High prevalence of secondary hypertension and insulin resistance in patients with refractory hypertension

Resistant hypertension: consensus document from the Korean society of hypertension

Although reports vary, the prevalence of true resistant hypertension and apparent treatment-resistant hypertension (aTRH) has been reported to be 10.3% and 14.7%, respectively. As there is a rapid increase in the prevalence of obesity, chronic kidney disease, and diabetes mellitus, factors that are associated with resistant hypertension, the prevalence of resistant hypertension is expected to rise as well. Frequently, patients with aTRH have pseudoresistant hypertension [aTRH due to white-coat uncontrolled hypertension (WUCH), drug underdosing, poor adherence, and inaccurate office blood pressure (BP) measurements]. As the prevalence of WUCH is high among patients with aTRH, the use of out-of-office BP measurements, both ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM), is essential to exclude WUCH. Non-adherence is especially problematic, and methods to assess adherence remain limited and often not clinically feasible. Therefore, the use of HBPM and higher utilization of single-pill fixed-dose combination treatments should be emphasized to improve drug adherence. In addition, primary aldosteronism and symptomatic obstructive sleep apnea are quite common in patients with hypertension and more so in patients with resistant hypertension. Screening for these diseases is essential, as the treatment of these secondary causes may help control BP in patients who are otherwise difficult to treat. Finally, a proper drug regimen combined with lifestyle modifications is essential to control BP in these patients.

Rates of Pheochromocytoma/Paraganglioma Screening in At-Risk Populations

CONTEXT

Pheochromocytomas and paragangliomas (PPGL) are rare causes of secondary hypertension, but when unrecognized, they can lead to serious complications. Data regarding PPGL screening are lacking.

OBJECTIVE

This study aimed to assess the rates and patterns of PPGL screening among eligible patients.

METHODS

We conducted a retrospective review of adults with hypertension seen in outpatient clinics of a large academic center between January 1, 2017, and June 30, 2020. We included patients with treatment-resistant hypertension, hypertension at age < 35 years, and/or adrenal mass(es).

RESULTS

Of 203 535 patients with hypertension identified, 71 088 (35%) met ≥ 1 inclusion criteria, and 2013 (2.83%) were screened for PPGL. Patients screened were younger (56.2 ± 17.4 vs 64.0 ± 17.1 years), more often women (54.1% vs 44.2%), and never-smokers (54.6% vs 47.5%, P < 0.001 for all). The rate of screening was highest in patients with hypertension and adrenal mass(es) (51.7%, vs 3.9% in patients with early-onset hypertension, and 2.4% in those with treatment-resistant hypertension). Multivariable logistic regression showed higher odds ratio (OR) of PPGL screening in women (OR [95% CI]: 1.48 [1.34-1.63]); Black vs White patients (1.35 [1.19-1.53]); patients with adrenal mass(es) (55.1 [44.53-68.15]), stroke (1.34 [1.16-1.54]), dyslipidemia (1.41 [1.26-1.58]), chronic kidney disease (1.40 [1.26-1.56]), and obstructive sleep apnea (1.96 [1.76-2.19]).

CONCLUSION

PPGL screening is pursued in roughly half of patients with adrenal nodules and hypertension, but rarely in patients with treatment-resistant or early-onset hypertension. Similar to screening for other forms of secondary hypertension, PPGL screening occurs more often after serious complications develop.

Who should be screened for primary aldosteronism? A comprehensive review of current evidence

Arterial hypertension is a major risk factor for cardiovascular disease. The prevalence of primary aldosteronism (PA) ranges from 5% to 10% in the general hypertensive population and is regarded as one of the most common causes of secondary hypertension. There are two major causes of PA: bilateral adrenal hyperplasia and aldosterone-producing adenoma. The diagnosis of PA comprises screening, confirmatory testing, and subtype differentiation. The Endocrine Society Practice Guidelines for the diagnosis and treatment of PA recommends screening of patients at an increased risk of PA. These categories include patients with stage 2 and 3 hypertension, drug-resistant hypertension, hypertensive with spontaneous or diuretic-induced hypokalemia, hypertension with adrenal incidentaloma, hypertensive with a family history of early onset hypertension or cerebrovascular accident at a young age, and all hypertensive first-degree relatives of patients with PA. Recently, several studies have linked PA with obstructive sleep apnea and atrial fibrillation unexplained by structural heart defects and/or other conditions known to cause the arrhythmia, which may be partly responsible for the higher rates of cardiovascular and cerebrovascular accidents in patients with PA. The aim of this review is to discuss which patients should be screened for PA, focusing not only on well-established guidelines but also on additional groups of patients with a potentially higher prevalence of PA, as has been reported in recent research.

