Prognosis of resistant hypertension, white-coat resistant hypertension, and refractory hypertension

Objective: To evaluate total and cardiovascular mortality in different forms of Resistant Hypertension (RH). Design and method: A total of 35129 treated patients were included from the Spanish ABPM Registry. Mean follow-up was 10 years. Total and cardiovascular mortality were compared in Cox models adjusted for clinical confounders. The following groups were compared: - Controlled Hypertension (CH; N = 8146; 23.2%): normal office BP treated with 3 or less antihypertensive drugs vs. RH (N = 9408; 26.8%): elevated office BP treated with 3 or more drugs or normal office BP treated with 4 or more drugs. - Controlled RH (CRH; N = 831; 8.8%): normal office BP treated with 4 or more drugs vs. Uncontrolled RH (UCRH; 8577; 91.2%): elevated office BP treated with 3 or more drugs. - Among patients with UCRH, the following groups were compared: True RH (TRH; 5288; 61.7%): elevated (>130/80 mmHg) 24-h BP vs. White-coat RH (WCRH; 3289; 38.3%): normal 24-h BP. - Refractory hypertension (RefrH; 823; 8.7%): elevated office BP while treated with 5 or more drugs vs. Non-refractory RH (the remaining RH patients). Results: Compared to CH, RH was associated with an increased risk in total mortality (HR: 1.22; 95%CI: 1.13 - 1.31) and cardiovascular mortality (1.37; 1.21 - 1.55). Compared with CRH, UCRH was not associated with a significant increased risk in total or cardiovascular mortality. Compared to WCRH, TRH increased the risk of mortality (1.45; 1.32 - 1.60) and cardiovascular mortality (1.68 (1.43 - 1.98). Finally, RefrH also increased the risk of total mortality (1.16; 1.01 - 1.34) and cardiovascular mortality (1.30; 1.05 - 1.62) in comparison to non-refractory RH. Either total or cardiovascular mortality was not increased in WCRH, compared to CH. Conclusions: RH increased the risk of total and mortality with respect to CH. Among RH, office BP control does not modify such prognosis, while 24-h BP is a powerful determinant, with a clear increased risk in those with elevated 24-h BP (TRH), compared to those with normal 24-h BP (WCRH). The study confirms the clinical importance of RH, as well as the usefulness of ABPM in stratifying those patients, in order to improve therapeutical efforts to reduce the global risk.