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Compendium on the Pathophysiology and Treatment of Hypertension

M. C. Acelajado,Z. Hughes,S. Oparil,D. Calhoun

Published 2019 in Circulation Research

ABSTRACT

Resistant hypertension (RHTN) is defined as high blood pressure (BP) in a hypertensive patient that remains above goal despite use of ≥3 antihypertensive agents of different classes, typically including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system, either an ACE (angiotensin-converting enzyme) inhibitor or an ARB (angiotensin receptor blocker), and a diuretic, given at maximal or maximally tolerated doses. The definition also includes BP that is controlled on ≥4 antihypertensive medications, controlled RHTN. The diagnosis of RHTN requires exclusion of common causes of pseudoresistance, which include improper BP measurement technique, which usually results in falsely elevated readings; white coat RHTN, defined as uncontrolled office BP but controlled out-of-office BP in a patient on ≥3 antihypertensive agents; undertreatment, including clinical inertia, which is the failure to establish appropriate BP targets and escalate treatment to achieve treatment goals; and medication nonadherence. The term apparent treatment RHTN is used to indicate patients diagnosed as having RHTN based on the number of prescribed medications and the office BP but in whom pseudoresistance cannot be excluded, that is, when medication dose, adherence, or out-of-office BP values are not documented. These definitions are summarized in the Table. The term RHTN has been used to identify patients with difficult-to-treat hypertension who might benefit from special diagnostic or therapeutic procedures or referral to a hypertension specialist. Observational studies and clinical trials of antihypertensive treatment have shown that patients with RHTN are at increased risk of cardiovascular disease (CVD) compared with patients with more easily controlled hypertension, as well as higher risk of incident cardiovascular events, even after effective BP control is achieved. This definition has also been useful for identifying patients with RHTN in a standardized fashion for research purposes, particularly in standardizing enrollment criteria worldwide for clinical trials of evolving treatment strategies for RHTN, including novel device-based approaches.

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