Treating Resistant Hypertension

Las Vegas—Hypertension and resistant hypertension—a major cause of cardiovascular morbidity—were addressed during a workshop at the CRS meeting. James J. Matera, DO, FACOI, Nephrology Hypertension Associates of Central New Jersey, examined factors contributing to resistant hypertension and optimal antihypertensive treatment strategies to assist patients in reaching their goal.

Poor blood pressure (BP) control is one of the most common risk factors for death worldwide. It is responsible for 62% of cases of cerebral vascular disease and 49% of cases of ischemic heart disease. As the population ages, clinicians will see more patients with obesity, type 2 diabetes, and chronic kidney disease (CKD), all leading to increased incidence of resistant hypertension, according to a study published in Cleveland Clinical Journal of Medicine [2013;80(2):91-96]. Dr. Matera, who is also co-director of physician integration, CentraState Medical Center, defined resistant hypertension as an elevated BP >140/90 mm Hg despite the use of 3 antihypertensive agents, including a diuretic. Resistant hypertension can also be defined as a form of secondary hypertension. Secondary causes of hypertension may be reversible and treatable if recognized as a source.

Resistant hypertension can be divided into 2 broad categories: (1) pseudoresistance; and (2) true resistance. Each category has a list of possible causes. Common causes of true resistance are volume overload, excessive alcohol use, use of nonsteroidal anti-inflammatory drugs (NSAIDs), and some over-the-counter supplements. Causes of pseudoresistance include improper technique in measuring BP, white coat syndrome, and patient compliance with medications. Dr. Matera said it is important for clinicians to “delineate between true resistance and pseudoresistance for management of [BP].”

Dr. Matero reviewed the American Heart Association’s (AHA) recommendations for diagnosing and treating resistant hypertension [Hypertension. 2008;51(6):1403-1419]. The evaluation of patients with resistant hypertension should be directed toward confirming true treatment resistance, identification of causes contributing to treatment resistance, and documentation of target-organ damage, according to the AHA.

Dr. Matera broke out the recommendations into 7 steps:

• Step 1: Confirm true resistance. Office BP >140/90 mm Hg on ≥3 antihypertensive medications at optimal doses, including, if possible, a diuretic
• Step 2: Exclude pseudoresistance. Is the patient adherent with prescribed regimen? Obtain home, work, or ambulatory BP readings to exclude white coat syndrome
• Step 3: Identify and reverse contributing lifestyle factors. This includes obesity; physical inactivity; excessive alcohol intake; and high salt, low fiber diet
• Step 4: Discontinue or minimize interfering substances. These include NSAIDs, decongestants, oral contraceptives, and stimulants
• Step 5: Screen for secondary causes of hypertension. These include obstructive sleep apnea, primary aldosteronism, CKD, and Cushing’s syndrome
• Step 6: Pharmacologic treatment. Maximize diuretic therapy, including possible addition of mineralocorticoid receptor antagonist; combine agents with different mechanisms of action; and change to loop diuretics for volume sensitive patients
• Step 7: Refer to a specialist. Refer to hypertension specialist if BP remains uncontrolled after 6 months of treatment

He also reviewed important changes from the Joint National Committee (JNC) 7 hypertension guidelines that are now included in the updated JNC 8 guidelines published in Journal of the American Medical Association (Table). Dr. Matera told attendees, “Do not let the new guidelines limit your evaluation of the hypertension patient.”—Eileen Koutnik-Fotopoulos