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Cardio Diabetes Medicine 2017 97

Resistant Hypertension

in Clinical Practice

Dr Virendra Kumar Goyal, DM., FICP., FACP., FIACM.,

HOD-Internal Medicine, G. B. H.
American International Institute of Medical Sciences

ABSTRACT: their associated medical therapies, which confound
Resistant hypertension is a common clinical prob- interpretation of study results; and the difficulty in
lem faced by primary care clinicians and specialists. enrolling large numbers of study participants. Ex-
It is not rare, involving perhaps 20% to 30% of study panding our understanding of the causes of resis-
participants. The prognosis of resistant hyperten- tant hypertension and thereby potentially allowing for
sion is unknown, but cardiovascular risk is undoubt- more effective prevention and/or treatment will be
edly increased as patients often have a history of essential to improve the long-term clinical manage-
long-standing, severe hypertension complicated by ment of this disorder.
multiple other CV risk factors such as obesity, sleep
apnoea, diabetes, and CKD. The diagnosis of resis- INTRODUCTION
tant hypertension requires use of good blood pres- Resistant hypertension is defined as blood pressure
sure technique to confirm persistently elevated blood that remains above goal in spite of the concurrent
pressure levels. Pseudo resistance, including lack of use of 3 antihypertensive agents of different classes
blood pressure control secondary to poor medica- at optimal dose amounts, out of which one should
tion adherence or white coat hypertension, must be be a diuretic. Arbitrary, resistant hypertension is de-
excluded. Resistant hypertension is almost always fined in order to identify patients who are at high
multifactorial in etiology. Successful treatment re- risk of having reversible causes of hypertension and/
quires identification and reversal of lifestyle factors or patients who, because of persistently high blood
contributing to treatment resistance; diagnosis and pressure levels, may benefit from special diagnos-
appropriate treatment of secondary causes of hy- tic and therapeutic considerations. Patients whose
pertension; and use of effective multidrug regimens. blood pressure is controlled but require 4 or more
Observational assessments have allowed for identi- medications to do so should be considered resistant
fication of demographic and lifestyle characteristics to treatment.
associated with resistant hypertension, and the role
of secondary causes of hypertension in promoting PREVALENCE
treatment resistance is well documented; however, The prevalence of resistant hypertension is unknown;
identification of broader mechanisms of treatment however, it is not uncommon.
resistance is lacking. In particular, attempts to eluci-
date potential genetic causes of resistant hyperten- Uncontrolled hypertension is not synonymous with
sion have been limited. Recommendations for the resistant hypertension. The former includes patients
pharmacological treatment of resistant hypertension who lack blood pressure control secondary to poor
remain largely empiric due to the lack of systematic adherence and/or an inadequate treatment regimen,
assessments of 3 or 4 drug combinations. Studies as well as those with true treatment resistance.
of resistant hypertension are limited by the high CV African-American participants had more treatment
risk of patients within this subgroup, which gener- resistance & black women had the lowest control rate
ally precludes safe withdrawal of medications; the (59%) and non-black men the highest (70%).
presence of multiple disease processes (e.g., sleep
apnoea, diabetes, CKD, atherosclerotic disease) and

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