Progression in diagnosis and treatment of resistant. We assessed possible associations of antihypertensive drug classes, specific agents inside each class, and types of combinations, with the presence of nontrh vs. The whitecoat effect should be ruled out by outofoffice blood pressure monitoring. When using further diuretic therapy for step 4 treatment of resistant hypertension.
Ideally, one of the 3 agents should be a diuretic and all agents should be prescribed at optimal dose amounts. Catheterbased renal denervation rdn is a procedure with the potential to normalize systolic blood pressure sbp. The goal is to provide a practical reference to assist clinicians with uptodate management of patients with high bp. Evidencebased management of resistant hypertension is discussed with special considerations of. The present study aimed to identify the effects of cpap treatment on blood pressure of pa tients with resistant hypertension and osahs in a chinese population. Diuretics lower blood pressure by helping your kidneys get rid of extra salt and water in your body. Catheterbased renal denervation is beneficial for patients with treatmentresistant essential hypertension. Aldosterone may play an important role in resistant hypertension and aldosterone receptor blockers can be very useful. Advanced treatment for resistant hypertension, including a thorough reevaluation of your existing care plan, medication and lifestyle. Resistant hypertension rh is defined as blood pressure above a goal despite adherence to at least 3 optimally dosed antihypertensive medications of different classes, one of which is a diuretic. Treatment typically involves a change in your medications.
Finally, identifiable causes of resistant hypertension should be sought table 1114. Resistant hypertension was initially defined to identify a group of highrisk patients who may benefit from specialized care, including evaluation and treatment of secondary causes of hypertension. How effective is spironolactone for treating resistant. Resistant hypertension is also a relatively common condition, given a large number of individuals with hypertension. This preferred triple drug regimen may be changed depending on the. Evaluation of patients with resistive hypertension should first confirm that they have true resistant hypertension by ruling out or correcting factors associated with. Despite its prevalence, many patients have uncontrolled or difficulttocontrol blood pressure. Conclusions this study shows a high prevalence of true resistant hypertension. Nov, 2017 john warner, md, president of the american heart association, interviews paul whelton, md, writing group chair for the 2017 hypertension clinical practice guidelines and the need for the guidelines, the new classification system, and what it means for clinicians and their patients. Low adherence to treatment is an important cause of resistant.
Apparent atrh is used when optimal therapy, adherence, and measurement artifacts are unknown. The updated resource has 15 chapters that show how chws can help individuals prevent or manage heart disease, stroke, high blood pressure and cholesterol, diabetes. What is new in the management of resistant hypertension. This prevalence is lower than that of apparent treatment resistant hypertension, demonstrating the importance to exclude causes of pseudo resistant hypertension including whitecoat hypertension with the use of ambulatory bp measurement. Catheter based renal denervation catheterbased renal denervation for reduction of blood pressure in patients with treatmentresistant hypertension has seized the first place on a top 10 medical innovations list. Algorithm for treatment of hypertension reference card from the seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure jnc 7 evaluation classification of blood pressure bp category sbp mmhg dbp mmhg normal resistant hypertension. Resistant hypertension is a severe medical condition which is estimated to appear in 918% of hypertensive patients. Prevalence of resistant hypertension is increasing. Patients with resistant hypertension are at high risk for adverse cardiovascular events and are more likely than those with controlled hypertension to have a secondary cause, which is usually at least in part reversible. Sep 07, 2012 diuretics lower blood pressure by helping your kidneys get rid of extra salt and water in your body. Resistant hypertension 2410282512221022930252015105 0 ouzan 2002 mahmud 2005 nishizaka 2003 chapman 2007. Nov 05, 2015 treatment resistant hypertension trh is defined by office blood pressure bp uncontrolled on. Important issues include new diagnostic thresholds, out of office bp monitoring, intensified treatment goals, and a different approach to resistant hypertension. In resistant hypertension the optimal blood pressure is illusive despite very well tailored therapy.
