Florian Rader, MD

Comorbidities and Diagnostic Pitfalls of resistant hypertension

The first and most important step in managing hypertension is obtaining an accurate and reliable assessment of true blood pressure. Blood pressure measurement in medical offices presents several challenges, including the "white coat reaction" where patients experience nervousness that artificially elevates their readings. This necessitates measuring blood pressure both in and outside the office setting.

Incorporating home blood pressure monitoring and ambulatory blood pressure monitoring is crucial to identify white coat hypertension and distinguish it from sustained hypertension. These methods also help recognize masked hypertension, where blood pressure is actually lower in the office than during daily activities.

Recognizing and managing comorbidities or risk factors of resistant hypertension is essential, as these often drive elevated blood pressure levels. Treating these underlying conditions helps improve overall blood pressure control. Weight management is particularly important—reducing weight and decreasing BMI makes blood pressure control significantly easier to achieve.

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Clinical Signs and Prevalence of Resistant Hypertension

Resistant hypertension is defined as blood pressure exceeding 130/80 mmHg while being treated with three different antihypertensive medications, typically including one thiazide diuretic. Alternatively, it can be defined as blood pressure above 130/80 mmHg while on four medications, or controlled blood pressure requiring four medications.

At specialized resistant hypertension centers, healthcare providers frequently encounter this condition. Approximately half of patients seen at these centers meet the definition of resistant hypertension, being treated with at least three or four blood pressure medications with or without adequate control. Most patients initially arrive with uncontrolled blood pressure, and the treatment goal is to reduce their readings to reasonable levels.

The prevalence of resistant hypertension appears to be increasing, though the reasons are not well-studied. Risk factors include chronic kidney disease, obesity, sleep apnea, left ventricular hypertrophy (thickening of the heart muscle), and increased age. As the population experiences increased survival and life expectancy, resistant hypertension becomes more common because the associated risk factors are also becoming more prevalent.

Florian Rader, MD

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