INCREASE IN TREATMENT-REFRACTORY HYPERTENSION: PROGRESS IN CURRENT TREATMENT BY PRIMARY CARE

Abstract

The prevalence of treatment resistant hypertension (TRH) defined as blood pressure (BP) uncontrolled on ≥3 antihypertensive medications in optimal doses, preferably including a diuretic, or controlled on ≥4 BP medications is unknown. Clinical trials suggest that 20–30% of hypertensives have TRH. Using U.S. NHANES data, the prevalence of apparent (a) TRH among treated, uncontrolled (BP ≥140/≥90 mmHg) individuals rose from 15.9% in 1988–1994 to 28.0% in 2005–2008; ‘aTRH’ is used, since medication dose, adherence, and measurement artefacts are unavailable in NHANES. About 30–50% of patients with aTRH have pseudoresistance, i.e., inaccurate BP, non-representative BP (‘office’ effect), or non-adherence. The Spanish Ambulatory BP Monitoring Registry reported that 3 in 8 patients with aTRH have ‘office’ resistance with normal ambulatory BP. Primary care clinicians can manage most TRH patients. First, primary care clinicians verify whether the regimen is appropriate, patient adherence, and carefully measured office readings are elevated. Second, document BP values out-of-office. Third, for the 50–70% with ‘true’ TRH, identify contributing lifestyle factors and facilitate improved health behaviors. Fourth, minimize prescription and ‘over-the-counter’ medications that raise BP. Fifth, screen for suspected secondary causes of hypertension. Sixth, use efficacious strategies for improving the antihypertensive regimen, e.g., optimizing diuretic therapy, adding an aldosterone antagonist, renin- or hemodynamic-guided therapeutics, and α,β-receptor blockade. This approach should control most patients with ‘true’ TRH. Seventh, for patients remaining uncontrolled, referral to a Clinical Hypertension Specialist is recommended. Primary care clinicians can improve community BP control and outcomes with a systematic approach to managing patients with TRH.