Controversies in Hypertension V: Resistant and Refractory Hypertension

Link to article at PubMed

Am J Med. 2023 Oct 11:S0002-9343(23)00618-6. doi: 10.1016/j.amjmed.2023.09.015. Online ahead of print.


Apparent resistant hypertension, defined as uncontrolled office blood pressure despite ≥ 3 antihypertensive medications including a diuretic or use of ≥ 4 medications regardless of blood pressure, occurs in ≤ 15 % of treated hypertensives. Apparent refractory hypertension, defined as uncontrolled office pressure despite use of 5 or more medications including a diuretic, occurs in ≤ 10% of resistant cases. Both are associated with increased comorbidity and enhanced cardiovascular risk. To rule out pseudo-resistant/pseudo-refractory hypertension, employ guideline-based methodology for obtaining pressure, maximize the regimen, rule-out white-coat effect, and assess adherence. True resistant hypertension is characterized by volume overload and aldosterone excess, refractory by enhanced sympathetic tone. Spironolactone is the preferred agent for resistance, with lower doses and/or potassium binders if eGFR below 45; if significant albuminuria, finerenone is indicated. The optimal treatment of refractory hypertension is unclear, but sympathetic inhibition (α/β-blockade and/or centrally acting sympathoinhibitors) seems reasonable. Renal denervation has shown minimal benefit for resistance but its role in refractory hypertension remains to be defined.

PMID:37832756 | DOI:10.1016/j.amjmed.2023.09.015

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