Considering the growing prevalence of hypertension and the strong link with cardiovascular disease, it is vital to understand the causes and treatment of resistant hypertension. Resistant hypertension is defined as blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. The diagnosis and treatment of resistant hypertension, the. Evaluation of hypertension differential diagnosis of.
Diagnosis and management of resistant hypertension heart. The divisions of nephrology, cardiology and endocrinology, and the corrigan minehan heart center and the vascular center, jointly offer a resistant hypertension program which specializes in the evaluation, diagnosis and management of patients with resistant or difficult to treat hypertension. Abstractblood pressure that remains above target levels despite drug therapy is an increasingly common problem. Diagnosis and management of resistant hypertension american.
Management of resistant hypertension must begin with a careful evaluation of the patient to confirm the diagnosis and exclude factors associated with pseudoresistance, such as improper bp measurement technique, the whitecoat effect, and poor patient adherence to lifestyle andor antihypertensive medications. Effects of osa treatment on bp in patients with resistant. Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. The treatment and prognosis of resistant hypertension, indications for referral to a hypertension specialist, and how one identifies patients who should be screened for. Evaluation of possible rh begins with an assessment of adherence to medications. Prevalence of resistant hypertension is increasing. High blood pressure hypertension is one of the most important risk factors for cardiovascular diseases and is a significant cause of morbidity and mortality worldwide. Nonpharmacologic therapies, such as weight loss, exercise, dietary salt reduction, and moderation of alcohol intake should be encouraged in all patients. Accurate assessment of treatment adherence and use of good blood pressure. In the clinical evaluation of resistance to antihypertensive.
Calhoun da, jones d, textor s 2008 resistant hypertension. Spironolactone for resistant hypertensionhard to resist. Resistant hypertension rh is defined as blood pressure above a goal despite adherence to at least 3 optimally dosed antihypertensive medications of different classes, one of which is a diuretic. A scientific statement from the american heart association professional.
In the absence of suspected secondary causes of hypertension, referral to a hypertension specialist is recommended if the blood pressure remains elevated in spite of 6 months of treatment. Accfaha 2011 expert consensus document on hypertension in the elderly. Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension. Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment resistant hypertension trh. Evaluation and management of the patient with difficulttocontrol or resistant hypertension anthony j. Resistant hypertension is defined as high blood pressure requiring 3 or more medications for adequate control or controlled blood pressure requiring 4 or more medications.
Diagnostic evaluation and treatment hypertension is a very common modifiable risk factor for cardiovascular. It carries a significantly increased risk of endorgan damage and cardiovascular events compared with more easily controlled hypertension. The 2017 accaha guidelines definition represents a more aggressive approach to diagnosis and treatment of hypertension compared with joint national committee jnc 7 and jnc 8 recommendations, where blood pressure in the range of 1209 mmhg8089 mmhg is considered prehypertension and blood pressure 14090 mmhg is considered elevated. Specific causes of secondary hypertension will be briefly mentioned. In an evaluation of 41 consecutive patients 24 men, 17 women with treatment resistant hypertension, 83% were diagnosed.
Nov 20, 2012 resistant hypertension is defined as high blood pressure that remains uncontrolled despite treatment with at least three antihypertensive agents one of which is usually a diuretic at best tolerated doses. Diagnosis and management of resistant hypertension. As defined, resistant hypertension includes patients whose blood pressure is controlled with use of. A post hoc analysis of a subgroup of 41 patients with resistant htn showed that cpap promoted a significant reduction only in 24h diastolic bp. Common secondary causes of resistant hypertension and. Treatment of the patient with resistant hypertension includes removal of contributing factors, appropriate diagnosis and treatment of secondary causes, and use of effective multidrug regimens.
Resistant hypertension is most often related to isolated systolic hypertension and is characterized by aldosterone excess and increased intravascular volume. Pdf diagnosis and treatment of resistant hypertension. New perspectives in diagnosis and treatment of resistant. A scientific statement from the american heart association professional education committee of the council for high blood pressure research. Definition, evaluation, and new therapeutic approaches to treatment dis disord, 2017 doi. Stretching the carotid sinus to treat resistant hypertension. Resistant hypertension, secondary hypertension, and. Resistant hypertension is defined as blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes. As defined, resistant hypertension includes patients whose blood. The evaluation of resistant hypertension includes confirming blood pressure measurements with an automated device that works without the clinician present and with 24hour ambulatory monitoring. Recommendations for the management of patients with resistant hypertension.
Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. Resistant hypertension was initially defined to identify a group of highrisk patients who may benefit from specialized care, including evaluation. Request pdf resistant hypertension, secondary hypertension, and hypertensive crises. Excess sodium and fluid retention, increased activation of the reninangiotensinaldosterone. Resistant hypertension rh is defined as abovegoal elevated blood pressure bp in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a longacting calcium channel blocker, a blocker of the reninangiotensin system angiotensinconverting enzyme inhibitor or angiotensin receptor blocker, and a diuretic. Characterization and treatment of resistant hypertension. Around a quarter of adults have hypertension, and by 2025, the number affected might be more than 15 billion people worldwide. What is the treatment for resistant hypertension high blood. A scientific statement from the american heart association professional education committee. Resistant hypertension diagnosis, evaluation, and treatment. Mechanisms and treatment of resistant hypertension pimenta.
Effect of the physical activity program on the treatment of. Resistant hypertension is a common medical problem. Diagnosis, evaluation, and treatment a scientific statement from the american heart association professional. Evaluation and management of the patient with difficultto. Methods we conducted a search in pubmed, embase, web of science and global index medicus to identify articles published from inception to 30. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Due to higher cardiovascular risk, this disorder requires special diagnosis and. Evaluation of resistant hypertension in clinical practice.
Resistant hypertension is characterised by failure to achieve a blood pressure of less than 14090 mm hg while on maximum tolerated doses of three different classes of antihypertensive drugs, including a diuretic appropriate for kidney function. Patients whose blood pressure is controlled with four or more medications are considered to have resistant hypertension. Her bp is 14090 in pcp office for several times while taking. American heart association professional education committee. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance. Much less is known about the impact of physical exercise on the management of treatment of resistant hypertension rh. 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. Resistant hypertension is a severe medical condition which is estimated to appear in 918% of hypertensive patients. Ideally, one of the 3 agents should be a diuretic and all agents should be prescribed at optimal dose amounts. The evaluation of patients with resistant hypertension should be directed toward confirming true treatment resistance. As a subgroup, patients with resistant hypertension have not been widely studied. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Resistant hypertension american board of family medicine.
Untreated obstructive sleep apnea is strongly associated with hypertension and in normotensive persons predicts development of hypertension. Regular physical activity is widely recommended for patients with arterial hypertension as an essential component of lifestyle modification. A diagnosis of true resistant hypertension should be made only after a thorough assessment to exclude apparent or pseudo resistant hypertension. The whitecoat effect should be ruled out by outofoffice blood pressure monitoring. Resistant hypertension is generally defined as uncontrolled clinic blood pressure 14090 mm hg after treatment with three or more antihypertensives.