Refractory arterial hypertension: important, but suboptimally characterized

Refractory arterial hypertension (HTN) is a newly described severe phenotype of anti-hypertensive therapy failure. It is defined as uncontrolled blood pressure on (near-)maximal treatment using ≥ 5 antihypertensive drugs, two of which are long-acting thiazide-like diuretics (e.g. chlorthalidone) and mineralocorticoid receptor antagonists, with an additional requirement in one of the first reports: uncontrolled blood pressure after a minimum of three visits to the department. We observed important differences in the definitions of refractory HTN over time and even in the same period in the most important documents in medicine today - guidelines. The AIMs of the study were threefold: to underline the high risk and consequent importance of this phenotype of HTN, to analyze the evolution of the definition of refractory HTN and the consonance in the guidelines on the topic, to study potential insufficiencies of the current definitions, and possibly suggest some improvements. Patients with refractory HTN are at a higher risk of developing cardiovascular complications such as heart failure (HF), left ventricular hypertrophy (LVH), or stroke than those with controlled resistant HTN. Moreover, hypertension-mediated organ damage and comorbidities such as diabetes and obstructive sleep apnea are more prevalent in patients with refractory HTN. Some guidelines list treatment for refractory HTN, but the definition of refractory HTN is actually resistant to HTN. Generally, what is recognized as insufficient for the definition of resistant HTN is also likely true for refractory HTN.