Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the “white-coat effect” (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Background Despite a recent American Heart Association (AHA) consensus statement emphasizing the importance of resistant hypertension, the incidence and prognosis of this condition is largely unknown. Methods and Results This retrospective cohort study in two integrated health plans included patients with incident hypertension started on treatment from 2002–2006. Patients were followed for the development of resistant hypertension based on AHA criteria of uncontrolled blood pressure despite use of three or more antihypertensive medications using medication fill and blood pressure measurement data. We determined incident cardiovascular events (death or incident myocardial infarction, heart failure, stroke or chronic kidney disease) in patients with and without resistant hypertension adjusting for patient and clinical characteristics. Among 205,750 patients with incident hypertension, 1.9% developed resistant hypertension within a median 1.5 years from initial treatment, or 0.7 cases per 100 person-years of follow-up. These patients were more often men, older, and had higher rates of diabetes compared with nonresistant patients. Over 3.8 years of median follow-up, cardiovascular event rates were significantly higher in those with resistant hypertension (unadjusted: 18.0% vs. 13.5%, p<0.001). After adjusting for patient and clinical characteristics, resistant hypertension was associated with a higher risk of cardiovascular events (HR 1.47, 95% CI 1.33–1.62). Conclusions Among patients with incident hypertension started on treatment, 1 in 50 patients developed resistant hypertension. Resistant hypertension patients had an increased risk of cardiovascular events supporting the need for greater efforts toward improving hypertension outcomes in this population.

BACKGROUND It is unknown whether warfarin or aspirin therapy is superior for patients with heart failure who are in sinus rhythm. METHODS We designed this trial to determine whether warfarin (with a target international normalized ratio of 2.0 to 3.5) or aspirin (at a dose of 325 mg per day) is a better treatment for patients in sinus rhythm who have a reduced left ventricular ejection fraction (LVEF). We followed 2305 patients for up to 6 years (mean [±SD], 3.5±1.8). The primary outcome was the time to the first event in a composite end point of ischemic stroke, intracerebral hemorrhage, or death from any cause. RESULTS The rates of the primary outcome were 7.47 events per 100 patient-years in the warfarin group and 7.93 in the aspirin group (hazard ratio with warfarin, 0.93; 95% confidence interval [CI], 0.79 to 1.10; P = 0.40). Thus, there was no significant overall difference between the two treatments. In a time-varying analysis, the hazard ratio changed over time, slightly favoring warfarin over aspirin by the fourth year of follow-up, but this finding was only marginally significant (P = 0.046). Warfarin, as compared with aspirin, was associated with a significant reduction in the rate of ischemic stroke throughout the follow-up period (0.72 events per 100 patient-years vs. 1.36 per 100 patient-years; hazard ratio, 0.52; 95% CI, 0.33 to 0.82; P = 0.005). The rate of major hemorrhage was 1.78 events per 100 patient-years in the warfarin group as compared with 0.87 in the aspirin group (P<0.001). The rates of intracerebral and intracranial hemorrhage did not differ significantly between the two treatment groups (0.27 events per 100 patient-years with warfarin and 0.22 with aspirin, P = 0.82). CONCLUSIONS Among patients with reduced LVEF who were in sinus rhythm, there was no significant overall difference in the primary outcome between treatment with warfarin and treatment with aspirin. A reduced risk of ischemic stroke with warfarin was offset by an increased risk of major hemorrhage. The choice between warfarin and aspirin should be individualized.

Key Points Question How does the accuracy of lung ultrasound compare with chest radiography for diagnosing cardiogenic pulmonary edema in patients presenting to any clinical setting with dyspnea? Findings In this systematic review with meta-analysis of 6 prospective cohort studies representing 1827 patients, lung ultrasonography was found to be more sensitive than chest radiography for the detection of cardiogenic pulmonary edema and had comparable specificity. Meaning Lung ultrasonography appeared to be useful as an adjunct imaging study in patients presenting with dyspnea at risk for heart failure.