Difficult-to-Control or Resistant Hypertension?
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INVITED COMMENTARY
Difficult-to-Control or Resistant Hypertension? Luis M. Ruilope
Published online: 10 October 2013 # Springer Science+Business Media New York 2013
Keywords Resistant hypertension . Difficult to control hypertension . Spironolactone . Renal denervation
According to European Society of Hypertension /European Society of Cardiology (ESH/ESC) Guidelines, hypertension is defined as resistant to treatment when a therapeutic strategy that includes appropriate lifestyle measures plus a diuretic and 2 other antihypertensive drugs belonging to different classes at adequate doses fails to lower blood pressure (BP) [1]. This definition does not vary from the one published in the first scientific statement devoted to the diagnosis, evaluation, and treatment of resistant hypertension published by the American Heart Association 5 years ago [2]. This statement recognized that this form of arterial hypertension is a common clinical problem, usually of multifactorial etiology, and accompanied by an increased cardiovascular risk dependent on the BP level and on the very frequent presence of other cardiovascular disease risk factors. Roughly, one-third of hypertensives will require 3 or more drugs and in this group a significant part can theoretically be considered as being resistant [3]. Recent data coming from US and Europe show that the prevalence of resistant hypertension could be rising [4], and oscillates around 12 % in pharmacologically treated hypertensives [5, 6]. Among patients with incident hypertension in whom pharmacologic treatment was begun, 1 in 50 developed resistant hypertension during a 18-month follow-up (incidence of
L. M. Ruilope (*) Instituto de Investigación, Hospital 12 de Octubre, 28041 Madrid, Spain e-mail: [email protected] L. M. Ruilope Department of Preventive Medicine and Public Health, Universidad Autonoma de Madrid, Madrid, Spain
1.9 % in 205,750 hypertensive patients), and the cardiovascular risk increased by more than 50 % during a median followup of 3.8 years [7]. These figures represent hundreds of thousands of patients that present with resistant hypertension, but the majority of these patients are probably difficult-tocontrol hypertensives who with an adequate program of prevention and treatment will get well-controlled [8]. Ambulatory blood pressure monitoring will discard at least one-third of the difficult-to-control hypertensives by showing daytime BP values inferior to 135 mm Hg [6]. Ruling out secondary forms of hypertension (particularly primary aldosteronism, renovascular hypertension, chronic kidney disease, and obstructive sleep apnea) and drugs able to induce hypertension will contribute to facilitate the control of BP in a significant number of these patients [1, 2]. On the other hand, early daily compliance and long-term adherence to therapy are the most important objectives in the treatment of patients with arterial hypertension [9]. Low adherence can be the most common cause of poor BP control in patients with difficult-to-control hypertension, affecting up
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