74
Blood Pressure Management
Figure 8. Resistant Hypertension: Diagnosis, Evaluation,
and Treatment
Confirm treatment resistance with 1 of the following:
• Office BP ≥130/80 mm Hg and on ≥3 antihypertensives
º
Combination of ACEi or ARB + CCB + thiazide-like diuretics preferred
• Office BP <130/80 mm Hg but requires ≥4 antihypertensives
º
Combination of ACEi or ARB + CCB + thiazide-like diuretics preferred
Exclude pseudoresistance
• Ensure accurate office BP measurements
• Assess for medication nonadherence with prescribed regimen
• Obtain home, work, or ambulatory BP readings to exclude white-coat effect
Refer to specialist:
• For known or suspected secondary cause(s) of hypertension
• If BP remains uncontrolled >6 months of treatment
Discontinue or minimize interfering substances
†
Screen for secondary causes of hypertension
†
Identify and reverse contributing lifestyle factors*
Pharmacological treatment
• Maximize diuretic therapy
º
Replace thiazide-type diuretics with chlorthalidone 12.5–25 mg qd or
indapamide 1.25–2.5 mg qd
• Add spironolactone (25–50 mg qd) or equivalent dosage of eplerenone
(25–50 mg BID) if eGFR ≥45
• Use chlorthalidone or loop diuretics in patients with CKD stage 4 or greater
• Add agents with different MOA
º
BB, central sympatholytic drugs, or nondihydropyridine CCB for elevated
heart rate
• Add potent vasodilators
º
Dual ERA, eg, aprocitentan, or direct acting vasodilator eg, hydralazine
or minoxidil (only if already on a BB [or bradycardic] and loop diuretic)
* Please refer to Section 5.2, on lifestyle factors.
†
Please refer to Table 11 for a complete list of drugs that elevate BP.
‡
Please refer to Section 3.2.3, on secondary hypertension, and Subsections 3.2.3.1., 3.2.3.2, and
3.2.3.3.
BID, 2 times daily; ERA, endothelin-receptor antagonist; MOA, mechanisms of action; and
qd, daily.
Copyright © 2018 American College of Cardiolog y Foundation and American Heart
Association, Inc. Adapted with permission from Calhoun et al. Copyright © 2008 American
Heart Association Inc.
