2.4.4.0 Re­sis­tant Hy­per­ten­sion

Re­sis­tant hy­per­ten­sion is defined as blood pres­sure ≥140/90 mmHg de­spite a ther­a­peu­tic strat­e­gy that in­cludes ap­pro­pri­ate lifestyle man­age­ment plus a di­uret­ic and two other an­ti­hy­per­ten­sive drugs be­long­ing to dif­ferent class­es at ad­e­quate doses. Prior to di­ag­nos­ing re­sis­tant hy­per­ten­sion, a num­ber of other con­di­tions should be ex­clud­ed, in­clud­ing med­i­ca­tion nonad­her­ence, white coat hy­per­ten­sion, and sec­ondary hy­per­ten­sion. In gen­er­al, bar­ri­ers to med­i­ca­tion ad­her­ence (such as cost and side ef­fects) should be iden­tified and ad­dressed (Fig. 10.1). Min­er­alo­cor­ti­coid re­cep­tor an­tag­o­nists are ef­fec­tive for man­age­ment of re­sis­tant hy­per­ten­sion in pa­tients with type 2 di­a­betes when added to ex­ist­ing treat­ment with an ACE in­hibitor or ARB, thi­azide-‍like di­uret­ic, and di­hy­dropy­ri­dine cal­ci­um chan­nel block­er (67). Min­er­alo­cor­ti­coid re­cep­tor an­tag­o­nists also re­duce al­bu­min­uria and have ad­di­tional car­dio­vas­cu­lar benefits (68-71). How­ev­er, adding a min­er­alo­cor­ti­coid re­cep­tor an­tag­o­nist to a reg­i­men in­clud­ing an ACE in­hibitor or ARB may in­crease the risk for hy­per­kalemia, em­pha­siz­ing the im­por­tance of reg­u­lar mon­i­toring for serum cre­a­ti­nine and potas­si­um in these pa­tients, and long-‍term out­come stud­ies are need­ed to bet­ter eval­u­ate the role of min­er­alo­cor­ti­coid re­cep­tor an­tag­o­nists in blood pres­sure man­age­ment.