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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.
Obstructive sleep apnea is associated with an increased risk of cardiovascular events; whether treatment with continuous positive airway pressure (CPAP) prevents major cardiovascular events is uncertain.