Do optimal antihypertensive drug regimens allow blood pressure normalization in all patients with resistant hypertension?

摘要

In the last decades, considerable efforts have been devoted to the diagnosis and treatment of arterial hypertension. The lowering blood pressure, obtained through lifestyle changes and drug treatment, has benefits in terms of cardiovascular morbidity and mortality which have now been extensively documented. In most adult hypertensive patients, it is presently recommended to decrease blood pressure <=140/90 mmHg. However, this target is not easy to reach, despite the availability of drugs acting through different mechanisms and the possibility of combining them to increase antihypertensive efficacy. Many factors may contribute to insufficient control of blood pressure, ranging from limited access to medical care to non-optimal therapeutic observance by patients and inertia of physicians in charge. Further complicating this state of affairs, the blood pressure of many patients is high in the medical office only, but not in the course of daily life activities. It is important here to recall the definition of resistant hypertension as stated in the most recent recommendations. According to experts of the American Heart Association, hypertension is resistant if blood pressure remains >=140/90 mmHg, despite the simultaneous intake of >=3 drugs acting through different mechanisms, all taken at optimal dosage, one of which ideally being a diuretic. As a corollary, hypertension is also considered resistant if 4 drugs are required to normalize blood pressure. Also pointed out in these guidelines, the possibility of pseudo-resistance (termed apparent treatment-resistant hypertension), which may arise, in particular, with technically suboptimal measurement of blood pressure, with poor therapeutic observance, or with white-coat hypertension.