Resistant Hypertension: Diagnosis, Evaluation, Treatment

New Guidelines Issued for Hypertension that Defies Treatment
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By Judith Groch, Contributing Writer, MedPage TodayPublished: April 11, 2008Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco
BIRMINGHAM, Ala., April 11 -- The American Heart Association has issued consensus guidelines for treating resistant hypertension, a common, difficult-to-manage condition.
Resistance is also established if hypertension is controlled but it's taken four or more drugs to get there.
The exact prevalence of resistant hypertension is unknown, but clinical trials suggest that it is not rare, involving 20% to 30% of study participants, the guideline committee wrote.
Older age and obesity are two of the strongest risk factors associated with resistant hypertension, and the condition is likely to become more common as the population ages and becomes heavier, the committee authors said.
As a first step in management, they emphasized, it is important to determine that a person's condition is resistant, not merely uncontrolled.
The committee's diagnostic advice:
Confirm treatment resistance. In addition to use of medications as noted above, office blood pressure, taken with good technique, should be greater than 140/90 or over 130/80 in patients with diabetes or chronic kidney disease;
Rule out the "white-coat effect" by use of ambulatory monitoring, if necessary;
Identify and reverse contributing lifestyle factors, such as obesity, physical inactivity, excessive alcohol ingestion, high salt and low-fiber diet;
Discontinue or minimize interfering substances, such as non-steroidal anti-inflammatory agents, diet pills, decongestants, stimulants, oral contraceptives, licorice, and ephedra;
Screen for secondary causes of resistant hypertension, such as obstructive sleep apnea, renal artery stenosis, primary aldosteronism, Cushing's syndrome, aortic co-arctation, and pheochromocytoma. /.../