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STATE-OF-THE-ART PAPER

Resistant Hypertension

An Overview of Evaluation and Treatment

Pantelis A. Sarafidis, MD, PhD^_* and George L. Bakris, MD, FAHA, FASN^,_*

^_* Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
Hypertensive Diseases Unit, Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, University of Chicago Pritzker School of Medicine, Chicago, Illinois

Manuscript received June 20, 2008; revised manuscript received August 18, 2008, accepted August 26, 2008.

^_* Reprint requests and correspondence: Dr. George L. Bakris, Hypertensive Diseases Unit, University of Chicago Pritzker School of Medicine, 5841 South Maryland Avenue, Chicago, Illinois 60637 (Email: gbakris{at}gmail.com).

Resistant hypertension is defined as failure to achieve goal blood pressure (BP) when a patient adheres to the maximum tolerated doses of 3 antihypertensive drugs including a diuretic. Although the exact prevalence of resistant hypertension is currently unknown, indirect evidence from population studies and clinical trials suggests that it is a relatively common clinical problem. The prevalence of resistant hypertension is projected to increase, owing to the aging population and increasing trends in obesity, sleep apnea, and chronic kidney disease. Management of resistant hypertension must begin with a careful evaluation of the patient to confirm the diagnosis and exclude factors associated with "pseudo-resistance," such as improper BP measurement technique, the white-coat effect, and poor patient adherence to life-style and/or antihypertensive medications. Education and reinforcement of life-style issues that affect BP, such as sodium restriction, reduction of alcohol intake, and weight loss if obese, are critical in treating resistant hypertension. Exclusion of preparations that contribute to true BP treatment resistance, such as nonsteroidal anti-inflammatory agents, cold preparations, and certain herbs, is also important. Lastly, BP control can only be achieved if an antihypertensive treatment regimen is used that focuses on the genesis of the hypertension. An example is volume overload, a common but unappreciated cause of treatment resistance. Use of the appropriate dose and type of diuretic provides a solution to overcome treatment resistance in this instance.

Key Words: resistant hypertension • management • evaluation • treatment

Abbreviations and Acronyms   ACE = angiotensin-converting enzyme   ARB = angiotensin-receptor blocker   BP = blood pressure   CCB = calcium-channel blocker   eGFR = estimated glomerular filtration rate   ERA = endothelin-receptor antagonist   NSAID = nonsteroidal anti-inflammatory drug   RAS = renin-angiotensin system

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