He m, mu j, liu f, ren k, wang y, guo t 2014 progression in diagnosis and treatment of resistant hypertension. Hypertension is considered resistant when all of the following are true someone is taking three different blood pressure medications at their maximally tolerated doses one of the blood pressure medications is a diuretic removes fluid and salt from the body. Daniela trabattoni, md, stefano galli, md, renata rogacka, md, giovanni teruzzi, md, piero montorsi, md. Management of resistant hypertension is exactly the fi eld where blood pressurecontrolling nonpharmacological methods fi t best. Observed pill ingestion to document lack of adequate bp response is not. It is possible that this elevation of blood pressure is associated with subclinical organ dysfunction. Evaluation, and treatment of high blood pressure jnc 6 was released in 1997, new knowledge has come to light from a variety of sources. New drugs and device therapy are currently under investigation for treatment of resistant hypertension.
Resistant hypertension is defined as hypertension that is poorly responsive to treatment and requires the use of multiple medications to achieve. Much less is known about the impact of physical exercise on the management of treatment of resistant hypertension rh. Due to higher cardiovascular risk, this disorder requires special diagnosis and. Hypertension medication treatment protocol1 this document is not intended as a substitute for the medical advice of a physician. Guideline for the diagnosis and management of hypertension in.
The seventh report of the joint national committee on. Evaluation and management of the patient with difficultto. Medline abstract for reference 1 of treatment of resistant. Resistant hypertension current medical diagnosis and. Patients with resistant hypertension are at a high risk for developing serious cardiovascular events and renal complications. Treatment of hypertension in older adults, particularly isolated systolic hypertension view in chinese treatment of hypertension in patients with diabetes mellitus view in chinese treatment of hypertension in patients with heart failure view in chinese treatment of resistant hypertension view in chinese. Resistant hypertension american board of family medicine. Version log version number date name initials drafts and modifications comments and reasons for modifications if relevant. The clinician should pay particular attention to the type of diuretic being used in relation to the patients kidney function.
A small study involving 57 people with resistant hypertension published online june, 2016, by the journal of clinical hypertension discovered that adding eplerenone to the standard threedrug treatment for 12 weeks lowered systolic blood pressure by almost eight points and diastolic blood pressure by more than four points compared with a. By continuing to use our website, you are agreeing to our use of cookies. Detection, evaluation, and treatment of high blood pressure jnc 6 was released in 1997, new knowledge has come to light from a variety of sources. Original article randomized controlled trial of continuous. Use particular caution in people with a reduced egfr because they have an increased risk of hyperkalaemia. Nov 20, 2012 resistant hypertension is defined as high blood pressure that remains uncontrolled despite treatment with at least three antihypertensive agents one of which is usually a diuretic at best tolerated doses. Optimal treatment of drug resistant hypertension pathway2. Resistant hypertension in a patient with chronic type b. Resistant hypertension explained by underlying endocrine imbalance researchers uncovered excess aldosterone as cause of antihypertensive treatment failure, and shed light on mechanisms to support breakthrough treatment success in resistant hypertension.
Pdf diagnosis and treatment of resistant hypertension. Resistant hypertension is defined as blood pressure above the patients goal despite the use of 3 or more antihypertensive agents from different classes at optimal doses, one of which should ideally be a diuretic. However, in our opinion, in the setting of resistant or refractory hypertension, symptoms of orthostasis or hypotension among those receiving antihypertensive therapy and concern for autonomic dysfunction or white coat hypertension, abpm or homebased bps should be obtained to help further guide treatment of hypertension in patients with ckd. Recommendations on the modification and intensification of antihypertensive regimens for a given patient taking 3 or more drugs is based on. Nonpharmacological methods in the treatment of resistant. New guidelines for resistant hypertension from the aha. Guidelines for treating resistant hypertension have been published in the uk and us. New perspectives in diagnosis and treatment of resistant hypertension elvira o. No endorsement is implied or intended by the american medical association of any thirdparty organization, product, drug or service. Recommendations for the management of patients with resistant hypertension.
