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. Resistant hypertension is generally defined as uncontrolled clinic blood pressure 14090 mm hg after treatment with three or more antihypertensives. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance. 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. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Effect of the physical activity program on the treatment of. Resistant hypertension american board of family medicine. Around a quarter of adults have hypertension, and by 2025, the number affected might be more than 15 billion people worldwide. Diagnosis and management of resistant hypertension american. 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 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. Specific causes of secondary hypertension will be briefly mentioned.
Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. 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. A scientific statement from the american heart association professional education committee. Resistant hypertension rh is defined as abovegoal elevated blood pressure bp in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a longacting calcium channel blocker, a blocker of the reninangiotensin system angiotensinconverting enzyme inhibitor or angiotensin receptor blocker, and a diuretic. A scientific statement from the american heart association professional education committee of the council for high blood pressure research. American heart association professional education committee. Resistant hypertension, secondary hypertension, and. A scientific statement from the american heart association professional. Diagnosis and management of resistant hypertension heart. Spironolactone for resistant hypertensionhard to resist.
Continuous positive airway pressure treatment in sleep apnea patients with resistant hypertension. Definition, evaluation, and new therapeutic approaches to treatment dis disord, 2017 doi. As a subgroup, patients with resistant hypertension have not been widely studied. Resistant hypertension is most often related to isolated systolic hypertension and is characterized by aldosterone excess and increased intravascular volume. Common secondary causes of resistant hypertension and. 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. Resistant hypertension was initially defined to identify a group of highrisk patients who may benefit from specialized care, including evaluation. High blood pressure hypertension is one of the most important risk factors for cardiovascular diseases and is a significant cause of morbidity and mortality worldwide. Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment resistant hypertension trh. As defined, resistant hypertension includes patients whose blood. Diagnosis and management of resistant hypertension. Due to higher cardiovascular risk, this disorder requires special diagnosis and. Pdf diagnosis and treatment of resistant hypertension. A diagnosis of true resistant hypertension should be made only after a thorough assessment to exclude apparent or pseudo resistant hypertension.
The diagnosis and treatment of resistant hypertension, the. Patients whose blood pressure is controlled with four or more medications are considered to have resistant hypertension. 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. In an evaluation of 41 consecutive patients 24 men, 17 women with treatment resistant hypertension, 83% were diagnosed. Evaluation of hypertension differential diagnosis of. Evaluation of possible rh begins with an assessment of adherence to medications. Nonpharmacologic therapies, such as weight loss, exercise, dietary salt reduction, and moderation of alcohol intake should be encouraged in all patients.
Evaluation and management of the patient with difficultto. The evaluation of patients with resistant hypertension should be directed toward confirming true treatment resistance. Prevalence of resistant hypertension is increasing. Methods we conducted a search in pubmed, embase, web of science and global index medicus to identify articles published from inception to 30. Evaluation and management of the patient with difficulttocontrol or resistant hypertension anthony j. The treatment and prognosis of resistant hypertension, indications for referral to a hypertension specialist, and how one identifies patients who should be screened for.
Request pdf resistant hypertension, secondary hypertension, and hypertensive crises. In the clinical evaluation of resistance to antihypertensive. Recommendations for the management of patients with resistant hypertension. Her bp is 14090 in pcp office for several times while taking. New perspectives in diagnosis and treatment of resistant. What is the treatment for resistant hypertension high blood. 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. Resistant hypertension is defined as blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes. Untreated obstructive sleep apnea is strongly associated with hypertension and in normotensive persons predicts development of hypertension. Diagnostic evaluation and treatment hypertension is a very common modifiable risk factor for cardiovascular. Evaluation of resistant hypertension in clinical practice. 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.
Ideally, one of the 3 agents should be a diuretic and all agents should be prescribed at optimal dose amounts. As defined, resistant hypertension includes patients whose blood pressure is controlled with use of. 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. The whitecoat effect should be ruled out by outofoffice blood pressure monitoring. It carries a significantly increased risk of endorgan damage and cardiovascular events compared with more easily controlled hypertension. Excess sodium and fluid retention, increased activation of the reninangiotensinaldosterone. 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. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is a common medical problem.
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. Accfaha 2011 expert consensus document on hypertension in the elderly. Characterization and treatment of resistant hypertension. 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. Effects of osa treatment on bp in patients with resistant. Resistant hypertension is a severe medical condition which is estimated to appear in 918% of hypertensive patients. Abstractblood pressure that remains above target levels despite drug therapy is an increasingly common problem.
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. Resistant hypertension diagnosis, evaluation, and treatment. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Stretching the carotid sinus to treat resistant hypertension. 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. 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.
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