Resistant Hypertension Updated Guidelines

PURPOSE OF REVIEW

To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature.

RECENT FINDINGS

RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.

Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.

Low Blood Pressure Is Associated With Greater Risk for Cardiovascular Events in Treated Adults With and Without Apparent Treatment-Resistant Hypertension

Apparent treatment-resistant hypertension (aTRH) may confound the reported relationship between low blood pressure (BP) and increased cardiovascular disease (CVD) in treated hypertensive patients. Incident CVD was assessed in treated hypertensive patients with and without aTRH (BP ≥140 and/or ≥90 mm Hg on ≥3 medications or <140/<90 mm Hg on ≥4 BP medications) at three BP levels: 1: <120 and/or <70 mm Hg and <140/<90 mm Hg; 2: 120-139/70-89 mm Hg; and 3: ≥140 and/or ≥90 mm Hg. Electronic health data were matched to emergency and hospital claims for incident CVD in 118 356 treated hypertensive patients. In adults with and without aTRH, respectively, CVD was greater in level 1 versus level 2 (multivariable hazard ratio, 1.88 [95% confidence interval [CI], 1.70-2.07]; 1.71 [95% CI, 1.59-1.84]), intermediate in level 1 versus level 3 (hazard ratio, 1.32 [95% CI, 1.21-1.44]; 0.99, [95% CI, 0.92-1.07]), and lowest in level 2 versus level 3 (hazard ratio, 0.70 [95% CI, 0.65-0.76]; 0.58, [95% CI, 0.54-0.62]). Low treated BP was associated with more CVD than less stringent BP control irrespective of aTRH.

Longitudinal plasma metanephrines preceding pheochromocytoma diagnosis: a retrospective case-control serum repository study

OBJECTIVE

Plasma metanephrines (PMN) are highly sensitive for diagnosis of pheochromocytoma, but the natural history of PMN before pheochromocytoma diagnosis has not been previously described. The aim of the study was to compare the progression of PMN before pheochromocytoma diagnosis to matched healthy and essential hypertension disease controls.

DESIGN

A retrospective case-control Department of Defense Serum Repository (DoDSR) study.

METHODS

We performed a DoDSR study that compared three longitudinal pre-diagnostic PMN for 30 biopsy-proven pheochromocytoma cases to three longitudinal PMN for age, sex, race, and age of serum sample matched healthy and essential hypertension disease controls. Predominant metanephrine (MN) or normetanephrine (NMN) production was identified for each case and converted to a percentage of the upper limit of normal to allow analysis of all cases together. PMN were measured by Quest Diagnostics.

RESULTS

The predominant plasma metanephrine (PPM) was >100 and 300% of the upper limit of normal a median of 6.6 and 4.1 years before diagnosis respectively. A greater percentage of pheochromocytoma patients had a PPM >100 and >300% of the upper limit of normal compared with combined healthy and essential hypertension disease controls <2, 2-8, and >8 years prior to diagnosis. For patients with a baseline PPM 90-300% of the upper limit of normal, a 25% rate of rise per year was 100% specific for pheochromocytoma.

CONCLUSIONS

PPMs elevate years before diagnosis which suggests that delayed diagnoses are common. For mild PMN elevations, follow-up longitudinal PMN trends may provide a highly specific and economical diagnostic tool.

Hypertension and hypertensive cardiomyopathy in patients with a relapse-free history of phaeochromocytoma

BACKGROUND

In patients with a relapse-free history of phaeochromocytoma/paraganglioma (PCC/PGL), persistent hypertension has been reported, but has not been well characterized.

