title: Drug therapy for resistant hypertension: simplifying the approach.
abstract: Despite the availability of many effective antihypertensive drugs, the drug therapy for resistant hypertension remains a prominent problem. Reviews offer only the general recommendations of increasing dosage and adding drugs, offering clinicians little guidance with respect to the specifics of selecting medications and dosages. A simplified decision tree for drug selection that would be effective in most cases is needed. This review proposes such an approach. The approach is mechanism-based, targeting treatment at three hypertensive mechanisms: (1) sodium/volume, (2) the renin-angiotensin system (RAS), and (3) the sympathetic nervous system (SNS). It assumes baseline treatment with a 2-drug combination directed at sodium/volume and the RAS and recommends proceeding with one or both of just two treatment options: (1) strengthening the diuretic regimen, possibly with the addition of spironolactone, and/or (2) adding agents directed at the SNS, usually a β-blocker or combination of an α- and a β-blocker. The review calls for greater research and clinical attention directed to: (1) assessment of clinical clues that can help direct treatment toward either sodium/volume or the SNS, (2) increased recognition of the role of neurogenic (SNS-mediated) hypertension in resistant hypertension, (3) increased recognition of the effective but underutilized combination of α- + β-blockade, and (4) drug pharmacokinetics and dosing.
authors.affiliation: Division of Nephrology and Hypertension, Department of Medicine, New York Presbyterian Hospital, Weill Cornell Medical School, New York, NY 10021, USA. sjmann@med.cornell.edu
authors.forename: Samuel J
authors.initials: SJ
authors.lastname: Mann
mesh_terms: D000959:Antihypertensive Agents / Q000627:therapeutic use*; D004305:Dose-Response Relationship, Drug; D004351:Drug Resistance / Q000502:physiology*; D004359:Drug Therapy, Combination; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000503:physiopathology; D012084:Renin-Angiotensin System / Q000502:physiology; D012964:Sodium / Q000378:metabolism; D013564:Sympathetic Nervous System / Q000502:physiology
chemical_list: D000959:Antihypertensive Agents; D012964:Sodium