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1、Resistant Hypertension: Diagnosis, Evaluation, and Treatment,JENNY,(A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research),Objective,Expanding our understanding of the causes of resistant hypertension and thereby p
2、otentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.,Contents,Diagnosis,Evaluation,Treatment,Definition,blood pressure remains above goal,three anti-hypertensive agents of different classes,one of the 3 ag
3、ents should be a diuretic,all agents should be prescribed at optimal dose amounts.,Resistant hypertension,Prevalence1,NHANES 53%,Framingham Heart Study 48%,ALLHAT2 50%,Patient Characteristics,Patient Characteristics Associated With Resistant Hypertension Older age High baseline blood pressure Obesit
4、y Excessive dietary salt ingestion Chronic kidney disease Diabetes Left ventricular hypertrophy Black race Female sex Residence in southeastern United States,Pseudoresistance,Poor Blood Pressure Technique,Poor Adherence,Lifestyle Factors,White-Coat Effect,Secondary Causes,Poor Blood Pressure Techniq
5、ue,a major cause of lack of blood pressure control,Poor Adherence,less than 40% of patients,the first year of treatment4,5 to 10 years of follow-up3,White-Coat Effect,Studies indicate that a significant white-coat effect (when clinic blood pressures are persistently elevated while out-of-office valu
6、es are normal or significantly lower) is as common in patients with resistant hypertension as in the more general hypertensive population, with a prevalence in the range of 20% to 30%.5,Lifestyle Factors,Obesity is a common feature of patients with resistant hypertension.,Excessive dietary sodium in
7、take,Heavy alcohol intake is associated with both an increased risk of hypertension, as well as treatment-resistant hypertension.,Non-narcotic analgesics Non-steroidal anti-inflammatory agents, including aspirin, selective COX-2 inhibitors Sympathomimetic agents (decongestants, diet pills, cocaine)
8、Stimulants (methylphenidate, dexmethylphenidate, dextroamphetamine, amphetamine, methamphetamine, modafinil) Alcohol Oral contraceptives Cyclosporine EPO Natural licorice Herbal compounds (ephedra or ma huang),Drug-Related Causes,Renal artery stenosis,Primary aldosteronism,Renal parenchymal disease,
9、Hyperparathyroidism,Cushings disease,Pheochromocytoma,Secondary Causes,Obstructive Sleep Apnea,Aortic coarctation,Evaluation,Medical History: duration, severity, progression of the hypertension; treatment adherence; response to prior medications,Assessment of Adherence,Blood Pressure Measurement,sit
10、 quietly correct cuff size; support the arm at heart level the average of 2 readings supine and upright blood pressures,Physical Examination,A mean ambulatory daytime blood pressure of 135/85 mm Hg is considered elevated.,Evaluation,Ambulatory Blood Pressure Monitoring,Biochemical Evaluation,A routi
11、ne metabolic profile Urinalysis A paired, morning plasma aldosterone Plasma renin activity,Noninvasive Imaging,Treatment,Maximize Adherence the use of a long-acting combination of products,2. Non pharmacological Recommendations Weight Loss Dietary Salt Restriction Moderation of Alcohol Intake Increa
12、sed Physical Activity Ingestion of a High-Fiber, Low-Fat Diet,3.Treatment of Secondary Causes of Hypertension,4. Pharmacological Treatment,Aliskiren,Effects of aliskiren and valsartan on plasma ANG I and II levels. Aliskiren alone or in combination with valsartan was tested in 120 mildly sodium depl
13、eted, Nor-motensive adults (age, 18 to 35 years) in a double-dummy, double blind, randomized, placebo-controlled, 4-period crossover study. Subjects received single doses of aliskiren 300 mg alone, aliskiren 150 mg in combination with valsartan 80 mg, valsartan 160 mg alone, and placebo separated by
14、 2-week washout periods,There is no doubt that aliskiren is an effective antihypertensive agent and that at effective doses it is well tolerated. It appears to be safe, but this statement is made with the obvious qualification for any novel drug or class that rare or long-term adverse events may tak
15、e time to become apparent.7,DOSE: 75mg-300mg qd p.o,Darusentan provides additional reduction in blood pressure in patients who have not attained their treatment goals with three or more antihypertensive drugs. As with other vasodilator drugs, fluid management with effective diuretic therapy might be
16、 needed .,a Vaccine Against Hypertension Targeting Angiotensin II, Reduces Early-Morning and Day-Time Blood Pressure,CYT006-AngQb,a virus-like-particle based conjugate vaccine targeting (Ang II),72 mild-to-moderate hypertensive patients.,the vaccine with an optimized dose regimen,injections of either 100 or 300 g,CYT006-AngQb reduced blood pressure in situations where the renin-angiotensin-aldosterone system is stimu
