Resistant Hypertension Definition, Diagnosis, Evaluation, and Treatment

Resistant Hypertension Definition, Diagnosis, Evaluation, and Treatment – In the AHA scientific agreement [1], the definition of the resistant hypertension was taken to be the definition of the 7th report of the National Committee on Prevention, Detection, Evaluation and Treatment of AH (Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure, JNC- 7, 2003) [3].

According to this definition, resistant hypertension should be considered AD, which remains above the target level against the background of the use of at least 3 antihypertensive drugs of different classes (ideally, all these drugs should be used in optimal doses and one of them should refer to diuretics).

Even if the blood pressure can be controlled, but only with the help of 4 or more antihypertensive drugs, such hypertension is still considered resistant.

Hypertension Definition

Resistant hypertension is defined as a fixed blood pressure above the goal with the use of 3 different antihypertensive agents of the class. Ideally, one of the 3 agents must be diuretic; And all agents should be prescribed at the optimal dosage amount.

Although the use of a number of medications is required, resistant hypertension is defined to identify patients at high risk for reversible hypertension and / or patients who, due to persistent blood pressure, can benefit from special diagnosis and therapeutic considerations. As defined, resistant hypertension includes patients whose blood pressure is controlled with the use of more than 3 drugs.

That is, patients whose blood pressure is controlled but require 4 or more medications are considered to be classified as resistant to treatment.

Classification of Resistant Hypertension Patients

Uncontrolled blood pressure is more often due to persistent increases in systolic blood pressure. Among the Framingham participants treated with hypertension, 90% had achieved the goal of diastolic blood <90 mmHg where only 49% were on the goal of systolic blood pressure <140 mmHg.

This dispaity in the control of systolic versus diastolic blood pressure worsens with age increases as systolic control rates exceed 60% for younger participants (<60 years) but <40% in older subjects (> 75 years). Prospectively, ALLHAT showed similar difficulties in controlling systolic blood pressure in only 67% of participants who had lower systolic blood pressure up to <140 mmHg, of which 92% of participants achieved a goal of diastolic blood pressure <90 mmHg.

In the Framingham study data analysis, the strongest predictor of lack of blood pressure was greater age, with participants> 75 years to less than one quarters as having controlled systolic blood pressure compared to participants <60 years.


The next strong predictor of lack of control of blood pressure is the presence of LVH and obesity (body mass index (BMI> 30 Kg / m2) (table 1). In the use of diastolic blood pressure control, the strongest negative predictor is obesity, with controlled blood pressure about one-third lower that is often compared to ideal participants (BMI <25Kg / m2).

In a prospective analysis of Framingham participants, in addition to older age, higher baseline systolic blood pressure was associated with an increased risk of never achieving the goal blood pressure.

Based on ALLHAT there are some things which are predicted therapeutic resistance. It is including older age, higher baseline systolic blood pressure, LVH, and obesity. They are defined to require 2 or more antihypertensive medications. Overall, the strongest predictor of resistant therapy was to have CKD as defined with serum creatinine> 1.5 mgdL.

Other predictors for multiple medical needs include diabetes and living in the southeastern region of the United States. African American participants had more therapeutic resistance, as did women, such as black women with controls (59%) and the highest non-white male (70%).

Although the exact prevalence is unknown, the above study indicates that resistant hypertention is a frequent clinical problem. Furthermore, progressively in older and more severely populated populations in relation to the increased incidence of diabetes and CKD, the prevalence of resistant hypertension can be anticipated to increase.

Diagnosis of Resistant Hypertension


There are several factors related to the Resistant Hypertension of each patient. Here are the diagnosis of this disease. So, please check them out here.

  1. Genetic or Pharmacogenetic

One of the diagnosis of resistant hypertension is about genetic or pharmacogenetic. An extreme phenotype  is presented by resistant hypertension. It is very possible and reasonable that it is to predict that genetic factors play a larger role than the general hypertension population.

