Treatment of Resistant Hypertension: A Reversible Phenomenon

Resistant essential hypertension is a reversible and not a permanent phenomenon. It is caused by at least two phenomena: long-standing hypertension leads to media hypertrophy with consequently enhanced response of resistance vessels to endogenous vasoconstrictors. As soon as media hypertrophy is reversed by consequent medical therapy, this enhanced response and therapy resistance will disappear. Further causes for "therapy resistance" are a high salt intake > 5 g/day, which surprisingly was not monitored in any of the Symplicity studies, and furthermore non-compliance with weight reduction (mean BMI in the Symplicity HTN-3 trial was 34!). The ABCD rule demands the combination of ACEI or ARB with saluretics on the one hand and the combination of CCB with betablockers on the other hand. The combination of all 4 drugs together with dietetic achievement of a fasting sodium/creatinine ratio < 40 mmol/g creatinine will allow "therapy resistance" to disappear in most cases. Replacement of thiazide diuretics by a long-acting loop diuretic and the additional administration of alpha blockers, centrally acting sympatholytic drugs, and hydralazine are further options. Information should be given to the patients that these multiple drug regimens are only required for a limited time and that drugs can be withdrawn one after the other with good blood pressure control. This will help with therapy adherence in this difficult phase of the natural history of previously ill-controlled hypertension.