Difficult-to-control hypertension is a common issue in primary care. Resistant hypertension is defined as a blood pressure (BP) measurement above goal despite the use of maximum or optimal dosages of three antihypertensive agents, including a diuretic. Before diagnosing resistant hypertension, family physicians should evaluate patients with difficult-to-control BP for comorbid conditions, medication nonadherence, white coat hypertension, secondary hyper-tension, and suboptimal therapy. Attention should be focused on ensuring accurate BP measurement technique in the office and confirmatory BP monitoring at home. Management of resistant hypertension should include evidence-based lifestyle interventions, adjustment of plans for social factors, and individualized medication regimens. A dihydropyridine calcium channel blocker, an angiotensin receptor blocker or angiotensin-converting enzyme inhibitor, and a thiazide diuretic should be part of the initial three-drug regimen. Therapy may be suboptimal if preferred antihypertensives are not used, medications are inadequately dosed, lifestyle factors are not addressed, comorbidities are improperly treated, or social factors are not recognized. In patients with resistant hypertension, a mineralocorticoid receptor antagonist is the preferred fourth-line option. Other antihypertensives to improve BP control should be considered based on patient factors and shared decision-making. For patients who are unable to tolerate medications or achieve adequate BP control, referral for interventional options (eg, renal sympathetic denervation, carotid baroreceptor amplification) should be considered.
Elevated blood pressure (BP) affects nearly half of all adults in the United States. Less than half of these adults have controlled hypertension, defined as a BP less than 140/90 mm Hg.1 BP can be difficult to control due to lifestyle factors, comorbid conditions, suboptimal medication use, inconsistent adherence to medication, or resistant hypertension. Difficult-to-control BP can be the result of patient-, physician-, and system-level issues.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| For accurate office and home BP measurement, ensure use of proper technique.6,9–13 | C | Multiple moderate-quality studies |
| Screening for hypertension with office BP measurement in adults 18 years or older is recommended; however, confirmation of BP outside the office is recommended before starting treatment.14,15 | A | Multiple high-quality studies |
| Before diagnosing resistant hypertension, exclude medication nonadherence, substance-induced causes for elevated BP, and suboptimal antihypertensive medication therapy.6,7 | C | Multiple moderate-quality studies |
| Use low- to standard-dose combination pills instead of titrating monotherapy to maximum doses for greater BP reduction.27,28 | C | Multiple moderate-quality studies |
| Mineralocorticoid receptor antagonists are the preferred fourth-line medication option for resistant hypertension.32,33 | C | Multiple moderate-quality studies |
BP = blood pressure.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
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