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A. Covic et al. (eds.), Resistant Hypertension in Chronic Kidney Disease,
DOI 10.1007/978-3-319-56827-0_21
Chapter 21
Teaching Programmes
David Goldsmith and Silvia Badarau
The disease burden attributable to arterial hypertension is substantial, accounting
for or contributing to 62% of all strokes and 49% of all cases of heart disease, cul-
minating in an estimated 7.1 million deaths a year, equivalent to 13% of total world-
wide deaths. Although most cases of hypertension can be effectively treated with
lifestyle changes or drugs, or both, hidden within this population lies a cohort at the
extreme end of the cardiovascular risk spectrum—those with hypertension that is
truly resistant to treatment. Finding this relatively small but important group of
patients is a diagnostic and practical challenge, even more so if the patient already
has a significant pathology, such as severe left ventricular hypertrophy (LVH), heart
failure or chronic kidney disease.
What is resistant hypertension? Resistant hypertension is defined in the 2008
American Heart Association scientific statement and the 2013 guidelines from the
European Society of Hypertension and Cardiology (ESH/ESC) as blood pressure that
remains above goal—typically seated clinic blood pressure > 140/90 mmHg—in spite
of concurrent use of three antihypertensive agents of different classes (1, 2), one of
which should be a diuretic, at optimal or maximally tolerated doses. The NICE guid-
ance from 2012 suggests that resistant hypertension should be diagnosed only after
confirming inadequate blood pressure control despite treatment, by the use of ambula-
tory blood pressure monitoring (i.e. mean daytime blood pressure > 135/85 mmHg),
thereby excluding the so-called white coat hypertension. The optimal target blood pres-
sure in patients treated for resistant hypertension is widely accepted to be < 140/90 mmHg
though lower targets than this should be considered in both diabetes and chronic kidney
disease (especially with proteinuria). Patients whose blood pressure is controlled to
goal with four or more medications are considered to have resistant hypertension (1, 2).
D. Goldsmith (*)
Guy’s and St Thomas’ Hospitals, London, UK
e-mail: [email protected]
S. Badarau
Department of Nephrology, Gr. T. Popa University of Medicine and Pharmacy, Iaşi, Romania