19 A Toolkit for Health Care Professionals Unmet Needs in Hypertension Managing Resistant Hypertension Step 1: Assess Current Management The first step begins with excluding other causes of hypertension, including white coat effect, medication nonadherence and secondary hypertension. Next, ensure the patient is keeping to a low-sodium diet (<1500mg/day) and maximizing lifestyle interventions with more than six hours of uninterrupted sleep, following a DASH-style diet, meeting weight goals, getting adequate physical exercise and stopping tobacco use. Finally, optimize a three-drug regimen and confirm adherence with three antihypertensive medications in different classes, i.e., RAS blocker, CCB and diuretic, at maximum or maximally tolerated doses. The diuretic selected must be appropriate for kidney function.5-Fig3, Management of RH, Pharmacological Treatment of RH After assessing the patient’s existing management plan, continue to follow the steps below to customize and adjust strategies if the patient’s BP remains above target. Step 2 Substitute an optimally dosed thiazide-like diuretic such as chlorthalidone or indapamide for the prior diuretic.5-Fig3, Pharmacological Treatment of RH, Specific Therapeutic Regimens RH Step 3 Add a mineralocorticoid receptor antagonist (MRA), i.e., spironolactone or epelerone.5-Fig 3, Specific Therapeutic Regimens, 11-Abstract, Research in Context, Table 2, Discussion Step 4 If the patient’s heart rate is above 70, consider adding a beta blocker (metoprolol or bisoprolol), a combined alpha-beta blocker (labetalol or carvedilol) or a central alpha antagonist (clonidine or guanfacine). Step 5 Add hydralazine, starting at 25 mg three times daily and up titrate to the maximum tolerated dose. For patients with HF with reduced ejection fraction, consider hydralazine with background isosorbide mononitrate 30-90 mg daily. 5-Fig3, Specific Therapeutic Regimens Step 6 Substitute minoxidil for hydralazine. Begin patients at 2.5 mg two or three times daily and up titrate to the maximum tolerated dose. Step 7 The final step is to refer the patient to a hypertension specialist12-10.2 or a certified hypertension center13 and consider referral for renal denervation (RDN), an emerging treatment option for patients with resistant hypertension.14 The FDA has approved two devices for RDN using either ultrasound or radiofrequency.14 RDN can reduce BP whether or not patients are taking antihypertensive medication, and individual responses vary.15,16 It is important for patients and health care professionals to engage in a thorough discussion to critically evaluate the benefits and potential risks associated with RDN and decide if RDN is the best treatment strategy for them. Further research is needed to identify those who may benefit most.34 Patients with RH are at higher risk for poor cardiovascular, kidney and other outcomes compared to patients without. Similarly, RH is associated with worse outcomes for comorbid conditions including cardiovascular and kidney disease.5-Prognosis of RH The AHA suggests a phased approach to managing RH.5-Fig3
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