AHA updates guidance on managing resistant hypertension

First step in managing resistant hypertension is to implement lifestyle interventions

The American Heart Association (AHA) released an updated scientific statement on the detection, evaluation, and management of resistant hypertension, defined as an above goal BP despite the use of three antihypertensive drug classes or target BP levels after taking four or more antihypertensive medications. Resistant hypertension is estimated to occur in approximately 12% to 15% of the population and is associated with substantial morbidity and mortality. Therefore, a thorough understanding of potential precipitating factors and appropriate lifestyle and medical management is essential.  

Patients presenting with resistant hypertension should be evaluated to ensure those with “white-coat” hypertension are not included and that the condition is not a result of nonadherence to the prescribed antihypertensive regimens. In general, patients with resistant hypertension should be taking a regimen that includes a long-acting calcium channel blocker (CCB), an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB), and a diuretic at maximum or maximally tolerated doses. The elevated BP may be due to a variety of factors such as lifestyle choices, medications, or underlying medical conditions. Lifestyle factors such as high dietary sodium intake, heavy alcohol use, and physical inactivity can all contribute to elevated BP levels, as can obesity, occupational stress, anxiety, depression, and reduced sleep duration/quality. 

Medications and other substances can also contribute to elevated BP levels. Medication lists should be reviewed to determine if patients are taking drugs that may increase BP and if the drugs can be stopped or switched to something else. Clinicians should also be vigilant in looking for use of OTC medications that may increase BP and be on the lookout for use of illicit sub-stances, such as cocaine and amphetamines. A variety of medical conditions, such as obstructive sleep apnea, primary aldosteronism, renal diseases, Cushing’s syndrome, and thyroid disorders, can also increase BP.

The AHA statement provides a step-by-step guide for the management of resistant hypertension. After lifestyle interventions and the ensuring that the three-drug regimen is optimized, step 2 is to substitute the prior diuretic with either chlorthalidone or indapamide. If the BP is still not at target, the addition of a mineralocorticoid receptor antagonist (i.e., spironolactone or eplerenone) is recommended in step 3. If the BP is still not controlled, a variety of other treatments are listed, but AHA noted that these steps (i.e., steps 4 to 6) should be individualized to the patient. For step 4, an assessment of the heart rate is needed and the addition of a beta blocker or a combined alpha-beta blocker can be considered in those without contraindications. If a beta blocker is contraindicated, use of a central alpha-agonist or once daily diltiazem can be considered. Hydralazine is listed as an option in step 5, and minoxidil is listed as a substitute for hydralazine in step 6 if the BP is still not at target.      

For the full article, see the December 2018 issue of Pharmacy Today at www.pharmacytoday.org