressureTechnique難治性高血壓第7頁(yè)amajorcauseoflackofbloodpressurecontrolPoorAdherencelessthan40%ofpatients40%ofpatientsthefirstyearoftreatment45to10yearsoffollow-up3難治性高血壓第8頁(yè)White-CoatEffectStudiesindicatethatasignificantwhite-coateffect(whenclinicbloodpressuresarepersistentlyelevatedwhileout-of-officevaluesarenormalorsignificantlylower)isascommoninpatientswithresistanthypertensionasinthemoregeneralhypertensivepopulation,withaprevalenceintherangeof20%to30%.5難治性高血壓第9頁(yè)LifestyleFactorsObesityisacommonfeatureofpatientswithresistanthypertension.ExcessivedietarysodiumintakeHeavyalcoholintakeisassociatedwithbothanincreasedriskofhypertension,aswellastreatment-resistanthypertension.難治性高血壓第10頁(yè)Non-narcoticanalgesicsNon-steroidalanti-inflammatoryagents,includingaspirin,selectiveCOX-2inhibitorsSympathomimeticagents(decongestants,dietpills,cocaine)Stimulants(methylphenidate,dexmethylphenidate,dextroamphetamine,amphetamine,methamphetamine,modafinil)AlcoholOralcontraceptivesCyclosporineEPONaturallicoriceHerbalcompounds(ephedraormahuang)Drug-RelatedCauses難治性高血壓第11頁(yè)RenalarterystenosisPrimaryaldosteronismRenalparenchymaldiseaseHyperparathyroidismCushing’sdiseasePheochromocytomaSecondaryCausesObstructiveSleepApneaAorticcoarctation難治性高血壓第12頁(yè)EvaluationMedicalHistory:

duration,severity,progressionofthehypertension;treatmentadherence;responsetopriormedicationsAssessmentofAdherenceBloodPressureMeasurementsitquietlycorrectcuffsize;supportthearmatheartleveltheaverageof2readingssupineanduprightbloodpressuresPhysicalExamination難治性高血壓第13頁(yè)Ameanambulatorydaytimebloodpressureof<135/85mmHgisconsideredelevated.EvaluationAmbulatoryBloodPressureMonitoringBiochemicalEvaluationAroutinemetabolicprofileUrinalysisApaired,morningplasmaaldosteronePlasmareninactivityNoninvasiveImaging難治性高血壓第14頁(yè)TreatmentMaximizeAdherence

theuseofalong-actingcombinationofproducts

2.NonpharmacologicalRecommendationsWeightLossDietarySaltRestriction

ModerationofAlcoholIntakeIncreasedPhysicalActivityIngestionofaHigh-Fiber,Low-FatDiet3.TreatmentofSecondaryCausesofHypertension4.PharmacologicalTreatment難治性高血壓第15頁(yè)AliskirenEffectsofaliskirenandvalsartanonplasmaANGIandIIlevels.Aliskirenaloneorincombinationwithvalsartanwastestedin120mildlysodiumdepleted,Nor-motensiveadults(age,18to35years)inadouble-dummy,doubleblind,randomized,placebo-controlled,4-periodcrossoverstudy.Subjectsreceivedsingledosesofaliskiren300mgalone,aliskiren150mgincombinationwithvalsartan80mg,valsartan160mgalone,andplaceboseparatedby2-weekwashoutperiods難治性高血壓第16頁(yè)Thereisnodoubtthataliskirenisaneffectiveantihypertensiveagentandthatateffectivedosesitiswelltolerated.Itappearstobesafe,butthisstatementismadewiththeobviousqualificationforanynoveldrugorclassthatrareorlong-termadverseeventsmaytaketimetobecomeapparent.7AliskirenDOSE:75mg-300mgqdp.o難治性高血壓第17頁(yè)Darusentan

Darusentanprovidesadditionalreductioninbloodpressureinpatientswhohavenotattainedtheirtreatmentgoalswiththreeormoreantihypertensivedrugs.Aswithothervasodilatordrugs,fluidmanagementwitheffectivediuretictherapymightbeneeded.難治性高血壓第18頁(yè)aVaccineAgainstHypertensionTargetingAngiotensinII,ReducesEarly-MorningandDay-TimeBloodPressureCYT006-AngQb

avirus-like-particlebasedconjugatevaccinetargeting(AngII)72mild-to-moderatehypertensivepatients.thevaccinewithanoptimizeddoseregimeninjectionsofeither100or300μg難治性高血壓第19頁(yè)CYT006-AngQbreducedbloodpressureinsituationswheretherenin-angiotensin-aldosteronesystemisstimul