Resistant hypertension, defined as blood pressure bp remaining above goal despite the use of. Data sources we conducted a comprehensive search of electronic databases pubmed, embase, africa wide. Taken together, these studies suggest that pseudo resistant hypertension due to nonadherence or whitecoat hypertension likely make up half of all uncontrolled resistant hypertensive individuals. 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 rh is defined as abovegoal elevated blood pressure bp in a patient despite the concurrent use of 3. Low adherence was the most common cause of poor blood pressure control in patients with apparent resistant hypertension, being twice as frequent as secondary causes of hypertension. Although the exact prevalence of resistant hypertension is currently unknown, indirect evidence from population studies and clinical trials suggests that it is a relatively common clinical problem. Clinical considerations and the potential for renal denervation. Jnc 8 update on hypertension guidelines alan cementina, md associate clinical professor. What is the definition of hypertension high blood pressure. Systemic hypertension is one of the most treatable cardiovascular risk factors. Uncontrolled high blood pressure bp can lead to heart attack, stroke, heart failure and other serious life threats. Resistant hypertension is defined as a blood pressure bp above goal despite adherence to at least 3 different optimally dosed antihypertensives, one of which is a diuretic.
Most of the studies n64, 70% only used office blood pressure bp measurement. Pdf hypertension resistant to lifestyle interventions and antihypertensive medications is a. Patients whose blood pressure is controlled with four or more medications are considered to have resistant hypertension. New guidelines for resistant hypertension from the aha, plus targets, treatments, and marriage.
Due to higher cardiovascular risk, this disorder requires special diagnosis and. Resistant hypertension rh is defined as the blood pressure bp of a hypertensive patient that is elevated above target level in spite of the use of three antihypertensive drugs of different classes, one of which must be a diuretic. Fortunately, hypertension resistant to a good drug regimen is rare. The aha definition of resistant hypertension does not make an attempt to distinguish between resistant and pseudoresistant hypertension. Despite these difficulties the pipeline is not dry, and different new antihypertensive strategies targeting the renin angiotensinaldosterone system raas, the endothelin or. Its exact prevalence is uncertain, but it accounts for perhaps 5% to 20% of referrals to most. Individuals with elevated office bps due to whitecoat hypertension, improper bp measurement or medication nonadherence do not have true resistant hypertension but have socalled pseudoresistant hypertension. The task force for the management of arterial hypertension of. Nationally recognized expertise in treating resistant hypertension and minimizing the harm it causes. In 2018, the american heart association aha heart disease and stroke statistics update reported that about 34% of u. Prevalence of resistant hypertension is increasing. Epidemiology, prognosis, and treatment of resistant. Resistant hypertension resistant hypertension is defined by the 2018 american heart association aha scientific statement, by the 2017 american college of cardiology accaha hypertension guideline, and by the 2018 european society of cardiology and european society of hypertension escesh statement as blood pressure that remains above.
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. The aha is launching a new initiative that elevates awareness and adoption of ahas 2017 hypertension clinical guidelines. Pdf diagnosis and treatment of resistant hypertension. Essential messages from 20 eshesc guidelines for the. Data sources we conducted a comprehensive search of electronic databases pubmed. Resistant hypertension an overview sciencedirect topics. Escesh arterial hypertension management of guidelines. How to use ambulatory blood pressure monitoring in resistant hypertension free. Resistant hypertension remains a clinical challenge with few management options beyond maximisation of medications. Prevalence of apparent resistant hypertension in diseasespecific populations. Understand how to optimize diuretic therapy and use mineralocorticoid receptor antagonists to improve blood pressure in patients with resistant hypertension. Resistant hypertension is defined as blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes.
Multiple prior crosssectional assessments of subjects with resistant hypertension compared to subjects without resistant hypertension have consistently indicated in the former an increased. Hypertension guideline resources uncontrolled high blood pressure bp can lead to heart attack, stroke, heart failure and other serious life threats. Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment resistant hypertension trh. The prevalence and prognosis of resistant hypertension in patients with heart. The prognosis for patients with resistant hypertension has not been evaluated, but the guidelines. Hypertension is usually defined as resistant or refractory when a therapeutic plan that includes consideration of lifestyle methods and a prescription of at least three different drugs including a diuretic in optimal doses has failed to diminish both systolic and diastolic blood pressure bp to threshold. Aldo renin is a 54yearold africanamerican smoker with a history of obesity, diabetes, hypertension htn, and hyperlipidemia. 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.
