抵抗性高血圧 (Ground Rounds) JAMA ... - …

1 1/10 (Ground Rounds) JAMA June Resistant Hypertension, A review of Diagnosis and Management WanpenVongpatanasin, MD JAMA ,June4,2014 Grand Rounds( ) CBR 10 MEDLINE, PubMed, OVID,Cochrane 1985 1 1 2014 3 31 600 inclusion criteria 36 WanpenVongpatanasin JNC7 Joint National Committee 3 140/90 AHA American Heart Association 3 4

2 13 Nonadherence CPAP K Primary aldosteronism ARR( ) 200 150 ARR 690 Primary aldosteronism pheochromocytoma Cushing thyrotoxicosis 2/10 30 3 1 chlorthalidon ACEI CCB ARB CCB ACEI ARB 4 5 1 Nonadherence nonadherence 8 40 nonadherence Nonadherence 80

3 Adherence nonadherence 50 60 2 1 Nonadherence 1 4 polypharmacy 4 2 24 office BP 140/90 24 130/80 3 30 3/10 3 4 20-25

4 3 3-6 4 1 3 1 1 11 12g 1 2g 1 6g 1 5/3mmHg 3 1 24 23/9mmHg 2010 NEJM NEJM 3 red meat 1 2 , Dietary Therapy in Hypertension , Clinical Therapeutics,NEJM,June 3.

5 2010 4/10 1 1 30 3 2 3 6/3mmHg 3 1 4 Primary Aldosteronism Primary aldosteronism 5 10 7 20 Primary aldosteronism ACEI ARB 6 Ca hydralazine -blocker 6 PAC pg/ml PRA.

6 Ng/ml/h ARR 30 15 ARR 200 Primary aldosteronism ARR PAC PRA ARR 200 Primary aldosteronism PAC PAC 150pg/ml ARR 690 80 primary aldosteronism 150pg/ml ARR 690 Primary Aldosteronism PAC ng/dl pg/ml 10 ng/dl 5/10 JAMA 15ng/dl 150pg/ml 3 3 2 JAMA ACEI ARB 4 6 K K 4 2L aldosterone10ng/dl CT MRI spironolactone eplerenone 50 60 JAMA Primary Aldosteronism

7 70 stage3 CKD 39 5 6 telmisartan(ARB, ) hydrochlorothiazide ( ) atenolol ( ) 185 210 90 100 Aliskiren Amlodipine valsaltan(ARB, )160 eplerenone(K )50mg carvedilol( )25mg hydralazine( )300mg clonidine( ) ,bumetanide ( ) 180/90 NSAID 2006 BP210/92, P58 BP201/91,P54 GFR48ml/ 90 K primary aldosteronism eplerenone (K ) valsartan(ARB, ) bumetanide( ) 6 6/10 52ng/dl (520pg/ml ) 16ng/dl 1ng/ml/hr ( )

8 26ng/dl CT 8 10mm 2 140/90 5 Obstructive sleep apnea 5 10 30 40 60 70 CPAP 3 5mmHg CPAP 7 10mmHg nonadherence primary aldosteronism pheochromocytoma Cushing thyrotoxicosis 6 Renal Artery Stenosis 2 24 Stent FDA controversial 947 stent sBP2mmHg fibromuscular dysplasia revascularization 7 3 chlorthalidone 3550 1 chlorthalidone(thiazide )

9 Hydrochlorothiazide ( ) 2 indapamide( ) hydrochlorothiazide 7/10 AHA chlorthalidone JNC8 Joint National Committee 8 ACEI CCB ACEI CCB ACEI+thiazide 3 ARB+CCB 6 ACEI ARB DM telmisartan ARB, ramipril ACEI: JNC8 Joint National Committee ACEI ARB Aliskiren( ) Aliskiren ACEI ARB K 9 Mineral corticoid receptor antagonist - - Mineralcorticoid Receptor Antagonist 4 spironolact