Treatment Resistant Hypertension: A Pragmatic Management Approach
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Abstract
Treatment resistant hypertension (TRH) is defined by office blood pressure (BP) uncontrolled on ≥3 or controlled on ≥4 antihypertensive medications, preferably at optimal doses and including a diuretic. Among treated hypertensives, ~30% of uncontrolled and 10% of controlled individuals have apparent treatment resistant hypertension (aTRH). The aTRH is used when optimal therapy, patient adherence, and BP measurement artifacts are unknown. In ≥50% of aTRH patients, BP measurement artifacts (‘office’ TRH), suboptimal regimens, or suboptimal adherence are present, i.e., pseudoresistance. Patients with ‘office’ TRH have fewer cardiovascular events (CVE) than those with persistent hypertension. Patients with suboptimal regimens or adherence and persistent hypertension appear to have excess CVE. ‘Office’ TRH is minimized by averaging several BP values obtained with an accurate, automated monitor, while the patient is alone in the examination room’. Home or ambulatory BP monitoring directly confirms ‘office’ TRH or persistent hypertension. Optimal therapy is reasonably defined by ≥3 different antihypertensive medication classes, e.g. thiazide-type diuretic, renin-angiotensin blocker and calcium antagonist at ≥50% of maximum recommended doses. Intensifying diuretic therapy is effective for controlling many TRH patients who are volume-expanded. Personalized strategies e.g., renin or hemodynamics, can inform successful therapy. Patient blood pressure self-monitoring and attention to adverse effects, medication costs, and pill burden can improve adherence. Suspected secondary hypertension should be evaluated and interfering substances or medications discontinued. These approaches will identify or correct the problem in ~80% of aTRH patients. Referral to a hypertension specialist is recommended for TRH patients not successfully managed with the pragmatic approach outlined.
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