Potassium2026-04

Diagnosis and Management of Resistant Hypertension: A Review.

Azizi Michel, Vongpatanasin Wanpen, Fisher Naomi D L, Mahfoud Felix et al. — JAMA

Summary

This paper reviews resistant hypertension, a type of high blood pressure that remains elevated despite treatment with multiple medications. It outlines how to diagnose this condition and discusses various management strategies, including lifestyle changes and specific medications. One key medication mentioned, spironolactone, can be effective but requires careful monitoring of potassium levels in the blood.

AI-generated summary — read the original

Key points

Resistant hypertension is high blood pressure that doesn't respond well to standard medication.
Diagnosis involves ruling out other causes like "white-coat" hypertension or medication non-adherence.
Treatment includes lifestyle changes and specific medications, such as spironolactone.
When spironolactone is used, monitoring blood potassium levels is important due to its effect on potassium.

What the study looked at

What question did the study ask? This review aimed to summarize current knowledge on how to diagnose and effectively manage resistant hypertension, a challenging form of high blood pressure. How was it studied? This was a comprehensive review paper, meaning the authors synthesized information from existing research, including randomized clinical trials and observational studies, to provide an overview of the condition and its treatments. It did not involve new experiments or participants directly. What did it find? The review clarified that true resistant hypertension affects about 10% of treated hypertension patients and requires careful diagnosis to exclude other factors. It highlighted that lifestyle changes are crucial, alongside optimizing diuretic therapy and using combination medications. Notably, it found that adding spironolactone, a medication that affects potassium levels, can significantly lower blood pressure in certain patients, provided their kidney function and potassium levels are within safe ranges. Other interventions like renal denervation were also discussed as potential treatments.

Dietary takeaway

While this paper focuses on medical management, it indirectly highlights the importance of potassium balance in the body, especially when certain medications like spironolactone are used for resistant hypertension. For the general public, maintaining a balanced diet rich in fruits and vegetables naturally provides potassium, which is important for overall cardiovascular health. However, this specific study does not provide dietary potassium recommendations, and any changes to medication or diet should always be discussed with a healthcare provider, as one study is not definitive.

Abstract

IMPORTANCE: Hypertension, defined as office systolic blood pressure (SBP) 130 mm Hg or greater and/or diastolic blood pressure 80 mm Hg or greater, affects 43.9% of women and 49.5% of men in the US. Approximately 19.7% of patients treated for hypertension have apparent resistant hypertension (blood pressure ≥130/80 mm Hg) despite using 3 or more antihypertensive medications, preferably a renin-angiotensin system blocker, a calcium channel blocker, and a thiazide-type diuretic, at maximally tolerated doses. OBSERVATIONS: Approximately 10% of patients treated for hypertension have true resistant hypertension confirmed with home or 24-hour ambulatory blood pressure monitoring to exclude white-coat hypertension (approximately 37.5% of apparent resistant hypertension) and after excluding medication nonadherence (approximately 50%) and secondary hypertension such as primary aldosteronism (approximately 5%-25%). Conditions associated with resistant hypertension include obesity, diabetes, chronic kidney disease, and sleep apnea. Resistant hypertension is associated with increased risk of cardiovascular death vs controlled blood pressure at 5 years to 10 years (absolute risk increase, 10.3% [95% CI, 8.7%-12.1%]). Lifestyle modifications for resistant hypertension include a low-sodium diet (<1500 mg/d), reducing or avoiding alcohol, 150 min/wk or more of aerobic exercise, and weight loss. Illicit drugs (eg, cocaine) and medications that increase blood pressure (eg, nonsteroid anti-inflammatory drugs, serotonin-norepinephrine reuptake inhibitors) should be avoided. Sleep apnea should be treated when diagnosis is confirmed. Pharmacologic optimization includes use of combination tablets of antihypertensives; intensifying diuretic therapy by using chlorthalidone; and sequential addition of antihypertensive medications using evidence-based algorithms. In a meta-analysis of 20 studies (9 randomized clinical trials [RCTs] and 11 observational studies [331 participants]), use of antihypertensive therapies that combine 2 to 3 medications into a single formulation reduced SBP by -3.99 mm Hg (95% CI, -7.92 to -0.07) vs equivalent doses given separately. For patients with apparent or true resistant hypertension who have an estimated glomerular filtration rate of 45 mL/min/1.73 m2 or greater and a serum potassium level of 4.5 mmol/L or less, adding spironolactone (25-50 mg/d) compared with placebo lowers office SBP by -13.3 mm Hg (95% CI, -17.89 to -8.72 [4 RCTs]) and 24-hour ambulatory SBP by -8.46 mm Hg (95% CI, -12.54 to -4.38 [2 RCTs]) in a network meta-analysis of 24 RCTs (3485 patients with resistant hypertension). A meta-analysis of 10 RCTs (2478 participants) reported that compared with a sham procedure, catheter-based renal denervation, which disrupts the sympathetic nerves in the renal artery walls, decreased 24-hour ambulatory SBP by -4.4 mm Hg (95% CI, -6.1 to -2.7) and office SBP by -6.6 mm Hg (95% CI, -9.7 to -3.6). CONCLUSIONS AND RELEVANCE: True resistant hypertension affects 10% of patients treated for hypertension and is diagnosed after excluding white-coat hypertension, medication nonadherence, and secondary hypertension such as primary aldosteronism. First-line treatment includes lifestyle modifications, diuretic therapy with chlorthalidone, and combination tablets of antihypertensives. Spironolactone and renal denervation decrease blood pressure in patients with true resistant hypertension.

View on PubMed →DOI: 10.1001/jama.2026.1221