Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hypertens. Mar 12, 2019; 9(1): 1-16
Published online Mar 12, 2019. doi: 10.5494/wjh.v9.i1.1
Achieving control of resistant hypertension: Not just the number of blood pressure medications
Kara Schmidt, William Kelley, Steven Tringali, Jian Huang
Kara Schmidt, William Kelley, Steven Tringali, Jian Huang, Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, Fresno, CA 93701, United States
Jian Huang, Medicine Service, VA Central California Health Care System, Fresno, CA 93703, United States
Author contributions: Schmidt K and Kelley W worked in equal parts in the drafting of the body of the manuscript; Schmidt K wrote the abstract, designed the figures, and contributed to formatting and submission; concept design and editing were done by Tringali S and Huang J.
Conflict-of-interest statement: No potential conflicts of interest relevant to this article were reported.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jian Huang, FACP, MD, Professor, Department of Internal Medicine, University of California San Francisco-Fresno Medical Education Program, 2615 E Clinton Ave, Fresno, CA 93701, United States.
Telephone: +1-559-2256100 Fax: +1-559-2416484
Received: November 14, 2018
Peer-review started: November 14, 2018
First decision: December 5, 2018
Revised: January 11, 2019
Accepted: January 21, 2019
Article in press: January 22, 2019
Published online: March 12, 2019

Resistant hypertension (RH) has a prevalence of around 12% and is associated with an increased risk of cardiovascular disease, progression to end-stage renal disease, and even mortality. In 2017, the American College of Cardiology and American Heart Association released updated guidelines that detail steps to ensure proper diagnosis of RH, including the exclusion of pseudoresistance. Lifestyle modifications, such as low salt diet and physical exercise, remain at the forefront of optimizing blood pressure control. Secondary causes of RH also need to be investigated, including screening for obstructive sleep apnea. Notably, the guidelines demonstrate a major change in medication management recommendations to include mineralocorticoid receptor antagonists. In addition to advances in medication optimization, there are several device-based therapies that have been showing efficacy in the treatment of RH. Renal denervation therapy has struggled to show efficacy for blood pressure control, but with a re-designed catheter device, it is once again being tested in clinical trials. Carotid baroreceptor activation therapy (BAT) via an implantable pulse generator has been shown to be effective in lowering blood pressure both acutely and in long-term follow up data, but there is some concern about the safety profile. Both a second-generation pulse generator and an endovascular implant are being tested in new clinical trials with hopes for improved safety profiles while maintaining therapeutic efficacy. Both renal denervation and carotid BAT need continued study before widespread clinical implementation. Central arteriovenous anastomosis has emerged as another possible therapy and is being actively explored. The ongoing pursuit of blood pressure control is a vital part of minimizing adverse patient outcomes. The future landscape appears hopeful for helping patients achieve blood pressure goals not only through the optimization of antihypertensive medications but also through device-based therapies in select individuals.

Keywords: Resistant hypertension, Pseudoresistance, Mineralocorticoid receptor antagonists, Device-based hypertension treatment, Renal denervation, Carotid baroreceptor activation therapy, Central arteriovenous anastomosis

Core tip: Resistant hypertension (RH) is associated with an increased risk of cardiovascular events as well as mortality. Updated American College of Cardiology and American Heart Association guidelines in 2017 promote the use of mineralocorticoid receptor antagonists, which is a major change from prior guidelines. Device-based therapies such as renal denervation and carotid baroreceptor activation have emerged as innovative treatment modalities. They are continuing to be refined to improve their safety as well as efficacy profiles. Overall more validation is needed for device-based therapies, especially in the RH population.