Elevated Blood Pressure Uncontrolled After Maximally-Tolerated Triple Antihypertensive Therapy

This protocol addresses the clinical situation in which blood pressure remains above goal despite a full three-drug antihypertensive combination taken at maximally tolerated doses. A defined next step exists for these patients.

Prior Treatment — Targets Not Reached

The preceding regimen consisted of sequential combination of an ACE inhibitor or ARB, a long-acting dihydropyridine calcium channel blocker, and a thiazide-like diuretic (chlorthalidone or indapamide) at maximally tolerated doses. Despite this three-drug approach, average SBP did not reach below 130 mm Hg and DBP did not reach below 80 mm Hg.

Next-Line Approach

For eligible patients, the protocol adds a specific class of agent — a mineralocorticoid receptor antagonist — as a fourth drug. Eligibility, agent selection, and monitoring parameters are detailed in the full protocol.

Treatment Targets

Average SBP below 130 mm Hg and DBP below 80 mm Hg.

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References

DOI: 10.1161/CIR.0000000000001356

In adults with uncontrolled resistant hypertension despite optimal treatment with first-line antihypertensive therapy (ie, a combination of ACEi or ARB plus CCB and thiazide-like diuretic [chlorthalidone or indapamide] and with an eGFR of >=45 mL/min/1.73 m²), addition of a MRA is recommended to control BP.

In adults with confirmed hypertension who are at increased risk for CVD, a DBP target of <80 mm Hg is recommended to reduce the risk of cardiovascular events and total mortality.

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