From the Guidelines
The recommended workup for resistant hypertension begins with confirming true resistance by ensuring proper blood pressure measurement technique, medication adherence, and ruling out white coat hypertension through ambulatory or home blood pressure monitoring, as stated in the 2024 ESC guidelines 1.
Key Components of Workup and Treatment
- Evaluation should include screening for secondary causes such as obstructive sleep apnea, primary aldosteronism, renal artery stenosis, chronic kidney disease, and pheochromocytoma.
- Laboratory tests should assess electrolytes, kidney function, thyroid function, and urinary albumin.
- Treatment involves optimizing the medication regimen with a three-drug combination including a thiazide-type diuretic, an ACE inhibitor or ARB, and a calcium channel blocker.
- If blood pressure remains uncontrolled, adding spironolactone as a fourth agent is recommended, particularly effective in patients with primary aldosteronism, as supported by the 2024 ESC guidelines 1 and the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.
Lifestyle Modifications and Additional Considerations
- Lifestyle modifications remain crucial, including sodium restriction, weight loss, regular physical activity, limited alcohol consumption, and following the DASH diet.
- The addition of further diuretic therapy, eplerenone, amiloride, or beta-blockers like bisoprolol or doxazosin may be considered if spironolactone is not effective or tolerated, as recommended in the 2024 ESC guidelines 1.
- Referral to a specialist center with sufficient expertise and resources is necessary for the management of resistant hypertension, as emphasized in the 2020 International Society of Hypertension global hypertension practice guidelines 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Definition and Diagnosis of Resistant Hypertension
- Resistant hypertension is defined as blood pressure that remains above the therapeutic goal despite concurrent use of at least three antihypertensive agents of different classes, including a diuretic, with all agents administered at maximum or maximally tolerated doses 2, 3, 4, 5.
- The diagnosis of resistant hypertension requires the exclusion of apparent treatment resistant hypertension, which is most often the result of non-adherence to treatment 5.
- Resistant hypertension is also diagnosed if blood pressure control requires four or more antihypertensive drugs 2, 5.
Evaluation and Treatment Approach
- The evaluation of resistant hypertension must begin with a careful evaluation of the patient to confirm the diagnosis and exclude factors associated with "pseudo-resistance," such as improper BP measurement technique, the white-coat effect, and poor patient adherence to life-style and/or antihypertensive medications 6.
- Lifestyle changes such as reduced sodium and alcohol intake, regular physical activity, weight loss, and discontinuation of substances that can interfere with blood pressure control are recommended 2.
- The treatment approach typically includes a combination of lifestyle adjustments and pharmacologic treatment, with a focus on the genesis of the hypertension 6.
- Antihypertensive medication regimens may include a diuretic, a long-acting calcium channel blocker, an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, and a mineralocorticoid receptor antagonist 2, 3, 4, 5.
Pharmacologic Treatment Options
- Mineralocorticoid receptor antagonists such as spironolactone are recommended as a fourth-line treatment for patients with resistant hypertension 2, 3, 4.
- Alternatives to spironolactone include amiloride, doxazosin, eplerenone, clonidine, and beta-blockers, as well as any other antihypertensive drugs not already in use 2.
- New approaches under research include selective non-steroidal mineralocorticoid receptor antagonists, selective aldosterone synthase inhibitors, and dual endothelin receptor antagonists 2, 5.