Panelists discuss how improving adherence requires both individual strategies like smartphone reminders and smart medication monitoring devices, as well as population-level interventions including reducing sodium content in processed foods and harmonizing hypertension guidelines to address the epidemic of poorly controlled blood pressure.
Panelists discuss how newer therapies will likely be incorporated into guidelines with improved reimbursement structures over time, similar to the evolution seen with lipid-lowering medications, making advanced treatments more accessible for patients with uncontrolled blood pressure.
Panelists discuss how follow-up strategies should include monthly visits initially with more frequent monitoring for high-risk situations, emphasizing home blood pressure monitoring and utilizing team-based care approaches with optimal visit intervals of 4 to 6 weeks to avoid both therapeutic inertia and overadjustment.
Panelists discuss how shared decision-making requires explaining the rationale for blood pressure control, addressing patient fears about medications, and utilizing newer drug classes like endothelin receptor antagonists that offer a “clean slate” approach for patients who have had negative experiences with traditional therapies.
Panelists discuss how medication reduction is occasionally possible in well-controlled patients over time, particularly with diuretics when sodium intake decreases or calcium channel blockers to reduce edema, while being cautious about maintaining adequate blood pressure control and avoiding drugs that worsen kidney function.
Panelists discuss how aggressive blood pressure targets below 130 mm Hg (preferably 120 mm Hg) should be pursued in most resistant hypertension patients using combination therapies, while individualizing goals based on patient age, tolerability, and comorbidities.
Panelists discuss how to sequence fourth-line treatments for resistant hypertension, with spironolactone remaining first choice for most patients with normal renal function, while newer endothelin receptor antagonists offer advantages for patients with chronic kidney disease or those intolerant to aldosterone antagonists.
Panelists discuss how the PRECISION trial subanalysis showed aprocitentan worked equally well in Black patients as in White patients, which is particularly important given the higher prevalence and complications of resistant hypertension in Black populations, with emphasis on adequate diuretic management to prevent peripheral edema.
Panelists discuss how the PRECISION trial demonstrated aprocitentan’s efficacy in lowering blood pressure by nearly 15 mm Hg within 4 weeks in resistant hypertension patients, including those with advanced chronic kidney disease, with durable effects and minimal adverse effects except for manageable peripheral edema.
Panelists discuss how endothelin receptor antagonism addresses resistant hypertension by blocking one of the most potent vasoconstrictors, reducing smooth muscle hypertrophy and fibrosis, with aprocitentan being the only endothelin receptor antagonist approved for resistant hypertension.
Panelists discuss how standard ACE therapy leaves multiple pathways unblocked in resistant hypertension, with spironolactone being the most evidence-based fourth-line therapy despite limitations, while emerging therapies target sympathetic nervous system overactivity, aldosterone excess, and endothelin-mediated vasoconstriction.
Panelists discuss how lifestyle modifications, particularly sodium restriction and plant-based diets, form the foundation of resistant hypertension management, with innovative approaches like teaching kitchens and food-as-medicine programs being more effective than traditional diet counseling.
Panelists discuss how patients with resistant hypertension should be referred to specialists after 3 to 6 months of unsuccessful treatment, emphasizing that while primary care providers can manage most hypertension cases, specialists with particular interest and experience are needed for complex cases.
Panelists discuss how resistant hypertension is defined as blood pressure remaining above 130/80 mm Hg despite 3 medications, including a diuretic, affecting 10% to 15% of hypertensive patients, and how to differentiate true resistance from pseudoresistance caused by adherence issues, improper measurement, white coat effect, and interfering medications.
A panelist discusses how the epidemic of uncontrolled hypertension affects over 50% of patients and emphasizes that with emerging new drugs, devices, and technologies, healthcare providers will soon need to move beyond simply prescribing three medications and instead systematically utilize all available treatment options to achieve blood pressure control.
A panelist discusses how aprocitentan represents the first new class of antihypertensive drugs in decades as a dual endothelin antagonist that effectively reduces blood pressure in resistant hypertension patients, particularly those with chronic kidney disease, though it requires monitoring for leg swelling and avoiding use in pregnancy.
A panelist discusses how spironolactone is typically the first fourth medication added for resistant hypertension but has limitations in patients with kidney disease or electrolyte issues, necessitating alternative strategies like renal denervation and highlighting the need for multiple treatment approaches to avoid polypharmacy-related adherence problems.
A panelist discusses how comorbidities like chronic kidney disease, obesity, and diabetes complicate resistant hypertension treatment by limiting therapeutic options and affecting medication adherence, while emphasizing that treatment should begin with lifestyle modifications and rationalizing the foundational three-drug regimen before intensifying therapy.
A panelist discusses how resistant hypertension is defined as blood pressure exceeding 130/80 despite treatment with three properly dosed medications or controlled pressure requiring four or more medications, affecting one in five or six hypertension patients, and emphasizes the importance of differentiating true resistance from pseudo-resistance through proper measurement techniques and systematic evaluation for secondary causes.
