Resistant hypertension

Abstract

R esistant hypertension is defined by a lack of response to therapy with three or more medications and is evidence of a more severe stage of hypertension, with over a fourfold greater risk of cardiovascular events compared with hypertensive patients achieving blood pressure targets (1). The Joint National Committee's recommendations on high blood pressure (2) define resistant hypertension as "the failure to reach goal blood pressure despite full doses of an appropriate 3 drug regimen including diuretics". The European Society of Hypertension definition (3) is "hypertension resistant or refractory to lifestyle measures and at least three medications, including a diuretic to lower blood pressure to target". These definitions are reasonable and would then be modified by the urgency to treat based on the actual stage of blood pressure, with higher stages indicating greater urgency to achieve control. The Canadian Hypertension Education Program (CHEP) has not developed a recommendation specific to resistant hypertension because of the lack of randomized controlled trials specific to treating the condition. Etiology and PathoPhysiologyThe main categories to consider for patients with resistant hypertension are presented in Table 1. Longstanding uncontrolled hypertension leading to resistant hypertension is most often the result of a drug regimen lacking a diuretic, or insufficient antihypertensive classes and dosages (4). Epstein (5) has described the common clinical characteristics of patients with resistant hypertension. These include obesity, diabetes, chronic kidney disease, black race, female sex and left ventricular hypertrophy. To these, Pickering (6) has added older age, and reviewed the literature associating each characteristic with arterial stiffness -a major component of arterial blood pressure. High blood pressure itself causes arterial stiffness and, if uncontrolled over time, it likely also leads to resistance to therapy. Conversely, there are anecdotal reports that over time (months to years), after blood pressure is brought to target, the dosage and number of antihypertensive agents can be reduced. Resistant hypertension may also be secondary to other medical conditions, most often chronic kidney disease or primary hyperaldosteronism as well as renovascular disease and obstructive sleep apnea (7). Low potassium and target organ damage, including albuminuria, retinopathy and left ventricular hypertrophy, were more frequent in those found to have true resistant hypertension compared with those with white coat hypertension (8).Nonadherence to therapy may be a much more common cause of resistant hypertension than appreciated, as reviewed by Park and Campese (9), who make the distinction between apparent resistance from lack of patient adherence as well as ineffective physician prescribing, versus true resistance. Clues to patient nonadherence are gathered by a careful patient history including a review of prescription refills. Other patient behaviours may lead to resistant hypertension. This includes taki...

Patient‐Centered Home Care Using Digital Medicine and Telemetric Data for Hypertension: Feasibility and Acceptability of Objective Ambulatory Assessment

“…Insufficient medical therapy is the most common reason for apparently resistant hypertension . At the same time, it is difficult to assess in clinical practice.…”

“…Insufficient medical therapy is the most common reason for apparently resistant hypertension. 8 At the same time, it is difficult to assess in clinical practice. Although clinicians can recognize good adherence, they are often unaware of how patients actually take their medicines.…”

Management of Resistant Hypertension

“…In other reports, the proportion of hypertensive patients who have blood pressures that are higher than their recommended targets has varied from about 11% [7] to 33% [8], depending on the strictness of the definition and the study population. The lowest estimate (~11%) is derived from applying a very strict definition (including physician referral specifically for uncontrolled hypertension) to a cohort of 1281 new patients seen at a tertiary Hypertension Center in Chicago from 1993 to 2001 [14].…”

“…At least nine major, high-level overviews of the topic have been published [1••, [6][7][8][9][10][11][12]. Public health authorities now recognize that these patients have a higher absolute cardiovascular and renal risk, greater health care expenditures, a higher prevalence of secondary hypertension and target-organ damage, and are, by definition, more "difficultto-control" than hypertensive patients whose blood pressures are controlled with only one or two medications.…”

Atenção farmacêutica humanizada em pacientes hipertensos no Hospital Universitário Lauro Wanderley (HULW)

“…Todos esses fatores fazem com que o quadro de morbidade e mortalidade aumente consideravelmente, sendo estes de grande relevância para os gestores de sistemas de saúde, pacientes e a sociedade como um todo. A redução da morbidade evitável relacionada a medicamentos tem um impacto positivo na qualidade de vida do paciente, na segurança do sistema de saúde e na eficiência no uso dos recursos 12,16,18,21 . Com o ideal de se obter um controle mais específico diante desses problemas de saúde pública foi criado o sistema ou o conceito "Atenção Farmacêutica", satisfazendo essa necessidade social e individual dos pacientes.…”