Essential Hypertension Still Uncontrolled After Optimised Triple-Drug Therapy
This protocol addresses the clinical situation where essential hypertension remains above target — or can only be controlled with four or more medications — despite a fully optimised three-drug antihypertensive regimen including a diuretic.
Blood pressure is uncontrolled despite treatment with three antihypertensive medications with complementary mechanisms of action, including a diuretic at maximally tolerated doses. This pattern — or blood pressure at goal but requiring four or more medications to maintain it — defines resistant hypertension.
The first-line approach to resistant hypertension — optimising the regimen to an ACE inhibitor or angiotensin receptor blocker combined with a calcium channel blocker and a thiazide-like diuretic at maximally tolerated doses, alongside a review and removal of medications with interfering effects on blood pressure — did not bring blood pressure below 130/80 mm Hg.
When the optimised three-drug regimen has not achieved the blood pressure goal, the protocol calls for the addition of a mineralocorticoid receptor antagonist as a fourth antihypertensive agent, with kidney function serving as a key eligibility criterion. The full structured protocol is accessible via the link below.
Treatment goal: blood pressure below 130/80 mm Hg.
References
DOI: 10.1161/CIR.0000000000001356
Resistant hypertension is defined as BP above goal despite treatment with 3 antihypertensive medications with complementary mechanisms of action, including a diuretic at maximally tolerated doses or BP at goal but requiring ≥4 medications (Figure 8).
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.
RCTs have shown that addition of spironolactone (25–50 mg/day) as the fourth drug reduced home and 24-hour SBP by 6.6 to 8.7 mm Hg when compared with placebo in patients with resistant hypertension and eGFR ≥45 mL/min/1.73 m².
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