METHODS

In 28 patients [mean age 54·5 (26-81) years] with a relapse-free history of PCC/PGLs, we prospectively analysed resting, supine blood pressure (BP), ambulatory BP, echocardiography, exercise testing, metabolic parameters and retrospectively collected data from the time of diagnosis (baseline). Echocardiographic measures were compared to healthy (n = 28) and hypertensive controls (n = 15).

RESULTS

Median follow-up was 6 [1-16] years. Three patients had normal office and ambulatory BP and three patients had only increased office BP. Fifty-four per cent of patients had a blunted circadian rhythm. Comparing normal, hypertensive and PCC/PGL patients, we found significant differences in end-diastolic septal thickness (8·8 ± 0·2, 13·8 ± 0·4, 10·0 ± 0·3 mm, P < 0·05), septal basal thickness (9·0 ± 0·3, 15·9 ± 0·5, 11·2 ± 0·4 mm, P < 0·05) and left ventricular mass (143 ± 8, 255 ± 19, 169 ± 9 g, P < 0·05). In five patients, seven major cardiovascular events were observed. Compared to baseline, no significant difference was found in systolic (140 ± 35 vs 137 ± 18 mmHg) and diastolic (85 ± 18 vs 83 ± 10 mmHg) BP. An increase or a decrease in BP (>10 mmHg) was found in 36% and 39% of patients, respectively. The number of antihypertensive drugs had not changed [1 (0-3) vs 1 (0-4)]. Fewer patients received insulin (1 vs 3) or oral antiglycaemic drugs (2 vs 7).

CONCLUSION

Our data indicate that hypertension persists after removal of PCG/PGL in a substantial proportion of patients. Hypertensive heart disease is common, and cardiovascular events are frequent in patients with a history of PCC/PGL.

Utility of bioimpedance spectroscopy (BIS) in the management of refractory hypertension in patients with chronic kidney disease (CKD)

BACKGROUND

Expansion of extracellular volume (ECV) is a frequent cause of resistant hypertension (RHT) in patients with chronic kidney disease (CKD). The aim of this exploratory study was that of applying bioimpedance spectroscopy (BIS) for the identification of CKD patients with RHT and expansion of ECV, while trying to control blood pressure (BP) using an intensification of diuretic treatment.

METHODS

We included 50 patients with RHT and CKD who underwent BIS. In order to control BP, diuretic treatment was intensified in those patients with expansion of the ECV. In all other cases, another antihypertensive drug was added.

RESULTS

The mean age was 68.2 ± 10.4 years, 68% were male and 58% were diabetic. The mean estimated glomerular filtration rate (eGFR) was 50.7 ± 22.4 mL/min/1.72 m(2). Baseline systolic BP was 167.2 ± 8.6 mmHg and diastolic BP was 84.8 ± 9.5 mmHg. The mean number of antihypertensive drugs received was 3.8 ± 0.9. Expansion of ECV was recorded in 30 (60%) patients and was more frequent in diabetics and in patients with more albuminuria. At 6 months of follow-up, a decline of 21.4 ± 7.1 mmHg was observed in systolic BP in the patients with expansion of ECV, compared with a decrease of 9.4 ± 3.4 mmHg in the normal ECV group (P < 0.01). We did not find differences in the decrease in diastolic BP between the groups. Nine patients (30%) with ECV expansion who increased diuretic therapy reached the target blood pressure (BP) of <140/90 mmHg, when compared with only two patients (10%) who had normal ECV and in whom other antihypertensive drug was added. A total decrease in body water of 1.9 ± 1.1 L was observed in patients with ECV expansion who intensified diuretic treatment at the expense of a decline in ECV of 1.1 ± 1 L. eGFR remained stable in both groups (47.1 ± 21.1 versus 54.1 ± 25.2 mL/min/1.73 m(2); P = 0.37).

CONCLUSIONS

An increase in ECV as measured by BIS frequently occurs in RHT in patients with CKD. Diabetic and severe proteinuric patients are more exposed to expansion of ECV. BIS is a potentially useful method for identifying and treating patients with RHT and expansion of ECV. The hypothesis generated by this exploratory study needs to be tested in a randomized clinical trial.

