Identify and correct medication nonadherence before labeling as resistant hypertension

The American Heart Association (AHA) has published a new updated scientific statement on the detection, evaluation, and management of resistant hypertension (HT) in its journal Hypertension online Sept. 13, 2018. Here are some salient recommendations included in the scientific statement:

lPatients, who need ≥3 anti-hypertensive drugs (commonly including a long-acting CCB, a blocker of the renin-angiotensin system (ACE inhibitor or ARB), and a diuretic at maximum or maximally tolerated doses), but continue to have BP that exceeds the goal for HT as per the 2017 ACC/AHA guideline for HT have resistant HT.

lPatients, who achieve target BP with ≥4 anti-hypertensive drugs, are also considered to have resistant HT.

lOlder adults and people who are obese, diabetic, or have peripheral artery disease and obstructive sleep apnea are more prone to develop resistant HT.

lBefore diagnosing as resistant HT, identify and correct medication nonadherence; ask if patients are taking other medications such as non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, cyclosporine, antidepressants (MAO inhibitors). Inaccurate BP measurement may also result in appearance of treatment resistance

lRule out white coat effect. Patients with the white-coat effect should not be included in the definition of resistant HT.

lScreen patients for secondary hypertension. Look for conditions such as primary aldosteronism, chronic kidney disease and renal artery stenosis

lLifestyle changes are also important in patients with resistant HT: Eating a DASH-style diet (more of fruit, vegetables, whole-grains, low-fat dairy products, poultry and fish while limiting red meat and foods high in added sugars and salt), avoiding too much alcohol, maintaining a healthy body weight and increasing physical activity.

lManagement 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. Customize a medication regimen based on the individual characteristics of the patient.

(Source: AHA News Release, Hypertension)

Dr KK Aggarwal

Padma Shri Awardee

Vice President CMAAO

Group Editor-in-Chief IJCP Publications

President Heart Care Foundation of India

Immediate Past National President IMA