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Patients whose blood pressure achieves target values on four or more different types of blood pressure lowering medication are considered to have resistant hypertension. According to a new scientific statement from the American Heart Association, resistant hypertension affects 12 percent to 15 percent of patients treated for high blood pressure.
Patients are diagnosed with resistant hypertension when they need three or more medications to treat high blood pressure but still have blood pressure that exceeds the goal for hypertension established in 2017 in the American Heart Association/American College of Cardiology guideline for hypertension.
The 2017 guideline specifies blood pressure below 130 millimeters of mercury (mmHg) for the top number or 80 mmHg for the bottom number as the goal. Resistant hypertension is common among African-Americans, men, older adults and, people who are obese, or those who have diabetes, peripheral artery disease, obstructive sleep apnea or other conditions.
Different conditions can mimic resistant hypertension, a correct diagnosis is essential so as not to over medicate. Improper medications will result in poorly controlled blood pressure that could appear to be resistant hypertension. Over-the-counter non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen, aspirin, naproxen and some prescription medications, such as oral contraceptives may raise blood pressure
Another condition that can mimic resistant hypertension is the “white coat effect,” when blood pressure is higher in the doctor’s office than at home because the patient is anxious. To rule out the “white coat effect,” patients should measure their blood pressure at home using a portable monitor or by wearing a device that can measure blood pressure at specific intervals over the course of a day.
Once the physician has confirmed a diagnosis of resistant hypertension, healthcare providers should work with their patients to help them improve their lifestyle. Eating a DASH-style diet, that emphasizes eating fruit, vegetables, whole-grains, low-fat dairy products, poultry and fish while limiting red meat and foods high in added sugars and salt has been clinically proven to lower blood pressure.
Maintaining healthy body weight and regular physical activity can lower blood pressure. Excessive intake of alcohol and tobacco affect blood pressure. After diagnosis of resistant hypertension patient will take three different classes of antihypertensive drugs, including a long-acting calcium channel blocker (CCB), an angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) which interacts with the renin-angiotensin system and a diuretic.
The healthcare provider can then customize a medication regimen based on the individual characteristics of the patient to make sure they are taking the most effective medication for their situation. If blood pressure remains uncontrolled, a mineralocorticoid receptor antagonist (MRS), which blocks a hormone associated with blood pressure called aldosterone, can be added to help lower blood pressure.
Secondary hypertension frequently arises from a condition called primary aldosteronism, a disorder of increased aldosterone secretion, which is found in about 20 percent of patients with resistant hypertension. Other major causes of secondary hypertension include chronic kidney disease and renal artery stenosis, a narrowing of one or more arteries that carry blood to the kidneys. Patients with high blood pressure may develop cardiovascular diseases such as heart attacks, heart failure and stroke, and their prognosis deteriorates further if they have resistant hypertension.