Controversies in Hypertension V: Resistant and Refractory Hypertension

Area of Science:

• Cardiology
• Nephrology
• Pharmacology

Background:

• Apparent resistant hypertension (uncontrolled BP despite ≥3 medications) affects ≤15% of hypertensives.
• Apparent refractory hypertension (uncontrolled BP despite ≥5 medications) affects ≤10% of resistant cases.
• Both conditions increase comorbidity and cardiovascular risk.

Purpose of the Study:

• To outline diagnostic and management strategies for apparent resistant and refractory hypertension.
• To differentiate true resistant/refractory hypertension from pseudo-resistance.
• To discuss optimal pharmacologic and interventional approaches.

Main Methods:

• Guideline-based methodology for blood pressure measurement.
• Optimization of antihypertensive regimens.
• Assessment for white-coat effect and medication adherence.
• Pharmacologic management targeting volume overload, aldosterone excess, and sympathetic tone.

Main Results:

• True resistant hypertension often involves volume overload and aldosterone excess.
• True refractory hypertension is linked to enhanced sympathetic tone.
• Spironolactone is preferred for resistant hypertension; finerenone indicated for albuminuria.
• Sympathetic inhibition is a potential strategy for refractory hypertension.

Conclusions:

• Accurate diagnosis and adherence assessment are crucial for managing resistant hypertension.
• Targeted therapies like spironolactone, potassium binders, or finerenone improve outcomes.
• Further research is needed to define optimal treatment for refractory hypertension.