Dtsch Med Wochenschr 2020; 145(02): 87-91
DOI: 10.1055/a-1031-0612
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© Georg Thieme Verlag KG Stuttgart · New York

Therapieresistente und ‑refraktäre Hypertonie

Therapy Resistant and Refractory Hypertension
Rainer Düsing
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Publication History

Publication Date:
20 January 2020 (online)

Abstract

Hypertension is defined as resistant to treatment when treatment fails to lower office systolic and diastolic blood pressure values to < 140/90 mmHg. The treatment strategy should include lifestyle measures and appropriate doses of three or more drugs acting by different mechanisms including a diuretic. An updated definition of treatment resistance includes all patients with ≥ 4 antihypertensive agents of different classes irrespective of their on-treatment blood pressure. The term “refractory” hypertension has been suggested for patients with uncontrolled blood pressure on ≥ 5 antihypertensive drugs including the thiazide-like diuretic chlorthalidone and the mineralocorticoid receptor antagonist spironolactone. “Pseudo resistance” especially due to white coat hypertension and non-adherence with the prescribed medication has to be ruled out to be able to identify patients with “true” treatment resistance. Therefore, before distinguishing true from pseudo resistance, the term “apparent” resistance should be used. While the prevalence of apparent resistance may be in the range of 10–15 % of treated patients, the exact prevalence of true resistance remains unknown due to the lack of appropriate studies but is likely to be rather small including a high proportion of patients with secondary forms of hypertension. Once identified most patients with true treatment resistance should receive intensified drug treatment primarily by expanded diuretic usage. Thus, resistant hypertension is primarily a diagnostic challenge: identifying patients with true resistance and those with secondary hypertension.

Die resistente Hypertonie ist primär eine diagnostische Herausforderung: Patienten mit wirklicher Therapieresistenz müssen identifiziert und eine sekundäre Hypertonieform muss nachgewiesen oder ausgeschlossen werden. Dieser Beitrag zeigt, wie Praxishypertonie und Non-Adhärenz ausgeschlossen werden, wie häufig sekundäre Hypertonieformen vorliegen und welche Möglichkeiten bei einer „wirklichen“ Therapieresistenz bestehen.

 
  • Literatur

  • 1 Williams B, Mancia G, Spiering W. et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Eur Heart J 2018; 39: 3021-3104
  • 2 Whelton PK, Carey RM, Aronow WS. et al. 2017 ACC/AHA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: Executive summary: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines. Hypertension 2018; 71: 1269-1324
  • 3 Achelrod D, Wenzel U, Frey S. Systematic review and meta-analysis of the prevalence of resistant hypertension in treated hypertensive populations. Am J Hypertens 2015; 28: 355-361
  • 4 de la Sierra A, Banegas JR, Oliveras A. et al. Clinical differences between resistant hypertensives and patients treated and controlled with three or less drugs. J Hypertens 2012; 30: 1211-1216
  • 5 Düsing R. Optimizing blood pressure control through the use of fixed combinations. Vasc Health Risk Manag 2010; 6: 321-325
  • 6 Durand H, Hayes P, Morrissey EC. et al. Medication adherence among patients with apparent treatment-resistant hypertension: systematic review and meta-analysis. J Hypertens 2017; 35: 2346-2357
  • 7 Vrijens B, Vincze G, Kristanto P. et al. Adherence to prescribed antihypertensive drug treatments: longitudinal study of electronically compiled dosing histories. BMJ 2008; 336: 1114
  • 8 Sinnott SJ, Smeeth L, Williason E. et al. Trends for prevalence and incidence of resistant hypertension: population based cohort study in the UK 1995–2015. BMJ 2017; 358: j3984 . doi:10.1136/bmj.j3984
  • 9 Carey RM, Calhoun DA, Bakris GL. et al. Resistant hypertension: Detection, evaluation, and management. A scientific statement from the American Heart Association. Hypertension 2018; 72: e53
  • 10 Williams B, MacDonald TM, Morant SV. et al. Spironolactone versus placebo, bisoprolol, and doxazosin to determine the optimal treatment for drug-resistant hypertension (PATHWAY‑2): a randomised, doubleblind, crossover trial. Lancet 2015; 386: 2059-2068
  • 11 Messerli FH, Makani H, Benjo A. Antihypertensive efficacy of hydrochlorothiazide as evaluated by ambulatory blood pressure monitoring. A metaanalysis of randomized trials. J Am Coll Cardiol 2011; 57: 590-600
  • 12 Williams B, MacDonald TM, Morant SV. et al. Endocrine and haemodynamic changes in resistant hypertension, and blood pressure responses to spironolactone or amiloride: the PATHWAY‑2 mechanisms substudies. Lancet Diabetes Endocrinol 2018; 6: 464-475 . doi:10.1016/S2213-8587(18)30071-8