Summary: In the 2023 ESH Guidelines, hypertension is defined as resistant to treatment when appropriate lifestyle measures and treatment with optimal or best tolerated doses of three or more drugs (RAS-blocker, CCB and Thiazide/Thiazide-like diuretic,) fail to lower office BP to to to <140/90 mm Hg.The prevalence of resistant hypertension (RHT) has been difficult to evaluate and after applying the strict criteria an estimate of the RHT prevalence is that it might involve about 5% of the overall hypertensive population. These patients are referred to as having a true-resistant hypertension (TRHT) phenotype.
The diagnostic work-up should rule out pseudoresistant hypertension and, once TRHT is identified, characterize the patient’s clinical status by history, physical examination and laboratory and imaging analysis for the assessment of risk factors and HMOD. Effective treatment of RHT should combine lifestyle changes, discontinuation of interfering substances, rationalization of current treatment and the sequential addition of antihypertensive drugs to the existing triple therapy.
In patients with RHT, the fourth line treatment should include the spironolactone, based on the evidence of its efficacy in the PATHWAY-2 trial, as well as in meta-analyses including those in patients with HFrEF.