La hipertensión resistente o refractaria es aquella en la que no se consigue el objetivo de control tensional a pesar de la prescripción de los cambios de estilo de vida adecuados y de un tratamiento farmacológico que incluya tres fármacos antihipertensivos, uno de ellos diurético, a dosis adecuadas. Las causas de dicha refractariedad son diversas, y entre ellas destacan la seudorrefractariedad o seudorresistencia, la falta de cumplimiento del tratamiento por parte del paciente, la inercia clínica, la prescripción de dosis o combinaciones inadecuadas de fármacos o la presencia de hipertensión secundaria no diagnosticada. En la presente revisión se analizan estos aspectos. Resistant or refractory hypertension is that in which the purpose of blood pressure control is not achieved in spite of the prescription of adequate changes in style of life and drug treatment that includes three antihypertensive drugs, one of them diuretic, at adequate doses. The causes of this refractoriness are different. Among them, pseudorefractoriness or pseudoresistance, lack of treatment compliance by the patient, clinical inertia, inadequate drug prescription or combinations, or presence of undiagnosed secondary hypertension stand out. These features are analyzed in the present review.

At least in hypertension, there has never been a perfect clinical trial. By its nature, hypertension poses several barriers to the performance and interpretation of even the most carefully planned and conducted therapeutic trial. First and perhaps foremost, blood pressure is a constantly moving target so that both the initial recognition of hypertension and its subsequent response to therapy are often difficult to validate. Certainly, the performance of only a few blood pressure measurements in an office setting usually provides blood pressure levels that are higher than multiple blood pressures taken out of the office.1 Both automatic ambulatory measurements2 and self-recorded home measurements3 have been found to be more predictive of future morbidity and mortality than office readings, but until now, all clinical trials have used a few office readings for identification of hypertension and quantification of therapeutic benefits. The inclusion of even many thousands of patients in a given trial does not erase the potential errors of the inherent variability in blood pressure that is often accentuated by the alerting reaction to office measurements. Moreover, even carefully selected meta-analyses may not cover the faults of incorrect data.4A second barrier to the interpretation of trials that last 3 to 5 years, as most do, is the usual long duration of hypertension before overt target organ damage develops. It is obvious that the results of trials of limited duration may not provide a valid indication of the effects of therapy over the longer duration of the disease. Moreover, only mortality is a certain end point; morbidities may be difficult to prove, and surrogate end points such as reduction of proteinuria are not adequate to document therapeutic benefit. In hopes of demonstrating a statistically adequate number of end points in the necessarily short duration of trials, selection …

Maintaining long-term control of hypertension requires that patients have confidence in their physicians and the medications prescribed. Another recent scare from Dr. C. Furberg, which was spread throughout the media without informing physicians, will undermine these efforts.

Our website uses cookies to enhance your experience. By continuing to use our site, or clicking "Continue," you are agreeing to our Cookie Policy | Continue JAMA Internal Medicine HomeNew OnlineCurrent IssueFor Authors Podcast Publications JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry (1919-1959) JN Learning / CMESubscribeJobsInstitutions / LibrariansReprints & Permissions Terms of Use | Privacy Policy | Accessibility Statement 2023 American Medical Association. All Rights Reserved Search All JAMA JAMA Network Open JAMA Cardiology JAMA Dermatology JAMA Forum Archive JAMA Health Forum JAMA Internal Medicine JAMA Neurology JAMA Oncology JAMA Ophthalmology JAMA Otolaryngology–Head & Neck Surgery JAMA Pediatrics JAMA Psychiatry JAMA Surgery Archives of Neurology & Psychiatry Input Search Term Sign In Individual Sign In Sign inCreate an Account Access through your institution Sign In Purchase Options: Buy this article Rent this article Subscribe to the JAMA Internal Medicine journal

One in 4 men over 60 years has concomitant hypertension (HTN) and benign prostatic hyperplasia (BPH). This study evaluated the efficacy of doxazosin (DOX), an α1-antagonist, for the treatment of concomitant BPH and HTN in patients whose blood pressure (BP) was controlled at entry with a non-α1-blocker (NA1B). The effect of DOX on BP was evaluated both when added to and following discontinuation of the NA1B. 84 men with HTN and symptomatic BPH receiving NA1B monotherapy were enrolled in this open-label study. BP control was defined as sitting systolic BP [SBP]/diastolic BP [DBP] 90–139 mm Hg/60–89 mm Hg (average of 2 or 3 measurements). DOX was increased to a max of 8 mg/day over 4–9 wks, reducing NA1B dosages as needed to maintain BP control (titration phase). Patients continued DOX (4 or 8 mg/day) + NA1B for 8 wks (combination-maintenance [CM] phase). NA1B was gradually tapered and completely discontinued if BP control was maintained (8-wk discontinuation phase). The addition of DOX to the NA1B resulted in clinically minor decreases in mean sitting and standing SBP and DBP. At the end of the discontinuation phase, BP was not significantly different than baseline. 47 (89%) of 53 patients who completed the study were able to convert to DOX monotherapy and maintain BP control. By the end of CM phase, total cholesterol and LDL had significantly (P ≤ 0.001) decreased (216 mg/dL to 199 mg/dL; 137 mg/dL to 123 mg/dL, respectively), and these changes were maintained on discontinuation of the NA1B. Significant improvements in BPH parameters (maximum urinary flow rate and AUA symptom scores) were evident after one week of DOX treatment and continued throughout the study (P ≤ 0.001). HTN can be treated effectively with DOX alone. Furthermore, the use of a single agent to treat both HTN and concomitant BPH may improve patient compliance.

