Treatment 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
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 . Patients whose blood pressure is controlled with four or more medications are considered to have resistant hypertension.
Patients with resistant hypertension are at high risk for adverse cardiovascular events and are more likely than those with controlled hypertension to have a secondary cause, which is usually at least in part reversible.
The treatment and prognosis of resistant hypertension that is not due to secondary causes will be reviewed here. The definition, prevalence, risk factors, and evaluation of resistant hypertension and secondary causes of hypertension, such as renovascular disease and primary aldosteronism, are discussed elsewhere. (See "Definition, risk factors, and evaluation of resistant hypertension" and "Evaluation of secondary hypertension".)
DEFINITION AND GOAL BLOOD PRESSURE
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 (selected based upon kidney function) . Patients whose blood pressure is controlled with four or more medications are considered to have resistant hypertension.
The goal blood pressure is less than 140/90 mmHg in average-risk hypertensive patients. There is evidence supporting a lower goal blood pressure (ie, <130/80 mmHg) in patients with atherosclerotic cardiovascular disease and in patients with proteinuric 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 and progression of nondiabetic chronic kidney disease in adults", section on 'Blood pressure goal'.)
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- DEFINITION AND GOAL BLOOD PRESSURE
- GENERAL PRINCIPLES
- Identify and treat secondary hypertension
- Stop medications that raise the blood pressure
- Refer to a hypertension specialist
- Out-of-office blood pressure monitoring
- NONPHARMACOLOGIC THERAPY
- PHARMACOLOGIC THERAPY
- Mineralocorticoid receptor antagonists
- CHOICE OF REGIMEN
- EXPERIMENTAL THERAPIES
- Catheter-based radiofrequency ablation of renal sympathetic nerves
- Electrical stimulation of carotid sinus baroreceptors
- Central arteriovenous anastomosis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS