1. Resistant Hypertension: Definition, Prevalence and Clinical Implications
Judith H. Veis, MD, FACP
Associate Director, Nephrology
Medstar Washington Hospital Center

2. I/we have no real or apparent conflicts of interest to report.
Judith H. Veis, MD
I/we have no real or apparent conflicts of interest to report.

3. Definitions Uncontrolled Hypertension Blood pressures not at goal
JNC 7: General goal < 140/<90
Specific populations < 130/<80
CKD, ASCVD, DM and CHF
Causes
Previously undiagnosed Hypertension
Medication Non-adherence
Resistant Hypertension

4. Definitions Resistant Hypertension
Failure to achieve goal BP despite adherence to a 3 antihypertensive drug regimen.
Controlled BP with 4 or more antihypertensive drugs.
One of the agents is a diuretic.
Drugs are optimally dosed.

5. Definitions Pseudo-Resistant Hypertension Inaccurate Measurement
BP measures should be taken after a patient has been seated quietly in a chair with back supported for five minutes.
Poor adherence to antihypertensive therapy.:
Multiple medications.
Frequent changes.
Side effects.
Cost!!!
White coat effect.
‘Inadequate treatment regimen’.

7. Secondary causes of Resistant Hypertension
Obstructive Sleep Apnea (OSA) is prevalent!!
Obesity
CKD
Primary aldosteronism
Renal artery stenosis
Pheocromocytoma
Cushing’s syndrome

8. Lifestyle factors. Dietary salt consumption: Alcohol consumption:
Assessment of 24 hrs UNa excretion ( goal <100 meq/24 hrs).
Alcohol consumption:
Alcohol should be limited to 1 ounce/day in RH patients.
Obesity

9. Drug-related causes of Resistant Hypertension
NSAIDs
Steroids
Sympathomimetics
Decongestants
Weight Loss Meds
Cocaine
Oral Contraceptives
Erythropoeitin
Licorice
Stimulants
Methylphenidate
Amphetamine
Modanifil
Calcineurin Inhibitors
Herbal Meds
Ephedra
Ma huang
Tricyclic antidepressants
Pisoni et al; Curr Cardiol Rep November; 11(6):

10. Persell et al; Hypertension. 2011; 57:1076-1080.
Prevalence
NHANES: National health and Nutrition Examination Survey
Persell et al; Hypertension. 2011; 57:

11. Persell et al; Hypertension. 2011; 57:1076-1080.
Risk Factors
Persell et al; Hypertension. 2011; 57:

12. Clinical Implications of Resistant Hypertension
Higher incidence
Cardiovascular events, particularly stroke
More LVH, carotid intimal thickening
Progressive kidney disease
NIDDM

13. Incidence and Prognosis of Resistant Hypertension
Retrospective, 2 integrated health plans
RH defined as uncontrolled BP despite use of > 3 medications or controlled with > 4 meds
Adherent if > 80% of meds filled
Outcome measure
Incident cardiovascular events
Death, MI, CHF, stroke or CKD
Daughtery et al. Circulation 2012

14. Incidence and Prognosis of Resistant Hypertension
205,750 patients with HTN
1.9% Resistant w/in 1.5 years of initial treatment
Risks of RH
Male, older age, more DM
Over 3.8 years, significantly more cardiovascular events with RH
18.0% vs. 13.5%, p < 0.001
Adjusted for patient and clinic characteristics
Hazard ratio for higher risk of CV events: 1.47
95% CI, 1.33 – 1.62
Daughtery et al. Circulation 2012

15. Incidence and Prognosis of Resistant Hypertension
Daughtery et al. Circulation 2012

16. Cardiovascular Risk in Resistant HTN
Comparison of true responders, masked resistant (normal clinic BP and high ambulatory BP), false resistant (high clinic and normal ambulatory BP) and true resistant
years follow-up
Events: fatal/nonfatal MI, revascularization (CAD or PVD), CHF, stroke and ESRD
Event-rate per 100 patient-yrs
True Responders, n = 340, rate 0.87
Masked HTN, n = 126, rate 2.42
False Resistant, n = 146, rate 1.2
True Resistant , n = 130, rate 4.1
Pierdomenica et al, Am J HTN 2005

17. Cardiovascular Risk in Resistant HTN
Pierdomenica et al, Am J HTN 2005

18. Conclusions
Resistant Hypertension is defined as uncontrolled HTN with BP > 140/90 on > 3 meds or controlled on > 4 meds
Exclude non-adherent patients
Prevalence ranges from 1.9 – 8.9% of HTN patients
Check for OSA in all patients and consider meds and other secondary causes
Note from a nephrologist
CONTROL VOLUME with DIURETICS
Increased CV event rates occur compared to controlled hypertension