Hypertension affects 32% of adults in western society, twothirds of whom are poorly controlled. Using the lower threshold as defined by the 2017 accaha guidelines, the prevalence of hypertension for patients 2044 years of age is 30% in men and 19% in women. Resistant hypertension rhtn is an increasingly common clinical problem 1, 2 that studies have suggested is almost always heterogeneous in terms of etiology, risk factors and comorbidities. Epidemiology, prognosis, and treatment of resistant hypertension. Despite improvements in hypertension awareness and treatment, 30%60% of hypertensive patients do not achieve bp targets and subsequently remain at risk for target organ damage. Its the norm for people with resistant hypertension to see their blood pressure drop precipitously while at pritikin, and often within one to two weeks, states dr. In the general, population of treated patients with hypertension, the prevalence of trueresistant, apparent treatmentresistant and. Undiagnosed primary aldosteronism is found in more than 10% of patients with resistant hypertension and spironolactone, in many cases in a high dose monotherapy, is the treatment of choice. Catheterbased renal artery denervation rdn was proposed in 2009 as a possible therapy for resistant hypertension and early feasibility trials caused excitement among cardiologists and antihypertensive specialists, showing remarkable and sustained blood pressure reductions. Most common secondary causes of resistant hypertension are obstructive. Abstractblood pressure that remains above target levels despite drug therapy is an increasingly common problem. Evaluation of resistant hypertension in clinical practice matthew r. Recognition and management of resistant hypertension.
Catheterbased renal artery denervation rdn was proposed in 2009 as a possible therapy for resistant hypertension and early feasibility trials caused excitement among cardiologists and antihypertensive specialists, showing remarkable and sustained blood pressure. Dec 20, 2015 resistant hypertension remains a clinical challenge with few management options beyond maximisation of medications. Resistant hypertension is defined as hypertension that is poorly responsive to treatment and requires. Danine fruge, md, medical director at the pritikin. As defined, resistant hypertension includes patients whose blood. Jan 16, 2014 resistant hypertension was initially defined to identify a group of highrisk patients who may benefit from specialized care, including evaluation and treatment of secondary causes of hypertension. Characteristics of resistant hypertension in a large, ethnically diverse hypertension population of an integrated health system.
Nationally recognized expertise in treating resistant hypertension and minimizing the harm it causes precise diagnosis to identify the type and root causes of your hypertension, including advanced home monitoring devices to track your blood pressure over a longer period of time teambased planning for challenging cases that brings together experts in nephrology, cardiology, endocrinology. Blood pressure effects of cpap in nonresistant and resistant hypertension associated with osa. Resistant hypertension rh is defined as the blood pressure bp of a hypertensive patient that is elevated above target level in spite of the use of three antihypertensive drugs of different classes, one of which must be a diuretic calhoun et al. Definition per jnc 7 2003 failure to reach goal bp pdf available in blood pressure 234 november 20 with 792 reads how we measure reads. Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. Recommendations for the management of patients with resistant hypertension. Even with steady improvement during the past 30 years in hypertension awareness, treatment, and control rates, a large proportion of hypertensive adults, despite conscientious clinical management, still fail to achieve their recommended blood pressure bp treatment targets on 3.
Resistant hypertension is a challenging problem in everyday practice, with multiple pitfalls at each step from diagnosis to treatment. Hypertension is resistant when bp exceeds goals, despite using three or more antihypertensive agents from different classes at optimal doses, one of which should be a diuretic. Hypertension epidemiology the prevalence of hypertension in u. Hypertension is widely encountered in family medicine. Ideally, one of the 3 agents should be a diuretic and all agents should be prescribed at optimal dose amounts.
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 is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. The pritikin program whats important to point out is that frank is hardly alone. New guidelines for resistant hypertension from the aha. This month sees new aha guidelines, new explanations for the benefits of statins, protection against headaches, happily married vs single life, and proof of regression in an imaging study. It has also been proposed that the label of resistant hypertension should apply to bp that requires four or more. Despite its prevalence, many patients have uncontrolled or difficulttocontrol blood pressure. This is a pdf file of an unedited manuscript that has been accepted for publication. A companion to braunwalds heart disease fourth edition, 20. Hypertension is the worlds leading risk factor for cardiovascular disease cvd, stroke, disability, and death. Resistant hypertension is a medical problem without a clear solution, since antihypertensive medications and renal denervation the common treatment options to lower blood pressure in these patients have demonstrated reduced efficacy.
