What is the approach to managing resistant Hypertension (HTN)?

From the Guidelines

For resistant hypertension, I recommend a comprehensive approach starting with reinforcement of lifestyle measures, especially sodium restriction, and addition of low-dose spironolactone to existing treatment, as outlined in the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1.

Key Considerations

• The approach to managing resistant hypertension should prioritize lifestyle modifications, including sodium restriction, regular physical activity, and weight loss if overweight.
• The addition of low-dose spironolactone to existing treatment is recommended, as it has been shown to be effective in reducing blood pressure in patients with resistant hypertension 1.
• If spironolactone is not effective or tolerated, alternative options such as eplerenone, beta-blockers, or alpha-blockers may be considered 1.
• Evaluation for secondary causes of hypertension, including obstructive sleep apnea, primary aldosteronism, and renal artery stenosis, is also crucial in managing resistant hypertension 1.

Treatment Options

• Addition of low-dose spironolactone: 25-50mg daily, as a fourth agent, which is particularly effective for resistant hypertension 1.
• Alternative options: beta-blockers (metoprolol 25-100mg twice daily) or alpha-blockers (doxazosin 1-8mg daily) if spironolactone is contraindicated 1.
• Lifestyle modifications: reduce sodium intake to <2g daily, maintain regular physical activity, limit alcohol consumption, achieve weight loss if overweight, and follow the DASH diet 1.

Specialist Referral

• Resistant hypertension should be managed in specialist centers with sufficient expertise and resources necessary to diagnose and treat this condition 1.

From the FDA Drug Label

Many patients will require more than one drug to achieve blood pressure goals. For specific advice on goals and management, see published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC)

The approach to managing resistant Hypertension (HTN) is to use multiple drugs to achieve blood pressure goals, and to follow published guidelines such as those from the National High Blood Pressure Education Program’s Joint National Committee 2, 3, 4.

• Key considerations include:
  • Using more than one drug to achieve blood pressure goals
  • Following published guidelines for management
  • Considering comprehensive cardiovascular risk management, including lipid control, diabetes management, antithrombotic therapy, smoking cessation, exercise, and limited sodium intake.

From the Research

Definition and Diagnosis of Resistant Hypertension

• Resistant hypertension is defined as blood pressure levels that remain elevated above target despite the daily intake of three antihypertensive drugs in maximally tolerated dosages, including an angiotensin-converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB), a calcium channel blocker, and a diuretic 5, 6, 7, 8.
• The diagnosis of resistant hypertension requires the exclusion of non-adherence, "white coat effect", and incorrect BP-measurement 5, 6, 7, 8.
• Resistant hypertension can also be diagnosed in patients on four or more antihypertensive drug classes 5.

Lifestyle Interventions

• Lifestyle interventions, such as low dietary salt intake and regular physical activity, are recommended for patients with resistant hypertension 5, 6, 7, 8.
• Weight loss and discontinuation of substances that can interfere with blood pressure control are also recommended 6, 8.

Treatment Options

• Treatment options for resistant hypertension include lifestyle optimization and escalation of antihypertensive medication 5, 6, 7, 8.
• Mineralocorticoid receptor antagonists (MRA) should be the next treatment choice in most patients on triple treatment (ACE-I or ARB plus calcium channel blocker plus diuretic) 5, 6, 7.
• Alternatives to MRA include beta-blockers, long-acting nondihydropyridine calcium channel blockers, clonidine, and guanfacine 6, 8.
• New approaches under research include selective non-steroidal mineralocorticoid receptor antagonists, selective aldosterone synthase inhibitors, and dual endothelin antagonists 6.

Secondary Hypertension

• Secondary hypertension should be considered in patients with resistant hypertension, including endocrine disorders and renal disease 5, 6, 7, 8.
• The leading endocrine cause of secondary hypertension is primary hyperaldosteronism 5.
• Sleep apnoea disorders are now mostly considered as a comorbidity rather than as a cause of secondary hypertension 5.