We all understand that hypertension remains the world’s leading risk factor for cardiovascular disease, stroke, disability, and ultimately, death. Even with a multitude of updates from the Joint National Committee and steady improvement in hypertension awareness, treatment, and control rates, a vast majority of adults with hypertension still fail to achieve their recommended blood pressure treatment targets, even with three antihypertensive medications, and they have to be placed on four or more medications to achieve their targets. These patients are designated as having resistant hypertension (RH), and they remain at increased risk for morbidity and mortality.
The typical characteristics of a patient with RH include African American race, older age, and male sex. Comorbidities associated with RH include obesity, left ventricular hypertrophy, albuminuria, diabetes mellitus, chronic kidney disease, and a higher Framingham 10-year risk score. All are more common in patients with RH than in those without RH.
So, what do we do if we cannot get a patient’s blood pressure under control? Remember that the goal blood pressure for patients with RH is the same as that in patients with hypertension without treatment resistance. Try the following measures in your patient before referring to a hypertension specialist:
Switch to a more potent diuretic:
If estimated glomerular filtration rate (eGFR) is ≥30 mL/min/1.72 m2, start chlorthalidone at 12.5 mg daily with titration up to 25 mg daily. If indapamide is used, start at 1.25 mg daily, titrating up to 5 mg daily as needed.
If eGFR <30 mL/min/1.72 m2, try switching to a loop diuretic; furosemide and bumetanide are relatively short acting and usually require BID dosing.
Add a mineralocorticoid receptor antagonist: A mineralocorticoid receptor antagonist (eg, spironolactone 12.5 mg daily then titrating to 25 mg, or eplerenone 50 mg daily) can yield significant antihypertensive benefit when added to existing multiple-drug regimens in patients with RH.
I recommend referral to a hypertension specialist if blood pressure remains elevated despite 6 months of intensive treatment with at least three drugs classes. Other specialists may need to be consulted if you suspect a specific secondary cause of hypertension.