Elevated Blood Pressure When Mineralocorticoid Receptor Antagonist Therapy Has Not Reached Target

In some patients with elevated blood pressure, a four-drug regimen that includes a mineralocorticoid receptor antagonist as the fourth agent still falls short of target. This page describes the clinical situation at that point and the direction of the next treatment step.

Prior treatment — failure condition

The fourth agent added was a mineralocorticoid receptor antagonist (in patients with eGFR ≥45 mL/min/1.73 m²). Despite this step, the blood pressure goals — average SBP <130 mm Hg and DBP <80 mm Hg — remained out of reach. This protocol defines the step that follows.

Treatment target

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

Treatment approach — partial overview

The next step involves adding a further agent drawn from one of several distinct pharmacological classes — each addressing blood pressure through a different mechanism. The complete agent options, selection considerations, and any required combination rules are contained in the full protocol.

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References

DOI: 10.1161/CIR.0000000000001356

In adults with uncontrolled resistant hypertension who cannot tolerate or have contraindications to MRA, the addition of one of the following agents or classes—amiloride, BBs, alpha-blockers, central sympatholytic drugs, dual endothelin receptor antagonists, or direct vasodilators—is reasonable to control BP.
However, direct vasodilators such as hydralazine and minoxidil should be used in combination with a BB and a loop diuretic given their effects on sympathetic tone, sodium reabsorption, and fluid retention.

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