Treatment resistant hypertension--investigation and conservative management

Abstract

Background: The introduction of invasive treatments, some of which are irreversible, for the entity called treatment-resistant hypertension (TRH) creates the need for a comprehensive discussion of the diagnostic evaluation that TRH requires and the available options for its conservative treatment.

Method: The pertinent literature is selectively reviewed in the light of the authors' longstanding clinical experience.

Results: Our review of the literature suggests that the high prevalence of TRH in Germany (ca. 20%) can be nearly halved with the aid of more thorough diagnostic evaluation. Such an evaluation should include a review of the patient's antihypertensive drugs (adherence, daily dosing, concomitant medication), investigation for other vascular changes that might affect blood pressure measurement, and exclusion of white-coat hypertension, sleep apnea syndrome, and secondary rather than essential hypertension. As there have been no randomized trials of treatment for TRH, the physician confronted with such cases must devise treatments on the basis of observational data and pathophysiological reasoning (volume status considering renin levels, sympathetic blockade, vasodilatation). Such measures can presumably lower the number of truly treatment-resistant cases still further.

Conclusion: To save patients from preventable harm, patients should undergo a thorough diagnostic evaluation and-under close monitoring for side effects-conservative pharmacological and nonpharmacological treatments should be deployed before any invasive treatment is performed.

Figure

Investigation and management of suspected or confirmed treatment-resistant hypertension. ABPM, 24-hour ambulatory blood pressure monitoring; BP, blood pressure; RAA, renin angiotensin aldosterone; CPAP, continuous positive airway pressure