Profile of ambulatory blood pressure in resistant hypertension

Resistant hypertension (HT) is a condition that confers a high cardiovascular risk to the patient due to both persistent blood pressure elevation and the high prevalence of comorbidities and organ damage. Ambulatory blood pressure monitoring (ABPM) has become an important tool in the diagnosis and follow-up of the hypertensive patient, and it is even more important in the evaluation of those with resistant HT. Data from the Spanish ABPM Registry have allowed the comparison between large groups of resistant hypertensive patients seen in daily life and those controlled on antihypertensive treatment, as well as in resistant hypertensive patients who are classified based on ambulatory blood pressure values. In comparison with controlled patients, the cohort of resistant hypertensives has a worse circadian profile with a high proportion of nondipping, but also stark differences between office and ambulatory blood pressures. This enhanced white-coat effect was responsible for more than one-third of resistant hypertensive patients having normal 24-h blood pressures. Clinical data, including comorbidities, organ damage and circadian patterns, suggest a lower cardiovascular risk among white-coat resistant hypertensives. This finding was in agreement with longitudinal studies in smaller cohorts, suggesting fewer cardiovascular events and less mortality. In summary, it seems reasonable to routinely use ABPM in the initial evaluation of all resistant hypertensive patients. In a significant number of these patients, ABPM will also be an essential tool in follow-up, especially regarding the possible effects of all therapeutic maneuvers that are devoted to bringing blood pressure into target ranges.