[Prevalence of target organ damage and metabolic abnormalities in resistant hypertension]

BACKGROUND AND OBJECTIVE

Patients with resistant hypertension (RH) are relatively frequently visited in specialized units of hypertension. The aim of this study was to assess the prevalence of target organ damage, central obesity and metabolic syndrome in a cohort of patients with RH consecutively included in the Register of Resistant Hypertension of the Spanish Society of Hypertension (SHE-LELHA).

PATIENTS AND METHODS

Cross-sectional, multicenter epidemiologic study in usual clinical practice conditions. Patients with clinical diagnosis of resistant hypertension, that is, office systolic and diastolic blood pressure ≥ 140 mm Hg and/or ≥ 90 mm Hg, respectively, despite a prescribed therapeutic schedule with an appropriate combination of three or more full-dose antihypertensive drugs, including a diuretic, were consecutively recruited from specialized hypertension units spread through Spain. Demographic and anthropometric characteristics as well as cardiovascular risk factors and associated conditions were recorded, and all the subjects underwent 24-h ambulatory blood pressure monitoring. Left ventricular hypertrophy was considered as a left ventricular mass index ≥ 125 g/m(2) in males and ≥ 110 g/m(2) in females. Left atrial enlargement was defined as an indexed left atrium diameter ≥ 26 mm/m(2). Microalbuminuria was defined as a urinary albumin/creatinine ratio ≥ 22 mg/g in males and ≥ 31 mg/g in females.

RESULTS

513 patients were included, aged 64±11 years old, 47% women. Central obesity was present in 65.7% (CI 95% 61.6-69.9), 38.6% (CI 95% 34.4-42.8) had diabetes and 63.7% (CI 95% 59.4-67.9) had metabolic syndrome. The prevalence of left ventricular hypertrophy and left atrial enlargement, determined by echocardiography was 57.1% (CI 95% 50.8-63.5) and 10.0% (CI 95% 6.3-13.7) respectively. Microalbuminuria was found in 46.6% (CI 95% 41.4-51.8) of the subjects. Patients with metabolic syndrome were significantly older (65.4±11 and 62.5±12 years; P=.0052), presented a higher prevalence of diabetes (52.0% vs. 16.6; P<.0001) and were treated more frequently with ≥ 4 antihypertensive drugs (65.1 vs. 50.0%, P=.011).

CONCLUSION

The prevalence of central obesity, metabolic syndrome and target organ damage is very high in resistant hypertensive subjects.

Common secondary causes of resistant hypertension and rational for treatment

Resistant hypertension is defined as uncontrolled blood pressure despite the use of three antihypertensive drugs, including a diuretic, in optimal doses. Treatment resistance can be attributed to poor adherence to antihypertensive drugs, excessive salt intake, physician inertia, inappropriate or inadequate medication, and secondary hypertension. Drug-induced hypertension, obstructive sleep apnoea, primary aldosteronism, and chronic kidney disease represent the most common secondary causes of resistant hypertension. Several drugs can induce or exacerbate pre-existing hypertension, with non-steroidal anti-inflammatory drugs being the most common due to their wide use. Obstructive sleep apnoea and primary aldosteronism are frequently encountered in patients with resistant hypertension and require expert management. Hypertension is commonly found in patients with chronic kidney disease and is frequently resistant to treatment, while the management of renovascular hypertension remains controversial. A step-by-step approach of patients with resistant hypertension is proposed at the end of this review paper.

Management of resistant arterial hypertension: role of spironolactone versus double blockade of the renin-angiotensin-aldosterone system

BACKGROUND

Currently there is no consensus regarding which add-on therapy to use in resistant hypertension. This study was designed to compare two treatment options, spironolactone (SPR) versus dual blockade of the renin-angiotensin-aldosterone system (RAAS).

