ABC | Volume 114, Nº3, March 2020

Statement Brazilian Position Statement on Resistant Hypertension – 2020 Arq Bras Cardiol. 2020; 114(3):576-596 in insufficient doses, medical inertia, low adherence. 16,17 Both systolic and diastolic hypertension may be resistant, the former being more prevalent. 1 2. Prognostic Aspects Coordinator: Elizabeth Silaid Muxfeldt. Authors: Alexandre Alessi, Andrea Araújo Brandão, Osni Moreira Filho, and Elizabeth Silaid Muxfeldt. 2.1. Introduction RHTN is associated with high CV morbidity and mortality, increasing the risk of CV events by 47% in patients affected by this condition when compared with individuals with incident hypertension. 14 2.2. Office Blood Pressure and Ambulatory Blood Pressure Monitoring True RHTN, diagnosed by ABPM, is associated with twice the CV risk compared with RHTN due to a white-coat effect. 18 Overall, the average BP measurements obtained in all three ABPM periods are strong predictors of CV risk, while office BP has shown no prognostic value. 18,19 Longitudinal studies have highlighted high BP during sleep and the absence of nocturnal dipping as important predictors of CV risk. 18-20 Prognostic importance of the nighttime BP pattern has also been shown in meta-analyses. 21 2.3. Target-Organ Damage 2.3.1. Central Arterial Pressure and Arterial Stiffening Pulse wave velocity (PWV) has an independent predictive value in several subgroups of patients with hypertension. 22 Reduced arterial relaxation and elasticity have been observed in patients with RHTN compared with individuals with well-controlled hypertension, being a marker of prognosis and response to antihypertensive therapy. 23 In hypertensive patients, PWV provides additive value when incorporated into CV risk scores. 24 2.3.2. Left Ventricular Hypertrophy The electrocardiographic diagnosis of LVH has emerged as a predictor of risk for coronary disease (Cornell index) and cerebrovascular disease (Sokolow-Lyon index), and the regression of both indices reduces the risk of CV events by 35 and 40%, respectively. 25 2.3.3. Albuminuria Both baseline and serial changes in albuminuria have prognostic implications in RHTN. In a large prospective cohort of 531 patients with RHTN, the occurrence of moderately increased albuminuria (MIA) at baseline was an independent predictor of composite events and all-cause mortality. 26 A later analysis by the same group, this time including 1,048 patients, showed that MIA increased by 40% the risk of fatal and nonfatal CV events and all-cause mortality. 27 During follow-up, the persistence of MIA at 2 years was a risk factor for CV events, while persistent normoalbuminuria emerged as a protective factor. 26 Another cohort of 143 patients with RHTN assessed at baseline and after 6 years of follow-up showed that the development or persistence of MIA was associated with an increased risk of CV events. In contrast, the persistence of normoalbuminuria or regression of MIA was associated with a lower risk of major events. 28 2.3.4. Inflammatory Biomarkers Elevated C-reactive protein is an independent predictor of coronary and cerebrovascular disease, and a more important marker in patients with RHTN who are younger, obese, and have uncontrolled ABPM and a non-dipping pattern (absent or attenuated nocturnal decline). 29 3. Flowchart of Assessment of Resistant Hypertension Coordinator: Audes Diógenes de Magalhães Feitosa. Authors: Oswaldo Passarelli Júnior, Dilma do Socorro Moraes de Souza, and Audes Diógenes de Magalhães Feitosa. 3.1. Flowchart of the Diagnostic Approach in Resistant Hypertension On clinical suspicion of RHTN, diagnostic confirmation is required, and the first step in the investigation is the exclusion of causes of pseudoresistance, such as lack of treatment adherence (pharmacological and non-pharmacological), inadequate dosing, improper BP measurement technique, and white-coat effect 1 (Figure 1). Lack of BP control should be confirmed by ABPM and home blood pressure monitoring (HBPM). 30-32 Once pseudoresistance is excluded, the occurrence of RHTN is confirmed and a diagnostic investigation should be initiated with specific tests, according to recommendations of hypertension guidelines regarding the involvement of target- organ damage (TOD) and secondary hypertension. 33,34 The occurrence of associated comorbidities should be evaluated with specialized tests according to clinical suspicion. Out-of-office BP measurement is fundamental since such readings are usually higher than those measured at home, reflecting the frequent occurrence of the white-coat effect in this population. Treatment adherence is always challenging, especially in public centers. Patient-related problems that may occur include rejection to the excessive number of medications in complex dosing (excessive doses and tablets), medication side effects, sociocultural issues and lack of knowledge of the natural history of the disease, as well as other problems related to the physician, including poor doctor-patient relationship, non-synergistic dosing or wrong doses and omission or lack of knowledge in the investigation of treatable secondary causes. A potential problem related to health care services is difficulty in access to physicians, medications, and complementary tests. 581