Feb 27, 2020 consider an alphablocker or betablocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4. Resistant hypertension has several possible causes mayo. It highlights situations, such as pseudohypertension, that may masquerade as resistance, and it identifies drugs that may aggravate. In large clinical trials of hypertension treatment. In large clinical trials of hypertension treatment, 20% to 30% of participants meet the definition for resistant hypertension, and in tertiary care hypertension clinics, the. Treatment resistant hypertension trh is associated with particular clinical features, nonadherence, and suboptimal treatment.
Antihypertensive drug use in resistant and nonresistant hype. Resistant hypertension rhtn is defined as uncontrolled blood. Diagnosis and management of resistant hypertension. Resistant hypertension is defined as blood pressure bp that remains above goal in spite of use of three antihypertensive medications in effective doses, usually. Radiofrequency ablation of the renal sympathetic nerves as. New guidelines for resistant hypertension from the aha, plus targets, treatments, and marriage. Resistant hypertension, diuretics, calcium channel blockers, angiotensinconverting enzyme inhibitors. Treatment of resistant hypertension the three classes of drugs preferred as initial option in hypertension management are a thiazide diuretic, an ace inhibitor or angiotensin receptor blocker, and a calcium channel blocker. An evidencebased, plainlanguage training resource and reference for chws, as well as a curriculum that health educators, nurses, and other instructors can use to train chws.
May 15, 2009 evaluation and management of the patient with difficulttocontrol or resistant hypertension anthony j. Cl l d cli i m di l i i s i 2012cleveland clinic medical innovations summit 2012 data on file. Resistant hypertension rh is defined as abovegoal elevated blood pressure bp in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a longacting calcium channel blocker, a blocker of the reninangiotensin system angiotensinconverting enzyme inhibitor or angiotensin. In the current study, we have prospectively assessed the following. Pdf evaluation and treatment of resistant or difficult. Hypertension annals of internal medicine american college. Common secondary causes of resistant hypertension and. Evaluation and treatment of resistant or difficulttocontrol hypertension. Recognition and management of resistant hypertension american. In the treatment of resistant hypertension, evidence from specialty hypertension clinics has. Treatment resistant hypertension trh is defined by office blood pressure bp uncontrolled on. If blood pressure remains uncontrolled in people taking the optimal tolerated doses of four drugs, seek specialist advice. Catheter based renal denervation catheterbased renal denervation for reduction of blood pressure in patients with treatment resistant hypertension has seized the first place on a top 10 medical innovations list. Consider an alphablocker or betablocker for adults with resistant hypertension starting step 4 treatment who have a blood potassium level of more than 4.
Patients and methods patients three hundred and nine patients with resistant hypertension were recruited from the. Pharmacological treatment of resistant hypertension. Management of patients with resistant hypertension. Although management of hypertension is a daily activity of primary care practitioners, it remains one of the most demanding areas of medicine. Mar 28, 2011 up to onethird of people who were thought to have treatmentresistant high blood pressure may actually have white coat hypertension blood pressure that spikes in the doctors office. Emergent therapy for acuteonset, severe hypertension. The american heart association requests that this document be cited as follows. Resistant hypertension rhtn is an increasingly common clinical problem1,2 that almost always has multiple etiologies, risk factors, and comorbidities. Resistant hypertension in a patient with chronic type we use cookies to enhance your experience on our website. A 2017 metaanalysis of 4 rcts 869 patients evaluated the effectiveness of prescribing spironolactone for patients with resistant hypertension, defined as abovegoal blood pressure bp despite treatment with at least 3 bplowering drugs at least 1 of which was a diuretic.
