Резистентная артериальная гипертензия: диагностика, тактика и лечение
Аннотация
Научный доклад Профессионального комитет по профессоинальному образованию при Совете по исследованиям в области повышенного артериального давления (Американская Ассоциация Сердца) Резистентная артериальная гипертензия (АГ) представляет собой частую клиническую ситуацию, с которой сталкиваются как врачи общей практики, так и специалисты. Истинная распространенность резистентной АГ неизвестна, однако, по данным клинических исследований она не является редкой патологией и встречается у 20-30% пациентов, участвующих в исследованиях. Если принять во внимание, что возраст и ожирение являются основными факторами риска неконтролируемой АГ, распространенность резистентной АГ будет возрастать по мере увеличения возраста и массы тела популяции. Прогноз больных с резистентной АГ точно неизвестен, но риск сердечно-сосудистых осложнений у них, бесспорно, повышен, поскольку они, как правило, страдают длительной тяжелой гипертензией, осложненной множественными сопутствующими факторами риска, такими как ожирение, синдром апноэ во вне, сахарный диабет и заболевания почек. Диагностика резистентной АГ требует качественной техники измерения артериального давления (АД), позволяющей подтвердить стойкое его повышение. Следует исключить псевдорезистентность, включая плохой контроль АД при низкой приверженности к терапии и гипертензию «белого халата». Этиология резистентной гипертензии, как правило, многофакторная. Успешное лечение требует оценки и контроля компонентов образа жизни, которые поддерживают резистентность, диагностики и соответствующего лечения вторичных АГ, а также использования эффективных многокомпонентных лекарственных комбинаций. Больные с резистентной АГ в качестве особой группы широко не исследовались. Обсервационные исследования позволяют определить демографические факторы и компоненты образа жизни, связанные с резистентностью к терапии. Роль вторичной АГ в лекарственной толерантности также хорошо изучена, однако, понимание стандартных механизмов, ведущих к резистентности, отсутствует. В особенности мало данных о генетических детерминантах формирования резистентной АГ. В связи с отсутствием систематизированных исследований по применению 3-х или 4-х препаратов в комбинации, рекомендации по лечению больных с резистентной АГ по-прежнему во многом носят эмпирический характер. Ограниченность исследований в области лечения резистентной АГ определяется высоким риском этих пациентов, не позволяющим безопасно отменять проводимую терапию, наличием сопутствующей патологии (апноэ во сне, сахарный диабет, хроническая болезнь почек, атеросклероз), требующей сопутствующей терапии, что затрудняет интерпретацию исследований, а также сложностью набора большого числа испытуемых. Расширение нашего понимания причин резистентности к терапии, которое, тем самым, позволит осуществить более эффективное лечение и профилактику этого состояния, является основным направлением в улучшении клинического ведения таких пациентов.
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Рецензия
Для цитирования:
Статья Р. Резистентная артериальная гипертензия: диагностика, тактика и лечение. Артериальная гипертензия. 2008;14(3):187-202.
For citation:
Article E. Resistant Hypertension:Diagnosis, Evaluation and Treatment. "Arterial’naya Gipertenziya" ("Arterial Hypertension"). 2008;14(3):187-202. (In Russ.)
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