Resistant hypertension – diagnosis and treatment Review article
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Abstract
Blood pressure persistently higher than 140/90 mmHg despite optimal combination and doses of three or more drugs, including a diuretic, is commonly identified as Resistant Hypertension. Most frequently, treatment resistance is caused by inefficient non-pharmacological component, misprescription, secondary hypertension, and concomitant diseases. The non-pharmacological treatment deficiency would usually result from a failure to reverse lifestyle factors promoting resistance such as overweight, excessive salt or alcohol intake, and smoking. Drug mistreatment may involve a failure to prescribe diuretics, inappropriately low dosages and/or combinations of drugs, or use of blood pressure elevating agents. Obstructive sleep apnoea, hyperaldosteronism, renal artery stenosis are the most common symptoms of secondary causes of hypertension should always be evaluated as potential indicators of resistant hypertension. Diabetes, metabolic syndrome, chronic renal disease, depression, pain syndrome and insomnia are all factors contributing to increased risk of resistant hypertension. A thorough review of adequacy and reliability of blood pressure measurement technique combined with a 24 hour Holter monitoring may be helpful in verification of potential measurement errors and exclusion of pseudo hypertension resulting from misdiagnosis or mistreatment. Every suspicion of resistant hypertension needs to be verified by rejection of pseudo resistance and/or secondary hypertension through addressing lifestyle contributors and optimisation of treatment scheme. Suitable pharmacological treatment with multi drug regimen should involve antihypertensive agents of five basic classes, aldosterone antagonist included, if desirable. Where needed, invasive treatments such as catheter based renal denervation may be considered.
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