When blood pressure refuses to go down
Five to 15 percent of all patients with hypertension fail to respond to drug treatment. However, a range of treatment options are now available in these cases. Alongside the established measures stand new and promising interventions such as renal sympathetic denervation. Felix Mahfoud, Frank Himmel and their co-authors present the current treatment strategies for resistant arterial hypertension in the latest issue of Deutsches ??rzteblatt International (Dtsch Arztebl Int 2011; 108(43): 725).
A multimodal interdisciplinary strategy is necessary for the successful treatment of resistant arterial hypertension. Drug treatment must be tailored to the individual patient, and reversible or secondary causes of hypertension must be systematically sought and treated. The important non-pharmacological conservative treatment measures include optimization of weight, a low-salt diet, physical exercise, and abstinence from alcohol.
Minimally invasive renal denervation and baroreceptor stimulation are two alternative treatment options for selected patients with resistant arterial hypertension.
Renal sympathetic denervation is an interventional procedure with a low rate of complications that can bring about a significant and enduring reduction in blood pressure. For conclusive evaluation of the long-term effects and safety of this new approach, patients have to be enrolled in clinical registries and monitored at regular intervals following treatment. In Germany, the German Renal Denervation (GREAT) Registry has been set up for this purpose.
Arterial hypertension is among the most common chronic diseases in the western industrialized nations and is a major risk factor for cardiovascular morbidity and mortality.
Arterial hypertension is one of the most frequent chronic diseases in the industrialized nations of the West and represents a major risk factor for cardiovascular morbidity and mortality.
In Germany, only 5% to 17% of patients treated for hypertension achieve lasting control of their blood pressure. Around 5% to 15% of all patients with high blood pressure have resistant arterial hypertension (3). Care must be exercised to distinguish between true resistance to treatment and so-called pseudoresistance, which may result from poor compliance with treatment, situationally evoked blood pressure elevation (isolated office hypertension, also known as “white-coat hypertension”), or incorrect choice of medications.
In many patients with resistant hypertension there is a secondary, potentially reversible cause of high blood pressure. Thus, systematic evaluation of organic causes of hypertension is an essential part of the treatment program. The goal of this article is to review the treatment of resistant hypertension as reflected in current guidelines and in pertinent literature revealed by a selective Medline search, with particular emphasis on interventional renal sympathetic denervation.
Resistant arterial hypertension is defined as high blood pressure that cannot be adequately controlled according to the current guidelines (i.e., pressure of >140/90 mm Hg in general; >130???139/80???85 mm Hg in patients with diabetes mellitus, >130/80 mm Hg in chronic renal disease) despite concurrent use of three or more antihypertensive drugs of different classes, including a diuretic, at their maximum or highest tolerated doses. Cases of pseudoresistance, which may result from poor compliance with treatment, inadequate antihypertensive medication, incorrect means of measurement, or white-coat hypertension, must be identified. White-coat hypertension is present if the patient???s blood pressure is 140/90 mm Hg or lower when measured at home but >140/90 mm Hg in the doctor???s office or the hospital.
Dr. med. Felix Mahfoud
Deutsches Aerzteblatt International