Resistant hypertension: clinical approach

Resistant hypertension is defined as an uncontrolled office blood pressure in spite of the use of at least 3 anti-hypertensive drugs, ideally including a diuretic. Individuals using four or more medications with blood pressure control are also considered resistant hypertensives. Furthermore, refractory hypertension is defined as uncontrolled blood pressure despite the use of 5 or more drugs, including a long-acting thiazide diuretic and a aldosterone antagonist. Its increasing prevalence is associated with a progressive ageing of the population and the progression of obesity, related to a high cardiovascular and renal morbidity and mortality. The diagnostic approach is based on four steps: eliminate pseudoresistance, identify the white-coat effect phenomenon, investigate secondary causes of hypertension and identify target organ damage aiming at stratification of cardiovascular risk. The therapeutic objective is the controlof 24-hour blood pressure. Lifestyle changes must be stimulated and the first three drugs should include an adequate diuretic, a renin angiotensin-aldosterone-system inhibitor and a calcium channel blocker. Persisting an uncontrolled blood pressure, a fourth drug is added: spironolactone. Regarding the treatment of refractory hypertension, new therapeutic modalities have been developed as renal denervation and baroreflex stimulation.