Published Online
on April 7, 2008

A more recent version of this article appeared on June 1, 2008

This Article Free upon publication Full Text (PDF) All Versions of this Article: 51/6/1403    most recent HYPERTENSIONAHA.108.189141v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions patientINFORMation Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Calhoun, D. A. Articles by Carey, R. M. Search for Related Content PubMed PubMed Citation Articles by Calhoun, D. A. Articles by Carey, R. M. Pubmed/NCBI databases Medline Plus Health Information Blood Pressure Medicines High Blood Pressure Related Collections Obesity Compliance/Adherence Type 2 diabetes Clinical Studies AHA Statements and Guidelines

Resistant Hypertension: Diagnosis, Evaluation, and Treatment. A Scientific Statement From the American Heart Association Professional Education Committee of the Council for High Blood Pressure Research

David A. Calhoun MD, FAHA, Chair; Daniel Jones MD, FAHA; Stephen Textor MD, FAHA; David C. Goff MD, FAHA; Timothy P. Murphy MD, FAHA; Robert D. Toto MD, FAHA; Anthony White PhD; William C. Cushman MD, FAHA; William White MD; Domenic Sica MD, FAHA; Keith Ferdinand MD; Thomas D. Giles MD; Bonita Falkner MD, FAHA; and Robert M. Carey MD, MACP, FAHA

Abstract—Resistant hypertension is a common clinical problem faced by both primary care clinicians and specialists. While the exact prevalence of resistant hypertension is unknown, clinical trials suggest that it is not rare, involving perhaps 20% to 30% of study participants. As older age and obesity are 2 of the strongest risk factors for uncontrolled hypertension, the incidence of resistant hypertension will likely increase as the population becomes more elderly and heavier. The prognosis of resistant hypertension is unknown, but cardiovascular risk is undoubtedly increased as patients often have a history of long-standing, severe hypertension complicated by multiple other cardiovascular risk factors such as obesity, sleep apnea, diabetes, and chronic kidney disease. The diagnosis of resistant hypertension requires use of good blood pressure technique to confirm persistently elevated blood pressure levels. Pseudoresistance, including lack of blood pressure control secondary to poor medication adherence or white coat hypertension, must be excluded. Resistant hypertension is almost always multifactorial in etiology. Successful treatment requires identification and reversal of lifestyle factors contributing to treatment resistance; diagnosis and appropriate treatment of secondary causes of hypertension; and use of effective multidrug regimens. As a subgroup, patients with resistant hypertension have not been widely studied. Observational assessments have allowed for identification of demographic and lifestyle characteristics associated with resistant hypertension, and the role of secondary causes of hypertension in promoting treatment resistance is well documented; however, identification of broader mechanisms of treatment resistance is lacking. In particular, attempts to elucidate potential genetic causes of resistant hypertension have been limited. Recommendations for the pharmacological treatment of resistant hypertension remain largely empiric due to the lack of systematic assessments of 3 or 4 drug combinations. Studies of resistant hypertension are limited by the high cardiovascular risk of patients within this subgroup, which generally precludes safe withdrawal of medications; the presence of multiple disease processes (eg, sleep apnea, diabetes, chronic kidney disease, atherosclerotic disease) and their associated medical therapies, which confound interpretation of study results; and the difficulty in enrolling large numbers of study participants. Expanding our understanding of the causes of resistant hypertension and thereby potentially allowing for more effective prevention and/or treatment will be essential to improve the long-term clinical management of this disorder.

Key words: AHA Scientific Statements • hypertension • blood pressure

Find additional patient-related information at:

Read a summary of this article at americanheart.org

This article has been cited by other articles:

				C.-K. Kang, C.-A Park, H. Lee, S.-H. Kim, C.-W. Park, Y.-B. Kim, and Z.-H. Cho Hypertension Correlates With Lenticulostriate Arteries Visualized by 7T Magnetic Resonance Angiography Hypertension, November 1, 2009; 54(5): 1050 - 1056. [Abstract] [Full Text] [PDF]

				American College of Cardiology Foundation, American Heart Association, American College of Physicians Task Force on Compe, American Academy of Neurology, American Association of Cardiovascular and Pulmona, American College of Preventive Medicine, American Diabetes Association, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, et al. ACCF/AHA/ACP 2009 competence and training statement: a curriculum on prevention of cardiovascular disease. J. Am. Coll. Cardiol., September 29, 2009; 54(14): 1336 - 1363. [Full Text] [PDF]

				WRITING COMMITTEE MEMBERS, C. N. Bairey Merz, M. J. Alberts, G. J. Balady, C. M. Ballantyne, K. Berra, H. R. Black, R. S. Blumenthal, M. H. Davidson, S. B. Fazio, et al. ACCF/AHA/ACP 2009 Competence and Training Statement: A Curriculum on Prevention of Cardiovascular Disease: A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Competence and Training (Writing Committee to Develop a Competence and Training Statement on Prevention of Cardiovascular Disease): Developed in Collaboration With the American Academy of Neurology; American Association of Cardiovascular and Pulmonary Rehabilitation; American College of Preventive Medicine; American College of Sports Medicine; American Diabetes Association; American Society of Hypertension; Association of Black Cardiologists; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute; National Lipid Association; and Preventive Cardiovascular Nurses Association Circulation, September 29, 2009; 120(13): e100 - e126. [Full Text] [PDF]

				E. Pimenta, K. K. Gaddam, S. Oparil, I. Aban, S. Husain, L. J. Dell'Italia, and D. A. Calhoun Effects of Dietary Sodium Reduction on Blood Pressure in Subjects With Resistant Hypertension: Results From a Randomized Trial Hypertension, September 1, 2009; 54(3): 475 - 481. [Abstract] [Full Text] [PDF]

				L. J. Appel Another Major Role for Dietary Sodium Reduction: Improving Blood Pressure Control in Patients With Resistant Hypertension Hypertension, September 1, 2009; 54(3): 444 - 446. [Full Text] [PDF]

				F. Elijovich and C. Laffer A role for single-pill triple therapy in hypertension Therapeutic Advances in Cardiovascular Disease, June 1, 2009; 3(3): 231 - 240. [Abstract] [PDF]

				B. C. Rossier and L. Schild Epithelial Sodium Channel: Mendelian Versus Essential Hypertension Hypertension, October 1, 2008; 52(4): 595 - 600. [Full Text] [PDF]

				J. E. Hall Hypertension: Update 2008 Hypertension, September 1, 2008; 52(3): 425 - 428. [Full Text] [PDF]