Treatment strategies for resistant arterial hypertension.
Resistant hypertension is defined as blood pressure above the target range set by current guidelines despite the concurrent use of three or more antihypertensive drugs of different classes, including a diuretic, at their maximum or highest tolerated doses. This problem affects 5% to 15% of all hypertensive patients and is thus commonly seen by both primary care physicians and specialists. Review of current guidelines and pertinent literature revealed by a selective Medline search. The treatment of resistant hypertension is multimodal, involving systematic identification of secondary causes of hypertension as well as the exclusion of pseudoresistance (inadequate treatment). Non-pharmacological treatment includes weight loss, dietary salt restriction, exercise, and abstinence from alcohol. Drug treatment consists of an individualized combination of antihypertensive agents with different mechanisms of action. Activation of the sympathetic nervous system is considered to be a major element in the pathogenesis of resistant hypertension; a new interventional treatment, selective denervation of the renal sympathetic nerves, results in clinically relevant and sustained blood pressure reduction in ca. 84% of the patients undergoing the procedure (a mean decrease of office systolic blood pressure by 32 mm Hg and by 12 mm Hg at six months, p <0.001). Among the 206 patients who underwent this procedure in the setting of published studies, 5 had complications; these included pseudoaneurysm of the femoral artery and dissection of the renal artery during the introduction of the ablation catheter. The treatment of resistant hypertension is interdisciplinary and multimodal. The new and promising option of interventional renal sympathetic denervation can be considered for patients whose high blood pressure is inadequately controlled with medication.