ABC | Volume 114, Nº3, March 2020

Statement Brazilian Position Statement on Resistant Hypertension – 2020 Arq Bras Cardiol. 2020; 114(3):576-596 Figure 1 – Flowchart of the evaluation of resistant hypertension. ABPM: ambulatory blood pressure monitoring; HBPM: home blood pressure monitoring; Na + : sodium; BP: blood pressure. Exclude pseudoresistance Lack of adherence (24-h urinary Na + ) Inadequate dosing Inadequate BP measurement technique Resistant hypertension or HBPM Abnormal ABPM or HBPM Normal ABPM Exclude white-coat effect: ABPM or HBPM Pseudo-resistant hypertension Target-organ damage • Heart disease • Nephropathy • Cerebrovascular disease • Vascular disease Adherence Therapeutic optimization • Synergistic combinations • Proper dosing Lifestyle habits • Na + intake • Alcoholism • Obesity • Sedentary lifestyle Secondary hypertension Investigation according to the Brazilian Hypertension Guideline Specialized Complementary Tests Protocol of adherence • Frequent appointments • Hospitalization 24-h urinary Na + Multiprofessional team All these factors hinder the adherence to pharmacological and non-pharmacological treatment and must, therefore, be verified and circumvented. Salt intake should always be verified, if possible with a 24-hour urinary sodium measurement, as intake is often excessive due to the consumption of processed foods and lack of knowledge by the patients about excessive salt intake. Treatment should be optimized, preferably with the same physician and for a minimum of 6 months to strengthen the doctor-patient relationship. Added to that are regular recommendations regarding healthy lifestyle habits and continuous verification of treatment adherence, with synergistic dosing schedules and appropriate medication adjustments, respecting the occurrence of comorbidities indicating or contraindicating certain antihypertensive drug classes. 4. Blood Pressure Measurement Coordinator: Celso Amodeo. Authors: Weimar Kunz Sebba Barroso, Marco Antônio Mota Gomes, Annelise Machado Gomes de Paiva, and Eduardo Costa Duarte Barbosa. 4.1. Office Blood Pressure in Resistant Hypertension Although not diagnostic of RHTN, office BP should be verified, and the measurement procedure should follow the guidelines of the 7 th Brazilian Guideline of Arterial Hypertension. 33 The BP can be measured with a manual, semiautomatic, or automatic sphygmomanometer. Several measurements are recommended, with the patient sitting in a calm and comfortable environment to improve reproducibility and bring the values obtained in the office close to those obtained on ABPM during daytime. Consideration must be given to the occurrence of the white- coat effect, a phenomenon involving two situations. The first is a white-coat hypertension, in which BP is elevated in isolated office measurements but normal during ABPM or HBPM. The second is a white-coat effect, which is characterized by increased office BP in relation to the mean BP during daytime in the ABPM or the weekly average HBPM, without changing the diagnosis of hypertension or normotension. 35 These two situations can lead to a false diagnosis of RHTN, resulting in unnecessary test requests and medication use. White-coat hypertension may be referred to as a cause of pseudo-resistant hypertension. 36 4.2. Ambulatory Blood Pressure Monitoring in Resistant Hypertension This test is necessary to rule out the hypothesis of white- coat hypertension, which falsely suggests RHTN. 37 The diagnosis is confirmed when the mean BP during daytime and over 24 hours is below 135/85 mmHg and 130/80 mmHg, respectively. Compared with casual BP measurements, the values obtained are more strongly related to the risks arising from hypertension, especially during ABPM evaluation, when an absence or attenuation of the BP reduction during sleep is identified, along with an increase in the difference between systolic and diastolic BP. 37 Chart 2 presents the main applicability in hypertension of the ABPM, a fundamental test in RHTN evaluation, diagnosis, and follow-up. 582