Resistant and Refractory Hypertension: A Guideline Topline for Primary Care
Hypertension that is resistant or refractory to treatment increases the risk of comorbidity and cardiovascular risk. Click through this at-a-glance review of key issues.
Resistant hypertension can be defined as inability to achieve BP control despite maximum treatment using 3 or more antihypertensive medications or BP that requires 4 or more medications to maintain control.
Refractory hypertension is disease that is uncontrolled despite the use of 5 or more medications, including a diuretic.
Prevalence of resistant hypertension: Population-based estimate, 12-15%; estimate based on clinic-based studies, 15-18%
Clinical correlates of resistant hypertension include obesity, sleep apnea, diabetes and chronic kidney disease
Pathophysiology of resistant and refractory hypertension: the former is predominately mediated by sodium retention, volume overload, and aldosterone; the latter by enhanced sympathetic tone
Ensure hypertension treatment is appropriate and optimized to rule out treatment resistance
Differentiate the white coat effect on office blood pressure readings from an accurate measure; the effect is found in between 28% and 53% of people with apparent treatment-resistant hypertension
Rule out treatment-resistant hypertension by carefully assessing adherence to treatment.
"Physician perception of adherence is notoriously inaccurate, perhaps no better than a coin toss."
"Physician perception of adherence is notoriously inaccurate, perhaps no better than a coin toss."
Ensure BP readings are performed appropriately to avoid unreliable measures that may suggest resistant hypertension
Consider approaching treatment resistant hypertension by evaluating biochemical measures and sharing results with the patient as feedback
In cases of apparent treatment-resistant hypertension, revisit and reinforce prior measures implemented and also assess for secondary causes
Medication for treatment-resistant hypertension should be considered carefully and some medications are contraindicated in individuals with reduced estimated glomerular filtration rate
Treatment for apparent refractory hypertension should target the likely cause, increased sympathetic tone
Treatment-resistant hypertension is defined by inadequate response to multiple medications, but is correctly diagnosed and treated with more intensive regimens after other considerations, including whether the initial treatment regimen was optimized and the blood pressures were accurately determined. Hypertension that appears refractory to treatment requires further assessment of the treatment regimen, and ascertaining underlying pathophysiology to guide successful treatment modification. Both types are associated with increased comorbidity and increased cardiovascular risk.
This Patient Care Guideline Topline on resistant and refractory hypertension is drawn from a 2023 review, in a series on controversies in hypertension published this year in The American Journal of Medicine.1 The last clinical practice guideline on hypertension in the US was issued by the American Academy of Family Physicians (AAFP)2 in 2022, and was highlighted in a Guideline Topline here in 2023.
