Ambulatory Blood Pressure Monitoring in the Diagnosis, Prognosis, and Management of Resistant Hypertension: Still a Matter of our Resistance?

Abstract

Resistant hypertension, commonly described as the failure to achieve goal blood pressure (BP) despite an appropriate regimen of three antihypertensive drugs at the maximal tolerated doses, one of which is diuretic, is increasingly recognized as an important problem of public health. Large population studies with office measurements suggest that the prevalence of resistance hypertension is approximately at 6-12 % of the general hypertensive population and 8-28 % of treated hypertensives. However, these estimations do not take into account factors of pseudo-resistance, most importantly, the white-coat effect that can be effectively ruled out with ambulatory blood pressure monitoring (ABPM). Recent studies have clearly shown that when ABPM is used, at least 30-35 % of patients labeled as "resistant hypertensives" turn out to have well-controlled BP on ambulatory basis, a finding changing entirely the estimates of prevalence of resistance hypertension and actual patient handling. Furthermore, current evidence suggests that ABPM is a much more accurate predictor of cardiovascular events in resistant hypertension compared to office BP and thus can offer a better risk stratification for these high-risk individuals. Finally, ABPM offers the potential of a better evaluation of the effect of pharmacologic and non-pharmacologic therapeutic interventions. This review attempts to summarize recent evidence on the advantages of ABPM in the diagnosis, prognosis, and management of resistant hypertension.

Posicionamento Brasileiro sobre Hipertensão Arterial Resistente – 2020

“…A HAR verdadeira, diagnosticada pelo MAPA, tem o dobro do risco CV em comparação à HAR relacionada a efeito do avental branco. 18 De modo geral, as médias de PA obtidas nos três períodos do MAPA são fortes preditoras de risco CV, enquanto a PA de consultório não demonstrou nenhum valor prognóstico. 18 , 19 Estudos longitudinais destacaram a PA no sono elevada e a ausência de descenso noturno como importantes preditores de risco CV.…”

Ambulatory blood pressure and arterial stiffness in individuals with type 1 diabetes

“…Therefore, ambulatory BP monitoring (ABPM) might be more accurate than clinical BP measurement; it allows the detection of nocturnal BP and dipping patterns, and can reduce false-positive results by detecting white-coat hypertension, and false-negative results by detecting masked hypertension [5]. Indeed, several studies have shown the superiority of ABPM over office-or home-based BP monitoring to detect hypertension and predict cardiovascular outcomes [6,7].…”

Integrating Out-of-Office Blood Pressure in the Diagnosis and Management of Hypertension

“…Up to 28% of treated hypertensive patients have resistant hypertension, defined as requiring a minimum of three antihypertensive medications including a diuretic in order to achieve normotension (59). Out-of-office blood pressure monitoring can be particularly useful in the verification and management of treatment-resistant hypertension.…”

“…Additionally, poor adherence is a common issue, and may result in misperceived resistance to medication, known as pseudoresistance (59,61). As a result, patients may be prescribed a greater number of medications, at higher doses than indicated, increasing the risk of hypotension and other adverse effects when they do take their medications.…”