Hypertension guideline resources american heart association. Resistant hypertension is defined by the seventh joint national committee jnc 7 as the inability to achieve a blood pressure lower than 14090 mm hg despite optimal doses of 3 or more antihypertensive drugs, including 1 diuretic. Excess sodium and fluid retention, increased activation of the reninangiotensin. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatmentresistant hypertension in patients with ckd. Pdf resistant hypertension is a severe medical condition which is.
Weir, md professor and director division of nephrology university of maryland school of medicine. Because hypertension is largely managed with drug therapy, clinical pharmacists often participate in management, especially when hypertension may be difficult to manage because of factors such as adverse effects or resistant hypertension. Incomplete adherence was far more common than complete nonadherence. 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. Diagnosis and management of resistant hypertension. Treatment resistant hypertension in a communitybased practice network abstract.
Jin cn, liu m, sun jp, fang f, wen yn, yu cm, lee ap. A diagnosis of true resistant hypertension should be made only after a thorough assessment to exclude apparent or pseudo resistant hypertension. Psap 2019 book 1 t cardiology 8 hypertension readings of 98089 mm hg should receive drug therapy muntner 2018. Results we included 91 studies published between 1991 and 2017 reporting data of a pooled sample of 3 207 911 patients with hypertension on antihypertensive drugs globally. With this increased attention has come a considerably better understanding of disease epidemiology, prognosis, and treatment, yet much remains unknown. Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatmentresistant hypertension trh. Resistant high blood pressure or hypertension is defined as uncontrolled blood pressure on three or more hypertension medications including a diuretic for high blood pressure.
Hypertension is widely encountered in primary care and is the most common condition managed at primary care level. Objective the hypertension epidemic in africa collectively with very low rates of blood pressure control may predict an incremented prevalence of resistant hypertension rh across the continent. Resistant hypertension is a severe medical condition which is estimated to appear in 918% of hypertensive patients. 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. Resistant hypertension resistant hypertension icr journal. 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. Full text exercise as a tool for hypertension and resistant. Covering resistant hypertension definition, prevalence, guidelines 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. May 30, 20 resistant hypertension is a common clinical problem, which, until recently, has received little attention in the medical literature. Sleepdisordered breathing and resistant hypertension. Additionally, the existence of primary aldosteronism as a cause of resistant hypertension was not investigated in this cohort, leading to substantial bias. With such a narrow definition, resistant hypertension may not sound like a major issue, but over a 30year span from 1988 to 2008, the prevalence of resistant hypertension in the united states has risen from 8. Excess sodium and fluid retention, increased activation of the reninangiotensinaldosterone.
Biomed pap med fac univ palacky olomouc czech repub 20. Therefore, the prevalence of true resistant hypertension would be estimated at 5. Resistant hypertensioncomplex mix of secondary causes and. Precise diagnosis to identify the type and root causes of your hypertension, including advanced home monitoring devices to track your blood pressure over a longer period of time. A diagnosis of true resistant hypertension should be made only after a thorough assessment to exclude apparent or pseudoresistant hypertension. Methods we conducted a search in pubmed, embase, web of science and global index medicus to identify articles published from inception to 30 september 2017. Common secondary causes of resistant hypertension and. Resistant hypertension is defined as failure to achieve goal blood pressure bp when a patient adheres to the maximum tolerated doses of 3 antihypertensive drugs including a diuretic. The current landscape of major clinical trials and treatment.
The classic definition of hypertension which is resistant to treatment is a failure to achieve goal. 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. The aim of this study was to determine the prevalence of rh and associated risk factors in africa. The highly neglected burden of resistant hypertension in. Pdf resistant hypertension rh is defined as failure to achieve goal blood. Resistant hypertension rh has been studied in several different.
Resistant hypertension is a common clinical problem, which, until recently, has received little attention in the medical literature. When hypertension fails to respond to medical treatment there is usually another explanation, such as poor patient compliance, excessive salt ingestion, drug interactions, spuriously high office readings, or an unsuspected secondary cause for the hypertension. Causes of resistant hypertension stanford health care. Evaluation of resistant hypertension in clinical practice. Diagnosis and treatment of resistant hypertension article pdf available in blood pressure 234 november 20 with 792 reads how we measure reads. New drug therapies interfering with the reninangiotensin. Refractory hypertension rfh is an extreme phenotype of resistant. Resistant hypertension rhtn is defined as blood pressure bp that remains above goal in spite of concurrent use of three antihypertensive agents from different classes, prescribed at optimal doses, one of which is ideally a diuretic. Treatmentresistant hypertension trh affects between 3 and 30% of hypertensive patients, and.
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