190 - Can’t Stop, Won’t Drop … The BP That Just Won’t Quit: Diagnosis and Treatment of Resistant Hypertension

In this episode, we discuss the diagnosis and treatment of resistant hypertension, including a newer endothelin receptor antagonist (ERA) called aprocitentan (Tryvio®).

Key Concepts

1. The diagnosis of true resistant hypertension is based on requiring more than 3 antihypertensives (ACE inhibitor or ARB + calcium channel blocker + diuretic) to achieve goal BP, ruling out inaccurate BP readings, and ensuring patient adherence to their antihypertensive therapy.
2. Non-pharmacologic therapy (especially dietary sodium restriction), medication adherence, and lifestyle changes are critical to the treatment of resistant hypertension.
3. The preferred 4th line option for most patients with resistant hypertension is spironolactone.
4. After adding spironolactone, additional therapies are based on expert opinion and patient-specific factors. These additional therapies may include beta blockers, alpha-2 agonists, alpha-1 blockers, hydralazine, minoxidil, and aprocitentan.

References

• Carey RM, Calhoun DA, Bakris GL, et al. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension. 2018;72(5):e53-e90. doi:10.1161/HYP.0000000000000084
• Mancia G, Kreutz R, Brunström M, et al. 2023 ESH Guidelines for the management of arterial hypertension The Task Force for the management of arterial hypertension of the European Society of Hypertension: Endorsed by the International Society of Hypertension (ISH) and the European Renal Association (ERA). J Hypertens. 2023;41(12):1874-2071. doi:10.1097/HJH.0000000000003480