The overall objective of the study was to estimate the cost effectiveness of rdn in the uk for patients with diagnosed resistant hypertension. The endothelin receptor antagonists and minodoxil are being evaluated in the management of resistant hypertension. Excess sodium and fluid retention, increased activation of the reninangiotensinaldosterone. Apparent treatmentresistant hypertension atrh is defined as uncontrolled hypertension despite the use of. Pdf diagnosis and management of resistant hypertension. Resistant hypertension workup and approach to treatment. Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. Mechanisms and treatment of resistant hypertension scielo. Reference card from the seventh report of the joint. It has been proposed that a proportion of resistant hypertension may be the result of chronic high activity of the autonomic nervous system. Resistant hypertension causes of pseudoresistant hypertension1,2 suboptimal dosing of antihypertensive agents white coat effect however, a majority of patients with resistant hypertension and no identifiable secondary causes have an secondary causes of hypertension 1,2 obstructive sleep apnea primary aldosteronism 1. A variety of drugs are available to treat high blood pressure. Emerging evidence suggests that multiple mechanisms may be responsible for the development of treatment resistant hypertension trh.
The national high blood pressure education program coordinating. Resistant hypertension is high blood pressure that does not respond well to aggressive medical treatment. It has been demonstrated in patients with resistant hypertension in all five studies with more than 150 patients that have reported volume measure. Hypertension is widely encountered in family medicine. Of that, up to 10 percent, or around seven million people, have treatment resistant hypertension, where their blood pressure remains high over 14090 mmhg despite treatment with at least three or more different types of blood pressure medications including a diuretic. Cost effectiveness of renal denervation therapy for the.
The prevention and treatment of hypertension with algorithm based therapy pathway optimal treatment of drug resistant hypertension pathway2 principal results bryan williams, tom macdonald and morris brown on behalf of the pathway investigators. May 07, 2019 the goal is to provide a practical reference to assist clinicians with uptodate management of patients with high bp. Resistant hypertension is defined as elevated blood pressure bp despite treatment with at least 3 antihypertensive agents at optimal doses. New perspectives in diagnosis and treatment of resistant. A diagnosis of true resistant hypertension should be made only after a thorough assessment to exclude apparent or pseudo resistant. As defined, resistant hypertension includes patients whose blood pressure is controlled with use of. Resistant hypertension has several possible causes, including another underlying medical condition. Reasons for this include the imprecision of blood pressure measurement, the complexity of assessing cardiovascular risk, and the need to use multiple agents to control blood pressure. Causes of resistant hypertension stanford health care. Resistant hypertension is generally defined as blood pressure bp that remains above goal, in spite of the use of three antihypertensive medi.
Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Pdf resistant hypertension is defined as a lack of ambulatory blood pressure. Hinderliter, md, university of north carolina at chapel hill. Diagnosis and initial management of obstructive sleep apnea without polysomnography. The jnc 7 guidelines were a comprehensive expert consen sus of the prevention, detection, evaluation, and treatment.
The symplicity htn3 study showed that renal denervation therapy was not more effective than a sham control arm in treating resistant hypertension. Resistant hypertension failure to reach target blood pressure in persons who adhere to an appropriate 3drug regimen including a diureticis increasing in prevalence. Resistant hypertension is defined as blood pressure that remains above goal in spite of concurrent use of 3 antihypertensive agents of different classes. This document revises committee opinion number 623, emergent therapy for acuteonset, severe hypertension with preeclampsia or eclampsia, primarily to clarify the terminology around immediate release oral nifedipine and to clarify monitoring expectations during and after treatment of acuteonset, severe hypertension.
Evaluation of possible rh begins with an assessment of adherence to medications. Resistant hypertension is also a relatively common condition, given the large number of individuals with hypertension. Discuss the clinical evaluation of resistant hypertension, including approaches to rule out identifiable secondary or reversible causes recognize the importance of 24hour ambulatory blood pressure monitoring abpm in confirming the diagnosis of resistant hypertension and ruling out whitecoat hypertension. Treatment of resistant and refractory hypertension circulation.
Important issues include new diagnostic thresholds, outofoffice bp monitoring, intensified treatment goals, and a different approach to resistant hypertension. Treatment of resistant hypertension jscimed central. Gosmanova, md, fasn assistant professor of medicine. Because of the increasing prevalence of rhtn and its association with increased cardiovascular risk, there has been a growing interest in its epidemiology, pathophysiology, and effective treatment.
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