Diagnose and treat resistant hypertension

Resistant hypertension is diagnosed in patients who need three or more medications to treat hypertension, but who still have higher blood pressure than established in 2017 in the American guideline. Heart Association / American College of Cardiology. In addition, patients whose blood pressure reaches target values ​​for four or more different types of blood pressure lowering medication are also considered to have resistant hypertension.

The 2017 guideline specifies a blood pressure of less than 130 millimeters of mercury (mmHg) for the highest number or 80 mmHg for the lowest figure as an objective. Resistant hypertension is more common in African-Americans, men, the elderly and obese people, or who suffer from diabetes, peripheral arterial disease, obstructive sleep apnea or d? other conditions.

"Since many conditions can mimic resistant hypertension, a correct diagnosis is essential so that you do not exceed the medication." It is best to start by asking a patient who has already been prescribed antihypertensive medications. it does not take the medication properly will result in poorly controlled blood pressure that might appear to be resistant hypertension, "said Robert M. Carey, MD, chair of the statement writing group and professor of medicine at the Health Sciences Center from the University of Virginia.

The statement notes that 50 to 80% of people who should take antihypertensive medications do not take them properly because treatment can be expensive and have unwanted side effects, which can lead to poorly controlled blood pressure.

In addition, over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, aspirin, naproxen and some prescription medications, such as oral contraceptives, may also increase blood pressure . these drugs.

Another condition that can mimic resistant hypertension is the "white coat" effect, when the blood pressure is higher in the doctor's office than at home because the patient is anxious. To rule out the "white coat" effect, patients should measure their blood pressure at home with the help of a portable monitor or by wearing a device capable of measuring blood pressure at specific intervals during a day.

Once the doctor has confirmed the diagnosis of resistant hypertension, health care providers should work with their patients to help them improve their lifestyle. It has been clinically proven that it was clinically proven that a DASH-type diet, focused on the consumption of fruits, vegetables, whole grains, low-fat dairy products, poultry and fish , limited red meat and foods rich in added sugars and salt. Patients should also aim for a healthy weight and sufficient physical activity to help lower blood pressure.

"Some people with resistant hypertension can be extremely sensitive to salt in their diet," said Carey. "In one of the studies we examined, when salt intake was significantly reduced in people with resistant hypertension, blood pressure dropped rapidly."

Drinking too much alcohol and tobacco are also lifestyle factors that affect blood pressure.

Once a clear diagnosis of resistant hypertension is made, health care providers use various treatment regimens to help their patients. By definition, the patient will already take three different classes of antihypertensives, including a long-acting calcium channel blocker (CCB), an angiotensin converting enzyme inhibitor (ACE). ) or an inhibitor of angiotensin receptors (ARA). system and a diuretic (called "pills"). The health care provider can then customize a medication plan based on the patient's individual characteristics to ensure that he is taking the most effective medication for his situation. If blood pressure remains uncontrollable, a mineralocorticoid receptor antagonist (MRS), which blocks a blood pressure-related hormone called aldosterone, can be added to help lower blood pressure.

Carey said that it is also important to screen patients for secondary hypertension, an underlying condition that can cause high blood pressure. Treating patients for secondary hypertension can often cure them. Secondary hypertension frequently results from a condition called primary aldosteronism, a disorder of increased secretion of aldosterone, which occurs in approximately 20% of patients with resistant hypertension. Other major causes of secondary hypertension are chronic kidney disease and renal artery stenosis, a narrowing of one or more arteries that carry blood to the kidneys.

"Patients with high blood pressure are more likely to develop cardiovascular diseases such as heart attacks, heart failure and stroke, and their prognosis further deteriorates if they suffer from pain." 39, resistant hypertension, "said Carey. "It is extremely important to lower blood pressure by any means possible, because study after study has shown the negative consequences of pressures that remain above the target level."

The new declaration replaces a previous statement on the subject published in 2008 and is based on an analysis of more than 400 research studies by the drafting committee. The main changes from the 2008 statement are that the criteria for defining resistant hypertension have become more specific, recognizing the lack of sleep contributing to the lack of blood pressure control, the importance of the change in blood pressure. lifestyle to prevent and treat resistant hypertension.

In addition, recent studies have shown that health care providers are considering replacing chlorthalidone or indapamide (water pill) with diuretics with the most commonly prescribed diuretic hydrochlorothiazide and considering adding spironolactone, a drug that reduces aldosterone. antihypertensive diet.

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More information:
Hypertension (2018). DOI: 10.1161 / HYP.0000000000000084