What is the treatment for resistant hypertension (high blood pressure)?

Updated: Feb 22, 2019
  • Author: Matthew R Alexander, MD, PhD; Chief Editor: Eric H Yang, MD  more...
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2018 AHA updated guidelines

Three important points emphasized in the 2018 updated AHA guidelines on resistant hypertension include (1) routine queries about patients' sleep patterns, as poor sleep duration and quality can interfere with blood control (BP) control; (2) lifestyle modifications (eg, low-sodium diet, weight loss, exercise, ≥6 hours of uninterrupted sleep each night; and (3) considering a change in antihypertensive agents from hydrochlorothiazide to chlorthalidone or indapamide if an above-goal BP persists despite adherence to a three-drug regimen and an optimal lifestyle (if the BP remains elevated despite the drug change, consider adding spironolactone as a fourth agent. Be extra vigilant if the estimated glomerular filtrate rate [eGFR] is < 30 mL/min/1.73 m2). [42, 110]  Clinicians should also assess and ensure optimal medication adherence in patients with resistant hypertension.

If the patient's BP is still not at target despite the above steps, the AHA suggests the following steps on the basis of expert opinion, and emphasizes they should be tailored to the patient [42] :

  1. Unless the patient's heart rate is below 70 bpm, add a beta-blocker such as metoprolol succinate or bisoprolol, or a combined alpha-beta-blocker such as labetalol or carvedilol. If a beta-blocker is contraindicated, a central alpha-agonist such as a clonidine patch weekly or guanfacine at bedtime may be considered; if these agents are not tolerated, once-daily diltiazem may be considered. If the patient's BP is still not at target, then:

  2. Add hydralazine 25 mg three times daily and uptitrate to the maximum dose. Concomitant use of a beta-blocker and a diuretic is required. If a patient has congestive heart failure and reduced ejection fraction, administer hydralazine on a background of isosorbide mononitrate 30 mg daily (max: 90 mg daily). If the patient's BP is still not at target, then:

  3. Substitute minoxidil 2.5 mg two to three times daily for hydralazine and uptitrate. Concomitant use of a beta-blocker and a loop diuretic is required. If the patient's BP is still not at target, then:

  4. Consider referring the patient to a hypertension specialist and/or for clinical trials.

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