METHODS

Forty-two patients with true resistant hypertension were included in the study. An open-label prospective crossover design was used to add a second RAAS blocker to previous treatment and then SPR following 1 month of wash-out. BP was measured in the office and by ambulatory blood pressure monitoring (ABPM). Changes in laboratory tests were also studied for both treatments. The predictive values of aldosterone-renin ratio (ARR) and serum potassium of determining the antihypertensive response were analyzed for both arms.

RESULTS

Following the first stage of dual blockade, SBP dropped significantly both in office (reduction of 12.9 ± 19.2 mmHg)) and by ABPM (reduction of 7.1 ± 13.4 mmHg). Office DBP was unchanged but was significantly reduced as measured by ABPM (3.4 ± 6.2 mmHg). On SPR treatment, office BP was reduced 32.2 ± 20.6/10.9 ± 11.6 mmHg. By ABPM the reduction was 20.8 ± 14.6/8.8 ± 7.3 mmHg (P < 0.001). The BP control was achieved by 25.6% of patients in dual blockade and 53.8% in SPR with office blood pressure. By ABPM, 20.5% were controlled on dual blockade and up to 56.4% with SPR. Serum potassium was a weak inverse predictor of the blood pressure-lowering effect of SPR.

CONCLUSION

SPR has a greater antihypertensive effect than dual blockade of the RAAS in resistant hypertension. SPR at daily doses of 25-50 mg shows a potent antihypertensive effect when added to prior regimes of single RAAS axis blockade in patients with resistant arterial hypertension.

Secondary hypertension: obesity and the metabolic syndrome

The epidemic of obesity in the United States and around the world is intensifying in severity and scope and has been implicated as an underlying mechanism in systemic hypertension. Obese hypertensive individuals characteristically exhibit volume congestion, relative elevation in heart rate, and high cardiac output with concomitant activation of the renin-angiotensin-aldosterone system. When the metabolic syndrome is present, insulin resistance and hyperinsulinemia may contribute to hypertension through diverse mechanisms. Blood pressure can be lowered when weight control measures are successful, using, for example, caloric restriction, aerobic exercise, weight loss drugs, or bariatric surgery. A major clinical challenge resides in converting short-term weight reduction into a sustained benefit. Pharmacotherapy for the obese hypertensive patient may require multiple agents, with an optimal regimen consisting of inhibitors of the renin-angiotensin-aldosterone system, thiazide diuretics, beta-blockers, and calcium channel blockers if needed to attain contemporary blood pressure treatment goals.

Prevalence of primary hyperaldosteronism in resistant hypertension: a retrospective observational study

BACKGROUND

Results of several studies published since 1999 suggest that primary hyperaldosteronism (also known as Conn's syndrome) affects more than 10% of people with hypertension; however, such a high prevalence has also been disputed. Experts generally agree that resistant hypertension has the highest prevalence of primary hyperaldosteronism, on the basis of small studies. We aimed to assess the prevalence of primary hyperaldosteronism in a large group of patients with resistant hypertension.

METHODS

Patients with resistant hypertension (blood pressure >140/90 mm Hg despite a three drug regimen, including a diuretic) who attended our outpatient clinic were assessed for primary hyperaldosteronism. Serum aldosterone and plasma renin activity were determined and their ratio was calculated. Patients with a positive test (ratio >65.16 and aldosterone concentrations >416 pmol/L) underwent salt suppression tests with intravenous saline and fludrocortisone. Diagnosis of primary hyperaldosteronism was further confirmed by the response to treatment with spironolactone.

FINDINGS

Over 20 years, we studied 1616 patients with resistant hypertension. 338 patients (20.9%) had a ratio of more than 65.16 and aldosterone concentrations of more than 416 pmol/L. On the basis of salt suppression tests, 182 (11.3%) patients had primary hyperaldosteronism, and response to spironolactone treatment further confirmed this diagnosis. Hypokalaemia was seen only in 83 patients with primary hyperaldosteronism (45.6%).

INTERPRETATION

Although the prevalence of primary hyperaldosteronism in patients with resistant hypertension was high, it was substantially lower than previously reported. On the basis of this finding, we could assume that the prevalence of primary hyperaldosteronism in the general unselected hypertensive population is much lower than currently reported. Thus, the notion of an epidemic of primary hyperaldosteronism is not supported.

