Resistant Hypertension

High blood pressure (BP) is the leading risk factor for premature death and disability-adjusted life years in the world. The development of a large pharmaceutical base from which to manage patients with hypertension in addition to many patient years of clinical trial experience have made it possible to successfully manage many of these patients. Nonetheless, many questions remain, particularly with respect to the optimal BP goal in the general population of hypertensive patients, patients with comorbidities like diabetes mellitus, and those with previous target organ damage such as stroke. Recent meta-analyses confirm that lower systolic and diastolic BP levels are associated with substantial reductions in important health outcomes such as death, coronary heart disease, and stroke in general populations and in patients with diabetes mellitus. In contrast, the ACCORD study (Action to Control Cardiovascular Risk in Diabetes) failed to support the postulate that lower is better. The ACCORD trial tested a systolic BP goal of 120 mm Hg versus 140 mm Hg in type 2 diabetics with hypertension and did not find a significant difference in the primary outcome, a composite of death and nonfatal heart attack and stroke. Similarly, the SPS3 trial (Secondary Prevention of Small Subcortical Strokes) evaluated BP goals in patients with a previous lacunar stroke testing a systolic goal of 130 to 149 mm Hg versus <130 mm Hg. This trial also did not demonstrate significant reductions in ischemic stroke or intracranial hemorrhage in the more intensivetreated group. On the contrary, the SPRINT (Systolic Blood Pressure Intervention Trial) did show a significant improvement in the primary outcome, a pentad of heart attack, stroke, acute coronary syndrome, hospitalized heart failure, and cardiovascular death in the intensive (<120 mm Hg) versus standard (<140 mm Hg) treatment groups. Guideline committees have the charge of proposing goal BP values in patients with hypertension, despite the challenges attending the questions of optimal treatment goal, particularly with comorbidities. Irrespective of the proposed goal BP value, there are patients who do not achieve these goals despite usage of substantial amounts of medication. The SPRINT findings are provocative and suggest there is benefit in pursuing lower than currently advocated BP goals. In this review, we will address how SPRINT findings may prompt a re-evaluation of how we define resistant hypertension (RHTN), how we measure BP in practice, what process are at play in those who do not achieve goal BP values, and what therapies we use to pursue lower BP goals.