The Korean Journal of Medicine

The Korean Association of Internal Medicine (대한내과학회)
권호 표지

Resistant hypertension: Causes and management

고혈압이 조절 안 되는 원인과 대책

Park, Chong-Hun
박종훈

  • Published : 20090400
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Abstract

Resistant hypertension is defined as when the blood pressure cannot be reduced to below 140/90 mmHg in patients who are adhering to an adequate and appropriate triple drug regimen that includes a diuretic, in near full doses. Before changing or increasing the antihypertensive medication, several factors should be checked. A careful evaluation of the patient’s adherence to therapy and adequate measurement of blood pressure are needed to exclude pseudoresistance secondary to poor medical adherence or white coat hypertension. Patients should be asked regularly about medications or substances that could interfere with blood pressure control. Successful treatment requires the identification of causes and a reversal of life style factors contributing to treatment resistance. Diabetes, chronic kidney disease, nonsteroidal anti-inflammatory drugs, high salt intake, obesity, and alcohol abuse are frequent causes of uncontrolled hypertension in Korea. The diagnosis and appropriate treatment of secondary hypertension is also needed. When multiple medications are used, vasodilators are the most commonly used antihypertensive drugs that cause subsequent fluid retention or sympathetic tone elevation. Adequate, effective, and sufficient diuresis and catecholamine suppression are needed for patients who do not respond to several vasodilators.

어떤 고혈압 환자에서는 부작용 없이 목표 혈압에 도달하기 어려운 경우도 있을 수 있다. 그러나 단순히 고혈압 약물을 증량하기 전에 살펴보아야 할 요소와 단계가 있다. 혈압 측정 시 혈압이 정확하게 측정되었는지 백의 고혈압이나 백의 효과는 없는지 확인한다. 환자가 자신의 적정한 혈압조절과 유지를 위한 마음가짐을 가지고 있으며 치료에 적극적으로 참여하기 위해 의사와 의사소통이 잘되고 있는지 생각해 보고 항고혈압 약물을 잘 복용하도록 한다. 약물요법뿐만 아니라 체중조절 식이염분의 제한, 알코올 절제와 같은 비약물 요법도 충분히 노력할 가치가 있음을 인식하도록 한다. 이차 고혈압의 원인이 되는 질환에 대한 병력청취와 이에 대한 진단검사를 한다. 혈압을 상승시킬 수 있는 약물을 같이 복용하고 있지 않은지 체크한다. 복합적인 다수의 항고혈압 약제를 복용 중에는 혈관확장제의 과다사용으로 인해 용적과부하 또는 교감신경계의 이차적 항진이 일어났는지 살펴보고 충분한 이뇨제 사용과 적절한 베타차단제를 사용한다. 이뇨제는 반감기, 작용기전, 신기능 상태를 고려하여 적절히 선택하고 알도스테론 차단제도 고려한다. 그러나 무엇보다도 필요한 요소는 환자의 혈압조절에 대한 순응도를 높이기 위한 전반적인 배려일 것이다.

Keywords

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