Definition, risk factors, and evaluation of resistant hypertension
- David A Calhoun, MD
David A Calhoun, MD
- Professor of Medicine
- University of Alabama at Birmingham
- Raymond R Townsend, MD
Raymond R Townsend, MD
- Professor of Medicine
- Perelman School of Medicine
- University of Pennsylvania
- Section Editors
- George L Bakris, MD
George L Bakris, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Professor of Medicine
- The University of Chicago
- Norman M Kaplan, MD
Norman M Kaplan, MD
- Editor-in-Chief — Nephrology
- Section Editor — Hypertension
- Clinical Professor of Internal Medicine
- University of Texas Southwestern Medical Center
Patients with persistent hypertension despite multiple medications are at high risk for adverse cardiovascular events and are more likely than those with controlled hypertension to have a secondary (ie, identifiable) cause, which is usually at least in part reversible.
The definition, prevalence, risk factors, and evaluation of resistant hypertension will be reviewed here. Specific causes of secondary hypertension will be briefly mentioned. The treatment and prognosis of resistant hypertension, indications for referral to a hypertension specialist, and how one identifies patients who should be screened for secondary hypertension are discussed elsewhere. (See "Treatment of resistant hypertension" and "Evaluation of secondary hypertension".)
Resistant hypertension — Resistant hypertension is defined in the 2008 American Heart Association scientific statement and the 2013 guidelines from the European Societies of Hypertension and Cardiology (ESH/ESC) as blood pressure that remains above goal in spite of concurrent use of three antihypertensive agents of different classes [1,2]. Thus, patients whose blood pressure is controlled with four or more medications should be considered to have resistant hypertension.
If tolerated, one of the three agents should be a diuretic, and all agents should be prescribed at optimal doses (ie, 50 percent or more of the maximum recommended antihypertensive dose) . Goal blood pressure is less than 140/90 mmHg in average-risk hypertensive patients. There is evidence supporting a lower goal blood pressure in patients with atherosclerotic cardiovascular disease, stroke, diabetes mellitus, or chronic kidney disease. The supportive data are presented separately. (See "What is goal blood pressure in the treatment of hypertension?" and "Goal blood pressure in patients with cardiovascular disease or at high risk", section on 'Goal blood pressure' and "Antihypertensive therapy to prevent recurrent stroke or transient ischemic attack" and "Treatment of hypertension in patients with diabetes mellitus", section on 'Goal blood pressure' and "Antihypertensive therapy and progression of nondiabetic chronic kidney disease in adults", section on 'Blood pressure goal'.)
Although patients with resistant hypertension may have elevations in both systolic and diastolic pressures, isolated systolic hypertension is common. In the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT) of over 33,000 hypertensive patients treated with different antihypertensive drugs, only 67 percent of participants attained a systolic blood pressure below 140 mmHg, whereas 92 percent attained a diastolic pressure below 90 mmHg . Treatment of older adults with isolated systolic hypertension that is resistant to therapy may be more difficult since intensification of the therapeutic regimen may lead to unacceptably low diastolic pressures. (See "Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension", section on 'Resistant hypertension' and "Treatment of hypertension in the elderly patient, particularly isolated systolic hypertension".)
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- Resistant hypertension
- - Refractory hypertension
- Apparent, true, and pseudoresistant hypertension
- - White coat hypertension
- RISK FACTORS
- Suboptimal therapy
- Lifestyle and diet
- Extracellular volume expansion
- Secondary causes of hypertension
- - Clinical clues
- - Primary aldosteronism
- - Renal artery stenosis
- - Chronic kidney disease
- Obstructive sleep apnea
- BLOOD PRESSURE MEASUREMENT
- Ambulatory and home blood pressure monitoring
- Cuff inflation hypertension
- OTHER COMPONENTS OF EVALUATION
- Medical history
- Physical examination
- Laboratory evaluation
- Noninvasive imaging
- SUMMARY AND RECOMMENDATIONS