Dirençli hipertansiyon

Amaç: Dirençli Hipertansiyon (DH) sık karşılaşılan bir klinik problemdir. Prevalansı tam olarak bilinmemekle birlikte çalışmalarda nadir olmadığı görülmektedir. Bu yazımızda güncel literatür ışığında DH yönetimi derlenmiştir. Ana bulgular: DH bir tanesi diüretik olan 3 farklı antihipertansif ilaca rağmen kan basıncının hedef değerlerde olmaması olarak tanımlanmaktadır. Gerçek direnç, genellikle ilaç tedavisine uyumsuzluk sonucu oluşan yalancı direnç durumundan ayrılmalıdır. İnsidansı yaşlanmayla ve obeziteyle artmaktadır. DH’li hastaların değerlendirilmesinde katkıda bulunan faktörlerin yanında hiperaldosteronizm, obstrüktif uyku apne (OSA) sendromu, renal arter stenozu (RAS) ve feokromasitoma gibi sekonder hipertansiyon nedenleride araştırılmalıdır. Hiperaldosteronizm yeni tanımlanan en sık sekonder sebep olup son çalışmalarda standart tedaviye spironolakton eklenmesi ile çoğu DH hastasında anlamlı kan basıncı düşüşü tespit edilmiştir. DH’nin prognozu bilinmemekle beraber obezite, diyabet, böbrek yetmezliği gibi kardiyak risk faktörleriyle birlikte uzun süreli ciddi hipertansiyona maruz kalmak kardiyovasküler hastalık riskini artırmaktadır. Sonuç: DH’nin başarılı tedavisi gerçek direncin tespit edilmesini, hipertansiyonun sekonder sebeplerinin teşhis ve tedavisini, yaşam şekli değişikliklerini ve efektif çoklu ilaç rejimlerinin kullanılmasını içerir. Aşırı volüm yükü sıklıkla altta yatan sebep olduğundan kan basıncı hedefine ulaşmak için genellikle diüretikler gerekmektedir.

Resistant hypertension

Objective: Resistant hypertension is a common clinical problem. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare. In this paper, we reviewed management of resistant hypertension based on the current literature. Main Findings: Resistant hypertension is defined as failure to achieve goal blood pressure despite adherence to 3 different antihypertensive medications, one of which must be a diuretic. True resistant hypertension should be distinguished by apparent resistant hypertension, of which an important cause is medication nonadherence. The incidence of resistant hypertension will likely increase as the population becomes more elderly and more obese. The evaluation of patients with resistant hypertension focuses on identifying contributing factors and secondary causes of hypertension including hyperaldosteronism, obstructive sleep apnea, renal artery stenosis, and pheochromocytoma. Hyperaldosteronism is now recognized as the most common secondary cause. Recent studies indicate that the addition of spironolactone to standard treatment induces significant blood pressure reduction in most patients with resistant hypertension. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, diabetes, and chronic kidney disease. Conclusion: Successful treatment of resistant hypertension requires confirmation of true resistance, diagnosis and treatment of secondary causes of hypertension, adoption of appropriate lifestyle modifications, and effective use of multidrug antihypertensive regimens. Excessive volume retention often underlies resistant hypertension, so diuretics are generally necessary to achieve blood pressure goals.

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