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

Abstract

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.

Keywords: AHA Scientific Statements; antihypertensive agents; hypertension; hypertension resistant to conventional therapy.

Figure 1.

Estimated prevalence of each of the causes of pseudoresistant hypertension. BP indicates blood pressure. Modified from Bhatt et al with permission from the American Society of Hypertension. Copyright © 2016, American Society of Hypertension. *Indicates reference . †indicates references and . ‡indicates references , , and .

Figure 2.

Algorithm depicting the evaluation of resistant hypertension. ACEI indicates angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; and BP, blood pressure.

Figure 3.

Algorithm depicting the management of resistant hypertension. BP indicates blood pressure; CCB, calcium channel blocker; and RAS, renin-angiotensin system. *These diuretics maintain efficacy down to estimated glomerular filtration rates (eGFRs) of 30 mL⋅min⁻¹⋅1.73 m⁻². **Use caution if eGFR is <30 mL⋅min⁻¹⋅1.73 m⁻². ***Requires concomitant use of a β-blocker and diuretic. ****Requires the concomitant use of a β-blocker and loop diuretic.