Management of patients with refractory hypertension

Resistant hypertension is increasing in prevalence related in part to lower blood pressure goals in an aging population. Costs of this condition are high including target organ damage and the financial burden and emotional frustration of using increasing numbers of medications at higher dosages yet without achieving normal blood pressure levels. The key to managing this condition lies in recognition by the treating practitioner that first, the blood pressure is not controlled and requires a change in treatment and second, that further historical information, examination and laboratory testing may reveal the cause for resistance and the pathway to successful control. Causes for resistant hypertension include flaws in medication selections and dosing, secondary hypertension (most commonly due to renal parenchymal disease, renovascular hypertension, primary aldosteronism, or obstructive sleep apnea), lifestyle factors, and drug interactions. Decisions on the extent of testing or intervention appropriate for an individual patient require careful review to balance the risks of intervention against the risks of leaving a secondary cause unrecognized. A single treatment approach has not been proven superior, but several systematic approaches show demonstrated success in study settings, including protocol-based nurse intervention and follow-up, or use of serial physiologic measurements (systemic hemodynamic measurements, plasma renin activity, plasma volume) to adjust treatment.