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104 Resistant Hypertension in Clinical Practice

hypertension is complicated by the associated high • All failure hypertension should not be taken as re-
CV risk, which limits the safe withdrawal of medica- fractory hypertension, as pseudorefractory & sec-
tions and which restricts the types and duration of ondary hypertension may also simulate in one way
experimental interventions that can be used to ex- or other. Even white coat hypertension should be
plore proposed etiologies. Studies are further limited clearly separated before putting a level of resistant
by concomitant disease processes such as diabe- hypertension.
tes, CKD, sleep apnea, and atherosclerotic disease. • Compared with patients with white-coat hyper-
These concurrent diseases and their treatments are tension, true resistant hypertension is associated
difficult to systematically control for and confound with male gender,longer duration of hypertension,
interpretation of study results. Overcoming such a smoking, diabetes, target-organ damage (as mea-
challenge will likely require a consortium of hyper- sured by presence of LVH, impaired renal function,
tension centres allowing for multicenter participation.
microalbuminuria, documented CVD.
Lastly, even among patients with resistant hyperten- • ABPM is desirable for correct diagnosis and man-
sion, subgroups of patients with different aetiologies agement.
undoubtedly exist. As an extreme example, the young
patient with combined systolic and diastolic resistant • For true resistant hypertension along with avail-
hypertension is undoubtedly different in terms of able drugs (excluding secondary hypertension,and
aetiology, prognosis, and likely effective treatment ensuring normal renal functions), renal denerva-
than the elderly patient with severe, isolated, resis- tion should be considered when both kidneys are
tant systolic hypertension. Meaningful differentiation normal in terms of anatomy, vasculature without
of these subgroups will likely speed identification of stenosis/stenting of both renal arteries.
respective causes of treatment resistance and devel-
opment of specific treatment strategies. References
Much additional knowledge is needed to better iden- 1. The ALLHAT Officers and Coordinators for the ALLHAT Collaborative Re-
search Group (2002). Major Outcomes in High-Risk Hypertensive Patients
tify and treat patients with resistant hypertension. Randomized to Angiotensin-Converting Enzyme Inhibitor or Calcium Chan-
Cross-sectional and outcome studies have identified nel Blocker vs Diuretic: The Antihypertensive and Lipid-Lowering Treat-
patient characteristics associated with resistant hy- ment to Prevent Heart Attack Trial (ALLHAT). JAMA: The Journal of the
pertension, but underlying mechanisms of treatment American Medical Association, 288(23), pp.2981-2997.
resistance, particularly potential genetic mechanisms, 2. Persell, S. (2011). Prevalence of Resistant Hypertension in the United
have not been widely investigated. Efficacy assess- States, 2003-2008. Hypertension, 57(6), pp.1076-1080.
ments of specific multidrug regimens are needed to 3. de la Sierra, A., Segura, J., Banegas, J., Gorostidi, M., de la Cruz, J.,
better guide therapy. Armario, P., Oliveras, A. and Ruilope, L. (2011). Clinical Features of 8295
Patients With Resistant Hypertension Classified on the Basis of Ambulatory
Blood Pressure Monitoring. Hypertension, 57(5), pp.898-902.
HIGHLIGHT
4. Bangalore, S., Kamalakkannan, G., Parkar, S. and Messerli, F. (2007).
• Failure to achieve goal BP (<140/90 mmHg) using Fixed-Dose Combinations Improve Medication Compliance: A Meta-Anal-
3 different drugs with pharmacologically comple- ysis. The American Journal of Medicine, 120(8), pp.713-719.
mentary mechanisms, one of which is an appro- 5. Myers, M., Valdivieso, M. and Kiss, A. (2009). Use of automated office
priately dosed diuretic. blood pressure measurement to reduce the white coat response. Journal
of Hypertension, 27(2), pp.280-286.
• All three drugs given in maximally tolerated dos-
es .Failure to control blood pressure (BP) inevita- 6. Pickering, T. and White, W. (2008). When and how to use self (home)
and ambulatory blood pressure monitoring. Journal of the American Society
bly heralds renal deterioration as well as accom- of Hypertension, 2(3), pp.119-124.
panying increases in cardiovascular morbidity and
mortality.
• CKD itself is a predictor of cardiovascular events
as a result of failure to achieve adequate BP con-
trol.
• BP control should be a role in management of CKD
& diabetes mellitus.
• A resistant hypertension in CKD & DM, results
poor prognosis, high mortality, more prone to ter-
minal cardiovascular events.

GCDC 2017