Resistant Hypertension

Resistant Hypertension

Definition: Blood pressure above goal despite three hypertension medications in three different classes or BP’s controlled with 4 or more medications. Refractory hypertension when uncontrolled despite maximal therapy.

Pseudo-Resistant Hypertension

• white coat hypertension
• inaccurate BP measurement
• poor med compliance
• suboptimal therapy
• poor lifestyle and diet

If indicated, evaluate for:

• primary aldosteronism
• renal artery stenosis
• chronic kidney disease
• obstructive sleep apnea

Less commonly: pheochromocytoma, cushing’s disease, aortic coarctation

Pharmacological treatment

• Standard 3 drug regimen
  • ACEI or ARB, long-acting CCB, long-acting thiazide
• If eGFR <30, loop diuretic for long control
• Add spironolactone if HTN is resistant despite 3 drug regimen.
  • Trial 12.5 mg QD and titrate up to but not above 50 mg/day
  • If patients cannot tolerate spironolactone, use eplerenone or amiloride
• Add vasodilatory beta-blocker if still persistent.  Alternatives are guanfacine or clonidine.
• If still persistent, then use hydralazine in women or minoxidil in men.