Florian Rader, MD

How Clinicians can Prepare for the Future of Resistant Hypertension Care

Looking to the future, improving approaches to overcome high noncompliance rates with medical therapies remains a critical need. Promising developments include treatments that don't require daily medication ingestion, such as injectable long-acting medications dosed every few weeks or months, and device-based treatment options like renal denervation, which has recently received FDA approval.

Collecting more comprehensive safety data and long-term effectiveness data on these innovative approaches will help improve overall control rates for even the most challenging resistant hypertension cases. These advancements could significantly transform management strategies for difficult-to-treat patients.

Best practices for resistant hypertension management include obtaining accurate blood pressure measurements, focusing on out-of-office readings rather than office measurements, evaluating patients for secondary causes of resistant hypertension (particularly aldosterone dysregulation and primary aldosteronism), and implementing simple treatment protocols. Effective medication regimens typically include long-acting angiotensin receptor blockers, calcium channel blockers, thiazide diuretics, and mineralocorticoid receptor antagonists, which can help most patients reach the target blood pressure of 130/80 mmHg.

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A panelist discusses how future improvements in resistant hypertension management will focus on overcoming medication noncompliance through long-acting injectable treatments and device-based options like renal denervation, while emphasizing best practices including accurate out-of-office blood pressure measurements and systematic treatment protocols targeting 130/80 mmHg.

Selecting Patients for Aprocitentan

The ideal candidates for aprocitentan are patients who have tried multiple antihypertensive medications without achieving blood pressure control. This medication provides an additional class option, particularly beneficial for those with abnormal kidney function or problems with hyperkalemia (elevated potassium levels).

Patients with resistant hypertension complicated by chronic kidney disease who cannot tolerate other medication classes that affect kidney function or electrolyte levels should be strongly considered for aprocitentan therapy. The medication provides a viable alternative when traditional options are contraindicated.

Every medical practice encounters patients who exhibit intolerance to standard blood pressure medications. In these challenging cases, aprocitentan offers another therapeutic option to try when other approaches have failed due to side effects or intolerability.

A panelist discusses how aprocitentan is most beneficial for patients who have tried multiple antihypertensive medications without success, particularly those with chronic kidney disease, abnormal kidney function, or hyperkalemia who cannot tolerate other medication classes that affect electrolyte levels.

DERAs for Resistant Hypertension Management

A novel approach to lowering blood pressure involves targeting the endothelium system. While endothelium receptor blockers were previously used only for pulmonary hypertension, aprocitentan is now FDA-approved for treating systemic hypertension. This medication offers a new option by affecting previously unexplored mechanisms that influence blood pressure.

Clinical experience with aprocitentan is still in its early stages, with current access to the medication being suboptimal. However, limited use in patients has confirmed its effectiveness in lowering blood pressure. A notable advantage of aprocitentan is that it does not negatively affect kidney function, and some data suggests it reduces albumin spillover in the urine.

This medication class may be particularly beneficial for patients on multiple blood pressure medications who have chronic kidney disease and experience worsening kidney function or increased potassium levels with traditional antihypertensives. Aprocitentan does not affect these parameters, making it a valuable addition to the treatment arsenal.

A panelist discusses how patient compliance remains the primary obstacle to blood pressure control despite effective medications being available, while clinical inertia among healthcare providers and medication side effects affecting electrolytes and kidney function add additional complexity to resistant hypertension management.

Treatment Strategies for Resistant Hypertension

Treating resistant hypertension requires at least three blood pressure medications, often four or five. The key is selecting the right medications to maximize patient adherence by choosing options with minimal side effects.

Successful medication management involves prescribing once-daily dosing rather than multiple times per day, as compliance drops significantly with more frequent dosing schedules. Combination pills that contain multiple medications (such as an angiotensin receptor blocker, calcium channel blocker, and thiazide diuretic) in a single dose make adherence much easier for patients.

Engaging patients as champions of their own blood pressure management is another effective strategy. This involves providing a structured protocol for home blood pressure measurement, typically in the morning and evening with repeated readings at each time. These measurements allow for more accurate medication titration and provide immediate feedback to patients, as they can observe how their adherence affects their readings, which typically reinforces compliance.

A panelist discusses how successful treatment requires selecting the right three to five medications with minimal side effects, using once-daily combination pills to maximize adherence, and engaging patients as active participants through structured home blood pressure monitoring protocols.

Florian Rader, MD

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