Mineralocorticoid Receptor Antagonist or Renal Denervation?
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See related article, pp 397–403
Resistant hypertension (RH) is defined as blood pressure (BP) that remains above goal in spite of optimal doses of 3 antihypertensive agents of different classes, 1 ideally a diuretic.1 Patients achieving BP control with the addition of a fourth antihypertensive agent also meet the definition of RH. Thus, the population with apparent RH includes hypertensive patients who are both controlled (≥ 4 drugs) and uncontrolled (≥3 drugs) using office BP measurements. The article by Rosa et al2 in this issue of Hypertension addresses this important clinical problem.
The definition of apparent RH does not distinguish patients with true RH from those with pseudo-RH, including individuals with elevated office BP due to white coat hypertension, inaccurate BP measurement due to faulty technique, or lack of adherence to the prescribed antihypertensive regimen.1,3,4 When pseudoresistance has been excluded by 24-hour ambulatory BP monitoring, appropriate office BP measurement technique, and confirmation of medication adherence, the diagnosis of true RH can be endorsed. The prevalence of apparent RH has been estimated as ≈10% to 15% of the treated hypertensive population, but only ≈50% of these patients can be classified as having true RH as defined above.3–5 The diagnosis of RH carries an unfavorable prognosis. Patients with uncontrolled true RH are at high risk for end-stage renal disease, ischemic heart disease, congestive heart failure, cerebrovascular accident, cardiovascular events, and death compared with those with controlled RH and pseudo-RH.6
The pathophysiology of RH is poorly understood. Inappropriate sodium and fluid retention, …