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New Guidelines for Stubborn High Blood Pressure

Patients who don't respond to normal treatments may benefit

April 8, 2008

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Getting blood pressure under control is sometimes as simple as losing weight and adding a daily walk. But for many others, it's not that easy.

Patients who don't respond to normal treatment regimens are said to have "resistant" high blood pressure -- and until now, there hasn't been a broad medical consensus on how to handle such cases.

New guidelines adopted by the American Heart Association may change that. Published online in Hypertension: Journal of the American Heart Association, the association's guidelines are the first consensus statement to define a condition known as resistant hypertension and to recommend an approach for evaluation and treatment.

Hypertension is called resistant if a person’s blood pressure remains above goal despite their taking three medications to lower it. High blood pressure that is under control, but requires four or more medications to treat it is also considered resistant to treatment.

“Patients need to recognize the importance of blood pressure control and that in most cases they will need a combined approach of lifestyle changes and medication for effective treatment,” said David A. Calhoun, M.D., chair of the guideline-writing committee.

“Doctors must recognize that resistant hypertension requires special consideration in terms of evaluation and treatment,” Calhoun said.

Diuretics are often underused in people with resistant hypertension, and some patients may benefit from adding mineralocorticoid receptor antagonists (MRAs) to their treatment regimens, according to the statement. MRAs treat a condition called primary aldosteronism, which is found in about 20 percent of patients with resistant hypertension.

“The benefit of mineralocorticoid receptor antagonists in treating resistant hypertension has only been recently confirmed,” said Calhoun, a professor of medicine in the Vascular Biology and Hypertension Program at the University of Alabama at Birmingham.

“Hypertension specialists are likely using them to a greater degree, but they are probably not being broadly used to address this problem. Using MRAs requires special biochemical monitoring, particularly to measure blood levels of potassium due to the risk of hyperkalemia (a condition caused by abnormally high potassium levels in the blood).”

The scope of resistant hypertension has not been quantified, but clinical trials suggest it may affect up to 30 percent of people with high blood pressure.

“Older age and obesity are two of the strongest risk factors associated with resistant hypertension. The condition will likely become even more common as the population ages and becomes heavier,” the committee wrote.

People with resistant hypertension have a high cardiovascular risk and often multiple health conditions that complicate their blood pressure management.

It’s important to determine that a person’s condition truly is resistant, said the committee, which wrote: “Uncontrolled hypertension is not the same as resistant hypertension. Uncontrolled blood pressure can be caused by poor medication adherence and/or an inadequate treatment regimen.”

Confirming resistance is the first step in evaluating difficult-to-treat high blood pressure.

Successful treatment of resistant hypertension requires consideration of lifestyle factors that contribute to treatment resistance, diagnosing and treating secondary causes of high blood pressure and using multiple-drug treatments effectively, the committee said.

Lifestyle factors

Secondary causes

Patients with resistant hypertension often have potentially reversible causes of hypertension contributing to their treatment resistance.

Obstructive sleep apnea, renal parenchymal disease, primary aldosteronism and renal artery stenosis are often present in people with resistant hypertension. Treating these disorders, which may include referral to a specialist, can improve blood pressure control.

Medications

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