Understanding treatment options for easy- and difficult-to-treat hypertension

This review evaluates treatment methods for easy-to-treat and difficult-to-treat hypertension.

Elevated blood pressure, or hypertension, is associated with an increased risk of cardiovascular disease, heart attacks, and strokes. Therefore, controlling hypertension through a combination of medications and lifestyle changes is crucial. A blood pressure of 140/90 mmHg is generally considered to be the therapeutic target for hypertensive patients. While some patients with easy-to-treat hypertension may not find it hard to reach this blood pressure goal, other patients may find their blood pressure still uncontrolled even after treatment with several different medications, and are considered difficult-to-treat. The current review addresses possible causes behind easy- and difficult-to-treat hypertension, and current treatment methods recommended for each.

Patients with hypertension generally need treatment for extended periods of time, however most patients find following long-term treatment regimens difficult. One study reviewed found that only 38 to 64% of patients were persistent in following treatment regimens, and those with many potential side effects were least likely to be followed consistently. However, treatment compliance is known to be essential, as treatment discontinuation has been shown to increase the risk of heart attacks by 15% and the risk of stroke by 28%. The review suggests that simplifying treatments, either by lowering the number of pills that must be taken each day or by switching to a combination pill, may increase adherence to treatment.

In patients whose blood pressure is not controlled by one medication, adding a second medication can reduce blood pressure further than would be seen by increasing the dose of the current medication. This type of combination therapy can also lead to fewer side effects, as individual medication dosages are lower. Combinations including medications such as renin-angiotensin system (RAS) blockers, calcium channel blockers (CCB's) and diuretics, have been shown to reduce the risk of stroke by 30%, and the risk of cardiovascular events (such as heart attacks) and mortality by 13 to 20%.

Hypertension may be difficult-to-treat, and some patients even remain resistant to treatment despite therapy with three or more types of antihypertensive drugs. Before proper treatment of difficult-to-treat hypertension, several possible reasons for unsuccessful treatment must first be ruled out. These include poor adherence to treatment regimen or failure to comply with lifestyle changes (such as smoking cessation, physical activity and diet modifications). Another common cause of apparent treatment failure is referred to as white-coat hypertension, when blood pressure rises during doctor measurements due to patient anxiety. Continues home blood pressure monitoring can be examined if white-coat hypertension is suspected to obtain a more realistic evaluation of day-to-day blood pressure.

In patients with difficult-to-treat hypertension, studies have shown that the addition of spironolactone (Aldactone) to therapy may further decrease systolic blood pressure by up to 22 mmHg. For resistant hypertension, renal denervation (a procedure by which the nerves in the walls of the renal arteries are destroyed, inhibiting their ability to elevate blood pressure) has been the focus of recent investigation. While early studies showed renal denervation to successfully decrease blood pressure in as many as 80% of patients treated, a recently published randomized trial found no significant benefit with renal denervation when compared to optimal medical therapy.