Pioglitazone decreases ambulatory blood pressure in type 2 diabetics with difficult-to-control hypertension

Blood pressure (BP) control at recently established goals of <130/80 mm Hg is often difficult to achieve in diabetic patients. This work examines the effect of pioglitazone on 24-hour ambulatory BP monitoring in patients with type 2 diabetes and difficult-to-control hypertension. Twenty-seven participants with difficult-to-control hypertension (defined as ambulatory BP monitoring >or=125/75 mm Hg) taking antihypertensive medications (mean, 4.1+/-0.8 drugs) were enrolled in an open, prospective, blinded end point study of add-on therapy with pioglitazone 30 to 45 mg for 20 weeks. After 20 weeks of treatment, 24-hour ambulatory BP monitoring showed significant reductions (from 144+/-13 to 136+/-16 mm Hg systolic BP and from 79+/-9 to 76+/-10 mm Hg diastolic BP [P=.001]). Treatment was also associated with improvements in insulin sensitivity and glycemic and lipid profile. These findings suggest that pioglitazone could be a therapeutic option in diabetics who still have elevated BP values in spite of receiving treatment with at least 3 antihypertensive drugs.

Agregación de factores de riesgo cardiovascular y de prevalencia de síndrome metabólico en personas con hipertensión arterial resistente

BACKGROUND AND OBJECTIVE

The aim of this study was to analyse the clustering of cardiovascular risk factors and the prevalence of metabolic syndrome (MS) in this sample of subjects with resistant hypertension (RH).

PATIENTS AND METHOD

One hundred and fifteen subjects with RH were sequentially included. RH was defined as a level of office blood pressure (BP)>or=140/90 mmHg in subjects treated with at least 3 antihypertensive drugs (one of them a diuretic) during at least 2 months and with good compliance. The usual protocol of the Hypertension Unit and ambulatory BP monitoring during 24 h was applied on all the subjects, and an echocardiogram with Doppler was performed on 68 of them. Subjects with a daytime BP>or=135/85 mmHg were defined as pseudoresistant hypertensive.

RESULTS

The mean age (standard deviation) was 61 (10) years, and 50 patients (44%) were males. The mean office BP was 166/95 (16/9) mmHg. The daytime BP was 141/83 (15/12) mmHg. Out of the patients, 88 (76.5%) had a family history of cardiovascular disease; 64 (56%) of obesity; 43 (37%) of hypercholesterolemia; 34 (30%) of low high-density lipoprotein cholesterol; 32 (28%) of diabetes mellitus; and 63 (55%) were sedentary. The prevalence of MS was 54%; target organ damage was found in 70 cases (61%), and 44 (38%) had other associated clinical conditions. Out of the subjects with echocardiography, 49 (72%) presented left ventricular hypertrophy. Pseudoresistant hypertension was found in 31 (27%). There were no significant differences in clinical variables between subjects with RH or psudoresistant hypertension.

CONCLUSIONS

Patients with RH had high cardiovascular risk, independent of a good control of ambulatory BP, because of the high prevalence of cardiovascular risk factors and MS. An optimal antihypertensive treatment including specific programs for the control of obesity and a sedentary lifestyle are necessary in the management of these patients.

Treatment of resistant hypertension

Although the true prevalence of resistant hypertension is not known, it is likely that this condition will become increasingly common, driven by an aging population, obesity, nonadherence trends, and effects of target-organ disease. Current approaches focus on two goals: evaluation and correction of contributing causes, then selection of an effective drug regimen. Lifestyle factors contribute to resistance, particularly high sodium intake and weight gain. Secondary causes should be considered and corrected if feasible. Recent efforts have focused on the development of clinical pathways to guide treatment, based on plasma renin activity, aldosterone production, or hemodynamic measurements. The components of drug combinations beyond the second agent remain empiric. Although volume expansion plays a key role in drug resistance, clinical assessment of volume status is often difficult, frustrating efforts to achieve blood pressure control. Determination of the most effective approaches will require clinical trials using combination therapy.