New developments in the diagnosis and management of resistant hypertension

Arterial hypertension is a well-known disease with a worldwide high prevalence and impaired prognosis with respect to normotensive subjects, due to increased cardiovascular mortality and morbidity. Blood pressure levels over range can be successfully controlled with adequate treatment, but more than 10% of hypertensive people have their blood pressure uncontrolled despite a therapeutic regimen of 3 or more antihypertensive drugs. These patients, named to have resistant hypertension, have a worse cardiovascular prognosis than controlled hypertensive subjects. Twenty-four hour-ambulatory blood pressure monitoring (ABPM) reveals that at least one third of these patients have indeed white-coat resistant hypertension, a rather more benign entity. In view of this evidence, performance of 24 h-ABPM is mandatory and to document the occurrence of subclinical target organ damage in this population before the development of cardiovascular disease is needed. This would help the physician to more rigorously implement adequate measures to control hypertension. On the other hand, the definition itself of the disease implies that conventional pharmacological treatment is not effective enough for these patients to reach normal blood pressure values. To treat resistant hypertensives, recent reports pay attention to the need to recover traditional treatments--either non-pharmacologic such as strict sodium diet restriction or pharmacologic such as the use of aldosterone receptor blockers--or to implement those treatments that are novelties, such as renal sympathetic nervous system ablation or carotid barorreceptors stimulation. This review focuses on outlining the current evidence about the diagnostic confirmation of resistant hypertension, the need to characterize these patients through 24 h-ABPM, to identify the presence of subclinical target organ damage, and to deal with not only classical but also novel treatment approaches for blood pressure control.