Diagnosis and treatment of resistant hypertension: the critical role of ambulatory blood pressure monitoring.

Hypertension is an illness that generally requires lifelong treatment with blood pressure (BP)–lowering drugs. It is, therefore, understandable that increasing attention is being paid to interventional procedures that might provide a “cure” for hypertension and obviate the need for costly therapy that is not always without unwanted effects. Such interventional techniques are confined, for the moment, to patients with drug-resistant hypertension, ie, BP levels above a specified target despite adherence to at least 3 optimally dosed antihypertensive medications of different classes, including a diuretic, to which we would add for a minimum of 3 months on such maximal treatment. In clinical research involving these procedures (as for research involving pharmaceutical therapies), two key aspects of a given trial’s design merit particular attention: verification that individuals enrolled in the trial truly have drug-resistant hypertension and that there is no underlying cause for hypertension (ie, secondary hypertension); and the choice of BP endpoints to be assessed at specified timepoints following surgical interventions. There are now various measurement methodologies available to us with which to obtain BP data in both contexts, ie, as inclusion/exclusion criteria for entry into the trial and as measures of the intervention’s efficacy. A question we must ask in both settings is: What is the most informative way we can assess BP? We believe the answers are uniform and clear: ambulatory BP monitoring (ABPM) is the most appropriate and informative methodology and should be mandatory in all studies to investigate interventional efficacy.