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However, genetic assessment of patients with resistant hypertension is limited. In one of several genetic evalasui patients with resistant hypertension, investigators in Finland screened 347 patients with resistant hypertension for mutations of the β and γ subunits of the sodium epithelial (ENaC) tract.

These sub unit mutations can cause Liddle syndrome, a rare monegnik form of hypertension.

Enzyme CYP3A5 (11β-hydroxysteroid dehydrogenase type 2) plays an important role in the metabolism of cortisol and corticosterone, especially in the kidneys. Most CYP3A5 alleles (CYP3A5 * 1) have been associated with African-American patients with high systolic blood pressure in normotensive participants and hypertension are more resistant to therapy.

  1. Pseudoresisten (Bad Blood Pressure Measurement Techniques)

Inaccurate measurements of blood pressure may result in the appearance of resistant therapy. Two of the most frequent errors-measuring blood pressure before letting the patient sit quietly and the use of small cuffs-will result in false blood pressure readings.

Although the degree to which inaccurate measurements of blood pressure will result in labeling the wrong patient as uncontrolled hypertension is unknown, assessment of blood pressure measurement techniques in the office supports that this is a frequent clinical problem.

Poor Compliance

Poor adherence to antihypertensive therapy is a major cause of lack of blood pressure control. Retrospective analysis indicated that about 40% of patients with new hypertension diagnoses will not resume their antihypertensive medication during the first year of treatment. During 5-10 years of follow-up, less than 40% of patients may arise with prescribed antihypertensive therapy.

While poor adherence is the most frequent in healthcare, it can be a bit uncommon in patients seen by specialists. Lack of blood pressure control is different from resistant therapy. For a failed anti-hypertensive regimen, this should be taken correctly.

Covert Effect


Studies indicate that covert effect is significant (when persistent clinical blood pressure increases while office values ​​are normal and significantly lower) is common in patients with resistant hypertension in resistant hypertension populations, with a prevalence range of 20 to 30%.

Also, as with more general hypertensive patients, patients with resistant hypertension on the basis of a “veiled” phenomenon manifest less cause target organ damage and appear to have a lower cardiovascular risk than patients with persistent hypertension during ambulatory monitoring.

  1. Lifestyle Factor

Bad lifestyle can be a fatalic factor to resistant hypertension. It is including obesity, salt diet, and consuming alcohol.



Obesity is associated with more severe hypertension, an increased need for a number of antihypertensive medications and an increase from a state that never reaches the goal of blood pressure. The obesity causes hypertension is complex and never clear but includes sodium secretion disorder, increased activity of the sympathetic nervous system, and activation of the rennin-angiotensin-aldosterone system.

Salt Diet

Excessive dietary sodium intake can increase the risk of resistant hypertension development through increased direct blood pressure. It is done by dulling the effect of lower blood pressure in most cases of antihypertensive agents. This effect becomes more commonly seen in typical salt-sensitive patients, including the elderly. Afro american and especially patients with CKD.


Severe alcohol intakes are associated with an increased risk of hypertension, as hypertension therapy is resistant. In a cross-sectional analysis of a Chinese adult who drank> 30 drinks per week, the risk for various hypertensive benthic increased from 12% to 14%.

  1. Causes Related to Drugs

By giving wide use, non-narcotic analgesics, thermicidal steroidal anti-inflammatory agents (NSAIDs), aspirin and acetaminophen, are likely to be defense agents in aggravating blood pressure control. NSAIDs, in particular, are associated with moderate, but blood pressure predictions. Meta-analysis of the effects of NSAIDs has been indicated on average to increase at an average arterial pressure of about 5 mmHg.

Other medication classes that may aggravate blood pressure control include sympathomimetic contents such as decongestants and some diet pills, stimulants such as amphetamine, modafinil, and oral contraceptives. Glucocorticoids, such as prenidone, sodium that causes fluid retention and can produce significant increases in blood pressure.

