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Monitoring of the Patient with Resistant Hypertension
Since the scope of this chapter is monitoring and treatment issues, we assume that
the patient with RH has been assessed in terms of pseudoresistance to antihyperten-
sive therapy. At this point, recognition of causes of pseudoresistance should be
investigated one-by-one in a patient who fulfills the definition of RH. Since many
patients in Western health-care systems first see their GP and attend GP clinics more
frequently than specialized ones, GPs have the unique advantage of monitoring their
patients more closely and generally have more data regarding their patients’ compli-
ance with treatment. GPs can also more frequently see their patients and track their
progress with antihypertensive treatment.
Perhaps, the most important aim of the management of a patient with RH is the
sustained achievement of BP goals. To this end, GPs first determine the way with
which they monitor BP goals. These means of monitoring include office BP mea-
surements, ambulatory BP monitoring (ABPM), and home BP monitoring (HBPM).
Ambulatory Blood Pressure Monitoring
Office measurements of blood pressure offer some readily available data, but they
cannot provide as many measurements as attained with ABPM or home blood pres-
sure monitoring (HBPM). Moreover, office BP measurements cannot rule out
white-coat effect as a cause of resistant hypertension.
ABPM is an important component of both the diagnosis and monitoring of
RH. The technique allows the physician to correctly diagnose RH while excluding
white-coat hypertension. In addition, in a previously diagnosed patient with RH,
ABPM this time may be required to rule out white-coat effect as a potential cause
of RH. The American Heart Association recommends the use of ABPM in patients
with RH to rule out white-coat effect in a position statement [ 3 ]. Some other authors
also implemented ABPM in the diagnosis and monitoring of RH [ 4 ].
In a cross-sectional study, Muxfeldt et al. [ 5 ] evaluated 286 patients with
RH. Based on results of ABPM measurements, 161 of these patients were diag-
nosed as “true” RH, whereas 125 (43.7%) were white-coat RH. As can be seen with
the results of this study, ABPM can also provide additional data such as dipping
pattern and early morning surge, which are independent predictors of future cardio-
vascular risk. If a patient is diagnosed as white-coat RH, then treatment decisions
should not be based on office BP measurements; instead ABPM data should be used
to achieve BP targets.
ABPM can predict fatal and nonfatal cardiovascular outcomes more accurately
in patients with RH compared to office blood pressure measurements. Magnanini
et al. [ 6 ] studied 328 women with RH. Patients with true RH had a higher cardiovas-
cular event rate compared to patients with white-coat RH after a follow-up of
approximately 4 years. Daytime ambulatory BP was a significant predictor of
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