339Unanswered Questions
- Is there one class of drug that is commonly the most effective in resistant
hypertension? - What patient characteristics, if any, define which drug is likely to be the most
effective? - What are the ideal constituents of multidrug regimens in resistant hypertension?
A prospective randomised controlled trial of different drug combinations is
required - Is there a role for routine plasma renin measurements to stratify drug treatment
for resistant hypertension, and would this be cost-effective? Is there a role for
renin profiling in the management of resistant hypertension? - What is the future role of device therapies in resistant hypertension manage-
ment? Do they have an additive effect to antihypertensive drugs? - What strategies are most effective in supporting adherence to drug regimens and
lifestyle factors? - Are there system-based or team-based strategies that can organise the health sys-
tem to better identify, monitor and treat resistant hypertension?
Ongoing Audit and Research
Audit
- Any specialist centre, or referral unit, should keep an ongoing audit of the num-
ber of patients needing three BP-reducing drugs, or more than three drugs, to
achieve BP target, and also the number of patients on more than three BP-
reducing drugs whose BP remains above target. - Of those above, an ongoing audit should be kept of checks of accuracy of clinic,
and home, BP, use of ambulatory BP, checks of compliance with BP medication
(interview, pill counting, blood level measurement) and diagnostic effort under-
taken to exclude underlying endocrine or renal causation for secondary
hypertension. - In patients sent to a specialist centre for further evaluation, diagnosis and treat-
ment, an ongoing audit should be kept of the new perspectives, and findings,
arising from a specialist referral, compared to assumptions or diagnoses made
prior to referral. This would help to identify any clinical ‘blind spots’ in the
referring units.
21 Teaching Programmes