Recognition and management of resistant hypertension

Branko Braam, Sandra J. Taler, Mahboob Rahman, Jennifer A. Fillaus, Barbara A. Greco, John P. Forman, Efrain Reisin, Debbie L. Cohen, Mohammad G. Saklayen, S. Susan Hedayati

Research output: Contribution to journalArticle

14 Citations (Scopus)

Abstract

Despite improvements in hypertension awareness and treatment, 30%–60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.

Original languageEnglish (US)
Pages (from-to)524-535
Number of pages12
JournalClinical Journal of the American Society of Nephrology
Volume12
Issue number3
DOIs
StatePublished - 2017

Fingerprint

Hypertension
Diuretics
Antihypertensive Agents
Therapeutics
Organs at Risk
Mineralocorticoid Receptor Antagonists
Diet Therapy
Kidney
Pressoreceptors
Denervation
Life Style
Patient Care

Keywords

  • Antagonists
  • Antihypertensive Agents
  • Blood pressure
  • Cardiovascular disease
  • Chronic
  • Chronic kidney disease
  • Denervation
  • Diuretics
  • Humans
  • Hypertension
  • Kidney
  • Life Style
  • Mineralocorticoid Receptor
  • Pressoreceptors
  • Renal denvervation
  • Renal Insufficiency
  • Sodium intake

ASJC Scopus subject areas

  • Epidemiology
  • Critical Care and Intensive Care Medicine
  • Nephrology
  • Transplantation

Cite this

Braam, B., Taler, S. J., Rahman, M., Fillaus, J. A., Greco, B. A., Forman, J. P., ... Hedayati, S. S. (2017). Recognition and management of resistant hypertension. Clinical Journal of the American Society of Nephrology, 12(3), 524-535. https://doi.org/10.2215/CJN.06180616

Recognition and management of resistant hypertension. / Braam, Branko; Taler, Sandra J.; Rahman, Mahboob; Fillaus, Jennifer A.; Greco, Barbara A.; Forman, John P.; Reisin, Efrain; Cohen, Debbie L.; Saklayen, Mohammad G.; Hedayati, S. Susan.

In: Clinical Journal of the American Society of Nephrology, Vol. 12, No. 3, 2017, p. 524-535.

Research output: Contribution to journalArticle

Braam, B, Taler, SJ, Rahman, M, Fillaus, JA, Greco, BA, Forman, JP, Reisin, E, Cohen, DL, Saklayen, MG & Hedayati, SS 2017, 'Recognition and management of resistant hypertension', Clinical Journal of the American Society of Nephrology, vol. 12, no. 3, pp. 524-535. https://doi.org/10.2215/CJN.06180616
Braam, Branko ; Taler, Sandra J. ; Rahman, Mahboob ; Fillaus, Jennifer A. ; Greco, Barbara A. ; Forman, John P. ; Reisin, Efrain ; Cohen, Debbie L. ; Saklayen, Mohammad G. ; Hedayati, S. Susan. / Recognition and management of resistant hypertension. In: Clinical Journal of the American Society of Nephrology. 2017 ; Vol. 12, No. 3. pp. 524-535.
@article{f9fc64a964484e45843c2a078c9c5692,
title = "Recognition and management of resistant hypertension",
abstract = "Despite improvements in hypertension awareness and treatment, 30{\%}–60{\%} of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.",
keywords = "Antagonists, Antihypertensive Agents, Blood pressure, Cardiovascular disease, Chronic, Chronic kidney disease, Denervation, Diuretics, Humans, Hypertension, Kidney, Life Style, Mineralocorticoid Receptor, Pressoreceptors, Renal denvervation, Renal Insufficiency, Sodium intake",
author = "Branko Braam and Taler, {Sandra J.} and Mahboob Rahman and Fillaus, {Jennifer A.} and Greco, {Barbara A.} and Forman, {John P.} and Efrain Reisin and Cohen, {Debbie L.} and Saklayen, {Mohammad G.} and Hedayati, {S. Susan}",
year = "2017",
doi = "10.2215/CJN.06180616",
language = "English (US)",
volume = "12",
pages = "524--535",
journal = "Clinical Journal of the American Society of Nephrology",
issn = "1555-9041",
publisher = "American Society of Nephrology",
number = "3",

}

TY - JOUR

T1 - Recognition and management of resistant hypertension

AU - Braam, Branko

AU - Taler, Sandra J.

AU - Rahman, Mahboob

AU - Fillaus, Jennifer A.

AU - Greco, Barbara A.

AU - Forman, John P.

AU - Reisin, Efrain

AU - Cohen, Debbie L.

AU - Saklayen, Mohammad G.

AU - Hedayati, S. Susan

PY - 2017

Y1 - 2017

N2 - Despite improvements in hypertension awareness and treatment, 30%–60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.

AB - Despite improvements in hypertension awareness and treatment, 30%–60% of hypertensive patients do not achieve BP targets and subsequently remain at risk for target organ damage. This therapeutic gap is particularly important to nephrologists, who frequently encounter treatment-resistant hypertension in patients with CKD. Data are limited on how best to treat patients with CKD and resistant hypertension, because patients with CKD have historically been excluded from hypertension treatment trials. First, we propose a consistent definition of resistant hypertension as BP levels confirmed by both in-office and out-of-office measurements that exceed appropriate targets while the patient is receiving treatment with at least three antihypertensive medications, including a diuretic, at dosages optimized to provide maximum benefit in the absence of intolerable side effects. Second, we recommend that each patient undergo a standardized, stepwise evaluation to assess adherence to dietary and lifestyle modifications and antihypertensive medications to identify and reduce barriers and discontinue use of substances that may exacerbate hypertension. Patients in whom there is high clinical suspicion should be evaluated for potential secondary causes of hypertension. Evidence-based management of resistant hypertension is discussed with special considerations of the differences in approach to patients with and without CKD, including the specific roles of diuretics and mineralocorticoid receptor antagonists and the current place of emerging therapies, such as renal denervation and baroreceptor stimulation. We endorse use of such a systematic approach to improve recognition and care for this vulnerable patient group that is at high risk for future kidney and cardiovascular events.

KW - Antagonists

KW - Antihypertensive Agents

KW - Blood pressure

KW - Cardiovascular disease

KW - Chronic

KW - Chronic kidney disease

KW - Denervation

KW - Diuretics

KW - Humans

KW - Hypertension

KW - Kidney

KW - Life Style

KW - Mineralocorticoid Receptor

KW - Pressoreceptors

KW - Renal denvervation

KW - Renal Insufficiency

KW - Sodium intake

UR - http://www.scopus.com/inward/record.url?scp=85020713618&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=85020713618&partnerID=8YFLogxK

U2 - 10.2215/CJN.06180616

DO - 10.2215/CJN.06180616

M3 - Article

VL - 12

SP - 524

EP - 535

JO - Clinical Journal of the American Society of Nephrology

JF - Clinical Journal of the American Society of Nephrology

SN - 1555-9041

IS - 3

ER -