Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association

TLDR

Resistant hypertension is defined as uncontrolled blood pressure despite the use of three maximally tolerated antihypertensive drug classes—including a calcium channel blocker, an ACE inhibitor or ARB, and a diuretic—or when target blood pressure is achieved only with four or more drugs, and it is associated with a higher risk of adverse outcomes. This statement updates the American Heart Association guidance on detecting, evaluating, and managing resistant hypertension. After confirming medication adherence and excluding white‑coat hypertension, evaluation involves identifying lifestyle contributors, drug interactions, secondary hypertension, and organ damage, while management includes optimizing lifestyle, adding a thiazide‑like diuretic, a mineralocorticoid antagonist, and, if needed, further agents with complementary mechanisms, with specialist referral if blood pressure remains uncontrolled.

Abstract

Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the “white-coat effect” (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.