Evaluation of possible rh begins with an assessment of adherence to medications. A scientific statement from the american heart association professional education committee of the council for high blood pressure research. New perspectives in diagnosis and treatment of resistant. Due to higher cardiovascular risk, this disorder requires special diagnosis 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. 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. Diagnosis and management of resistant hypertension.
Resistant hypertension was initially defined to identify a group of highrisk patients who may benefit from specialized care, including evaluation. 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. As defined, resistant hypertension includes patients whose blood pressure is controlled with use of. Excess sodium and fluid retention, increased activation of the reninangiotensinaldosterone. Stretching the carotid sinus to treat resistant hypertension. Diagnostic evaluation and treatment hypertension is a very common modifiable risk factor for cardiovascular.
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. Effect of the physical activity program on the treatment of. Evaluation and management of the patient with difficulttocontrol or resistant hypertension anthony j. Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment resistant hypertension trh. 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.
It carries a significantly increased risk of endorgan damage and cardiovascular events compared with more easily controlled hypertension. Specific causes of secondary hypertension will be briefly mentioned. Accfaha 2011 expert consensus document on hypertension in the elderly. Untreated obstructive sleep apnea is strongly associated with hypertension and in normotensive persons predicts development of hypertension. Characterization and treatment of resistant hypertension. A scientific statement from the american heart association professional education committee. Request pdf resistant hypertension, secondary hypertension, and hypertensive crises. Resistant hypertension diagnosis, evaluation, and treatment. Nonpharmacologic therapies, such as weight loss, exercise, dietary salt reduction, and moderation of alcohol intake should be encouraged in all patients. Evaluation of resistant hypertension in clinical practice. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Resistant hypertension, secondary hypertension, and. Around a quarter of adults have hypertension, and by 2025, the number affected might be more than 15 billion people worldwide. Pdf diagnosis and treatment of resistant hypertension.
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. Evaluation of hypertension differential diagnosis of. Effects of osa treatment on bp in patients with resistant. 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. Prevalence of resistant hypertension is increasing. 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. Evaluation and management of the patient with difficultto. The evaluation of patients with resistant hypertension should be directed toward confirming true treatment resistance.
American heart association professional education committee. Diagnosis and management of resistant hypertension american. Abstractblood pressure that remains above target levels despite drug therapy is an increasingly common problem. Resistant hypertension is a common medical problem. Recommendations for the management of patients with resistant hypertension. Resistant hypertension is most often related to isolated systolic hypertension and is characterized by aldosterone excess and increased intravascular volume. Accurate assessment of treatment adherence and use of good blood pressure. Patients whose blood pressure is controlled with four or more medications are considered to have resistant hypertension. Resistant hypertension is defined as blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes.
The diagnosis and treatment of resistant hypertension, the. The treatment and prognosis of resistant hypertension, indications for referral to a hypertension specialist, and how one identifies patients who should be screened for. 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 evaluation of resistant hypertension includes confirming blood pressure measurements with an automated device that works without the clinician present and with 24hour ambulatory monitoring. Mechanisms and treatment of resistant hypertension pimenta. Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. 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. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels.
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. A scientific statement from the american heart association professional. Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. In the clinical evaluation of resistance to antihypertensive. Much less is known about the impact of physical exercise on the management of treatment of resistant hypertension rh. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance. Diagnosis and management of resistant hypertension heart. Regular physical activity is widely recommended for patients with arterial hypertension as an essential component of lifestyle modification.
Diagnosis, evaluation, and treatment a scientific statement from the american heart association professional. Methods we conducted a search in pubmed, embase, web of science and global index medicus to identify articles published from inception to 30. Ideally, one of the 3 agents should be a diuretic and all agents should be prescribed at optimal dose amounts. Spironolactone for resistant hypertensionhard to resist. 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. Calhoun da, jones d, textor s 2008 resistant hypertension. Her bp is 14090 in pcp office for several times while taking. Resistant hypertension is generally defined as uncontrolled clinic blood pressure 14090 mm hg after treatment with three or more antihypertensives. Resistant hypertension is a severe medical condition which is estimated to appear in 918% of hypertensive patients.
As a subgroup, patients with resistant hypertension have not been widely studied. As defined, resistant hypertension includes patients whose blood. In an evaluation of 41 consecutive patients 24 men, 17 women with treatment resistant hypertension, 83% were diagnosed. Common secondary causes of resistant hypertension and. What is the treatment for resistant hypertension high blood. 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. The whitecoat effect should be ruled out by outofoffice blood pressure monitoring. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded.
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