hypertension defines RHT as the condition where be confirmed by out- of-
office BP measurements
the BP values of a patient with hypertension remain showing uncontrolled 24-hour BP (130 mm Hg SBP
elevated above target despite concurrent use of or 80 mm Hg DBP) values. Evidence of adherence
three antihypertensive agents of different classes, to therapy and exclusion of secondary causes of
commonly including a long-acting CCB, a renin- hypertension are required to define RHT, otherwise
angiotensin system (RAS) blocker (an ACE inhib- RHT is only apparent and called pseudo-RHT.8
itor or angiotensin receptor blocker) and a diuretic. The guidelines therefore recommend thoroughly
All agents should be administered at maximum or confirming uncontrolled office BP values through
maximally tolerated doses and at the appropriate measurement of BP values outside of the office as
dosing frequency. Patients with the white coat effect ambulatory BP measurement (ABPM) or home BP
should not be included in the definition of RHT, measurement (HBPM), confirming adherence to
and the diagnosis of RHT requires the exclusion therapy and properly ruling out secondary causes
of non-adherence to antihypertensive medications. of hypertension when RHT is suspected in order to
Finally, this position paper also includes patients have a case of true RHT. Pseudo-RHT is the condi-
with RHT whose BP shows values below target but tion where office BP shows lack of BP control,
are on four or more antihypertensive medications, a while ABPM or HBPM shows well-controlled BP.
condition that has been referred to in the literature Nevertheless, if obtaining ABPM or HBPM is not
as controlled RHT.7 feasible, epidemiological studies refer to this condi-
In the 2023 ESH guidelines, RHT is defined tion as apparent RHT. On the other hand, in some
as hypertension in patients who fail to lower patients, office BP values are below target, showing
office BP to ESH treatment goals (BP levels good control, but ABPM or HBPM values are
below <140/90 mm Hg) once appropriate life- clearly showing lack of BP control. This condition is
style measures and treatment with optimal or best called masked RHT.9 Finally, refractory HT is a type
tolerated doses of three or more drugs (specifying of RHT where BP remains uncontrolled despite
a thiazide/thiazide-like diuretic, an RAS blocker being on five or more antihypertensive drug classes,
and a CCB) have been initiated. The ESH guide- including a diuretic.
lines also specify that inadequate BP control should
Table 1 Causes of pseudo-resistant hypertension
Related situations Causes Viable solutions
Inaccurate office BP measurements. Inadequate BP measurement protocol. Obtain office BP readings according to recommended
protocol.
Perform out-of-office BP measurement (HBPM or
ABPM).
Non-adherence to prescribed antihypertensive drugs. Reluctance or inability to adhere to prescribed drug strategy due Single pill combination, direct observed therapy clinic.
to significant pill burden, complicated dosing, excessive cost, high
frequency of adverse reactions with multidrug antihypertensive
regimens.
Poor patient–clinician relationships.
Interfering substances: steroidal and non-steroidal anti-inflammatory drugs, and Increasing BP. It is mandatory to discontinue or minimise their effects
sympathomimetic drugs such as amphetamines, decongestants, stimulants, oral by adapting a treatment strategy for better BP control.
contraceptives, licorice and Ephedra.
ABPM, ambulatory BP measurement; BP, blood pressure; HBPM, home BP measurement.
2 Camafort M, et al. Heart 2023;0:1–7. doi:10.1136/heartjnl-2022-321730
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