  1. Secondary causes

Secondary causes of hypertension are more common in patients with resistant hypertension, although the overall prevalence is unknown. The secondary causes of hypertension are greater in elderly patients due to the large prevalence of sleep apnea, renal parenchymal disease, renal artery stenosis, and possibly primary aldosteronism.

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Unusual secondary causes of hypertension include phaeochromocytoma, cushing syndrome, hyperparathyroidism, aortic coartase and intra cranial tumors.


The result of patients with resistant hypertension evaluations are including; Identification of causes that contribute to resistance, such as causes of secondary hypertension, and target-organ damage documentation (Fig. Accurate treatment adherence assessment Accurate and use blood pressure measurement techniques necessary to exclude pseudoresistance.

In most cases, resistant treatment is multifactorial in aetiology with obesity, more sodium intake diets, sleep apnea obstruction, and CKD being a common factor. Target-organ malfunctions such as retinopathy, CKD, and LVH support the diagnosis of uncontrolled hypertension as well as CKD cases will affect within the selected class of agents as well as achieve the objective blood pressure of 130/80 mm Hg

Treatment for Patients with Resistant hypertension

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There will be some recommendations for patients with resistant hypertension from the expert. It is in order to prevent the bad things happen during the patients are suffered from hypertension. Please read carefully the recommendations below.

  1. Therapeutic Recommendations

Resistant hypertension is almost always a multifactorial etiology. Predicated treatments are on identification and from lifestyle for factors of resistant contribution; Accurate and precise diagnosis of the causes of secondary hypertension and effective use of multi-drug regimens.

Lifestyle changes, including weight; Exercise routine; High-fiber, low-fat, low-salt dietary diet, and reduced alcohol intake should be encouraged where appropriate. Prevention of sleep apnea should be treated if present.

  1. Increased Compliance

Regimens recipes should be simplified as much as possible, including the use of a long-acting combination product to reduce the number of prescribed pills and allow for once-daily doses. Obedience is also further enhanced by clinic visits and with a record of patient’s blood pressure.

  1. Weight loss

Weight, though not specifically evaluated in patients with resistant hypertension, has a clear advantage in terms of how to reduce high blood pressure.

  1. Limitations of Salt Diet

The benefit of the salt diet is a general reduction in hypertensive patients observed with decreased systolic and diastolic blood pressure from 5-10 and to 2 6 mm Hg. African-American patients and the elderly tend to show greater profits

  1. Reduced alcohol intake

Neither by changes in physiological negative effects and / or improvements in drug compliance, the cessation of the weight of the alcohol-drinking process can significantly improve hypertensive control.

Daily alcohol intake should be limited to no longer than 2 drinks (1 ounce of ethanol) per day (for example, from 24 ounces of beer, 10 ounces of wine, or 3 ounces of hard liquor from 80) to most men and 1 drink per day For women-light or heavy people

  1. Increased Physical Activity

In a meta-analysis that included both normotensive and hypertensive cohorts studies, aerobic exercise produced an average decrease of 4 mm Hg in systolic and 3 mm Hg in diastolic blood pressure. Based on the observation of these benefits, patients should be encouraged to do at least 30 minutes at most days of the week.

  1. Foods High Fiber-Diet Low Fat

The process of ingesting foods rich in fruits and vegetables; High in low-fat dairy products, potassium, magnesium, and calcium; Low and total saturated fat (dietary approach to hypertension or stop dietary dash) reduced and systolic diastolic blood pressure by 11.4 and 5.5 mm Hg more, respectively, compared with diet control in hypertensive patients.

The benefits of a diet have not been evaluated separately in patients with resistant hypertension, but some degree of decreased blood pressure occurs.

  1. Therapy for Secondary Hypertension Cause

When major aldosteronism, pheochromocytoma, or Cushing’s disease is suspected or confirmed, the treatment will be specific to the disorder. Effective management of this disease requires appropriate referrals for specialists.

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