In the past few years, angiotensin II-receptor blockers have become available and are being heavily marketed and increasingly used. In various ways they differ from angiotensin-converting enzyme inhibitors (ACEIs). Until outcome data are available, they should continue to be used primarily in patients who should receive an ACEI but cannot tolerate the drug because of cough.

In Canada, as in all industrialized countries, hypertension is the most common indication for visits by adults to doctors, and is becoming even more prevalent largely as a consequence of two factors - the increasing age and the increasing obesity of the population. The control of hypertension in Canada and elsewhere is woefully inadequate. Recent guidelines from the United States and Canada emphasize similar principles designed to improve control. These include the assessment of overall cardiovascular risk, careful measurements of blood pressure, effective use of lifestyle modifications, targeted antihypertensive drug therapy and various manoeuvres to improve long term adherence to therapy. Cardiologists will play an increasingly important role in managing hypertension as a way to reduce the cardiovascular diseases that remain the leading causes of morbidity and mortality.

In view of the currently inadequate control of hypertension, multiple guidelines have recently been published to help improve the management of this increasingly common condition. In most regards these guidelines are in agreement, in particular as to the need for overall cardiovascular risk assessment, the selection of appropriate initial therapy, the need for long-acting formulations, and for a diuretic as part of most regimens.

The initial choice of an antihypertensive drug therapy must be made carefully in order to improve upon the currently inadequate management of hypertension. At the same time, the choices should be based on the strongest objective evidence, which is primarily data from large-scale placebo-controlled randomized trials. The recommendations offered in the sixth report of the U.S. Joint National Committee and the 1999 World Health Organization - International Society of Hypertension Guidelines appear to meet the current criteria for correct choices of initial therapy.

The use of diuretics for the treatment of hypertension had fallen significantly from 1990 until 1997, when their use again began to increase. Their recent return to popularity reflects 3 major factors: (1) the recognition of the effectiveness of much lower doses than used previously, thereby providing good antihypertensive action with fewer side effects; (2) the excellent reductions in morbidity and mortality achieved by low-dose diuretic-based therapy in multiple, randomized controlled trials in elderly hypertensives; and (3) the increasing recognition that some diuretic-induced shrinkage of effective blood volume is essential for adequate treatment of many, if not most, hypertensives.

In the past, the main criterion used to establish both the prognosis of hypertension and the therapeutic goal has been simply blood pressure level. More recently, various expert groups have recommended models to establish overall cardiovascular risk that include other risk factors beyond blood pressure alone. An example is the three-tiered risk classification used in the sixth report of the U.S. Joint National Committee (JNC-6). Based on the overall risk status the decision is made to begin treatment and to decide between lifestyle modifications and antihypertensive drug therapy. In the future, more exact criteria will undoubtedly be used to establish prognosis and therapeutic goals. An easy and accurate assessment of endothelial function could very well serve as one of these criteria.

THE DIAGNOSIS and treatment of hypertension is often accompanied by anxiety that may be manifested by recurrent episodes of acute hyperventilation, with symptoms that may interfere with the control of the disease. This study was designed to establish the prevalence and nature of anxiety-induced hyperventilation in a large group of difficult-to-control patients with hypertension. A prospective survey on the prevalence of anxiety-induced hyperventilation was performed with 300 consecutive adult patients referred to the author at a tertiary care referral clinic for difficult-to-treat primary (essential) hypertension. In those with suggestive episodic symptoms, voluntary hyperventilation was performed to validate the diagnosis. Of the 300 referred patients, 104 were suspected of having hyperventilation from preexisting episodic symptoms. Of the 104 patients, 88 reproduced their typical symptoms by the hyperventilation test. Eight did not reproduceall their usual symptoms and 8 others did not develop any symptoms during the 3-minute test. Anxiety-induced hyperventilation is common

Recent reports from an uncontrolled, retrospective cohort study in elderly hypertensives implicate short-acting calcium antagonists in causing increased mortality, gastrointestinal bleeding, and cancer. Multiple serious flaws in the study make the validity of these findings highly suspect and there remains absolutely no evidence that long-acting calcium antagonists are unsafe.