Resistant Hypertension: Diagnosis, Evaluation, and Treatment

Abstract

Abstract-Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. 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, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.

Low Pulse Pressure After Acute Ischemic Stroke is Associated With Unfavorable Outcomes: The Taiwan Stroke Registry

“…Among several factors that may increase the risk of stroke, hypertension is the single most important one 2. Uncontrolled blood pressure (BP) would lead to atherosclerosis and, in turn, harden and weaken the vessels in the brain, heart, and limbs, causing end‐organ damage 3. However, the occurrence of stroke may directly lead to an acute increase in BP 4, 5.…”

Prevalence and Clinical Characteristics of Refractory Hypertension

“…Resistant hypertension (RH) is defined as the persistence of high blood pressure (BP) ≥140 mm Hg of systolic BP or ≥90 mm Hg of diastolic BP, despite a therapeutic plan with 3 or more antihypertensive drugs, at the full tolerated doses, 1 of them diuretic, in subjects in whom secondary hypertension has been ruled out, as well as poor adherence to antihypertensive therapy 1. Several studies have observed a prevalence of around 12% to 14% of treated hypertensives 2, 3.…”

Apparent Treatment-Resistant Hypertension and Chronic Kidney Disease: Another Cardiovascular-Renal Syndrome?

“…6 By these terms, resistant hypertension includes patients at goal BP using 4 or more antihypertensive agents. Implicit in this definition is the exclusion of causes of pseudoresistant hypertension, including white-coat hypertension, medication nonadherence, and improper BP measurement technique.…”

“…To effectively exclude causes of pseudoresistant hypertension, current guidelines recommend obtaining either home BPs or, if available, ambulatory BPs. 6,7 Furthermore, patient compliance with antihypertensive therapy should be assessed by medication reconciliation and questioning family members. 7 Definition of aTRH aTRH has been coined to comprise patients meeting the AHA definition of resistant hypertension in whom causes for pseudoresistance have not been thoroughly investigated.…”

“…6,7,56,57 The apparent role of volume expansion in the pathophysiology of aTRH suggests that diuretics may be particularly important in this setting. Choice of diuretic class is primarily determined by eGFR, with thiazide diuretics being used preferentially for patients with eGFR of 30 mL/min/1.73 m 2 or more and loop diuretics preferred for patients with lesser eGFR.…”