Management of Resistant Hypertension Based on Recommendations from Different Guidelines and the Systolic Blood Pressure Intervention Trial

The long-term management of patients with resistant hypertension has been made even more difficult by a “moving target” goal blood pressure (BP). The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) guidelines defined resistant hypertension as the failure to achieve goal BP in patients who are adhering to full doses of an appropriate three-drug regimen that includes a diuretic. The Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 8) guidelines laid out more lenient target BP goals, without addressing the definition of resistant hypertension directly. The present scenario is a state of confusion, with providers selectively adopting recommendations from different guidelines. The Systolic Blood Pressure Intervention Trial (SPRINT) trial contributed to the confusion with further evidence supporting the strict control of hypertension. In addition, the failure of another trial on renal denervation in the US has essentially put an end to six long years of experimentation with catheter ablation in patients with resistant hypertension. Other therapies are still experimental. Adding a new dimension of medical management, spironolactone has made a comeback in resistant hypertension, with reports of better responsiveness when added to existing anti-hypertensive therapy. The present review discusses the current state and management options for patients with resistant hypertension considering the new evidence. Newer advances in pharmacological and device therapy are also discussed to improve understanding and quality in the management of resistant hypertension.