ABC | Volume 114, Nº3, March 2020

Statement Brazilian Position Statement on Resistant Hypertension – 2020 Arq Bras Cardiol. 2020; 114(3):576-596 predictor of heart failure, coronary artery disease (CAD), arrhythmias, and stroke. 70 In Brazil, the prevalence of LVH assessed by echocardiography in patients with RHTN ranges from 68 to 87%, 71,72 with concentric LVH being the most common geometric pattern in these individuals. 72,73 LVDD predisposes to cardiovascular events and heart failure, regardless of cardiac mass and BP levels. 74 The exact prevalence of LVDD in patients with RHTN is uncertain, but the strong association between this condition and LVH 74 suggests that LVDD is very frequent in this population. About one third of the patients with RHTN are diagnosed with CAD. 71 However, even in the absence of overt CAD, up to 28% of the patients with RHTN have myocardial ischemia, 72 which may result from decreased coronary reserve and increased myocardial oxygen consumption, particularly in patients with LVH, and increased arterial stiffness. 70,74 5.5. Renal Changes The association between RHTN and CKD is well established and may be causal or consequential. The anatomopathological substrate is hypertensive nephrosclerosis, resulting from hemodynamic abnormalities (glomerular hyperfiltration and hypertrophy), culminating in glomerulosclerosis. Nephrosclerosis (erroneously termed “ benign”) is characterized by arteriosclerosis and arteriolosclerosis, hyalinosis, tubulointerstitial lesions, global glomerulosclerosis, and focal segmental glomerulosclerosis. Known risk factors for CKD progression include age > 50 years, male sex, genetic predisposition, family history, African descent, hypertension duration and stage, low socioeconomic status, intensity of albuminuria, degree of renal dysfunction, dyslipidemia, obesity, diabetes, lifestyle habits (diet with excessive salt and/or protein, smoking), and use of nephrotoxic substances, among others. 75 Albuminuria and reduced estimated glomerular filtration rate (eGFR) identify patients at high CV and renal risks, and the reduction in albuminuria may be a therapeutic objective in RHTN. 26-28 Recommended tests for evaluation and follow-up of renal damage include urinalysis, serum creatinine for eGFR calculation using the equations MDRD or CKD-EPI, available at http://ckdepi.org/equations/gfr-calculator/ , renal and urinary tract ultrasonography, and calculation of the albuminuria or urinary protein/creatinine ratio for CKD staging 75 (Figure 2). 6. Phenotype of the Patient with Resistant Hypertension Coordinator: Luciano Ferreira Drager. Authors: Heitor Moreno Júnior, Juan Carlos Yugar-Toledo, and Luiz Aparecido Bortolotto. 6.1. Introduction This section describes initially the characteristics that distinguish patients with RHTN from those with non-resistant hypertension. Subsequently, it discusses the differences between patients with C-RHTN and UC-RHTN, and finally, addresses the approach to the extreme phenotype of the RHTN patients, i.e., patients with refractory hypertension. 6.2. Phenotype of the Patient with Resistant Hypertension Patients with RHTN often present some characteristics that distinguish them from those with non-resistant hypertension, including older age, obesity, a profile of increased salt intake, CKD, diabetes, presence of TODs such as LVH, female sex, and african descent. 1 The Brazilian multicenter study ReHOT has shown that diabetes, prior stroke, and BP at study entry ≥ 180/110 mmHg (hypertension stage 3) were independent predictors of true resistance. 13 While some of these Figure 2 – Prognosis of chronic kidney disease according to degrees of albuminuria and decline in estimated GFR. 76 Green: low risk; yellow: moderate risk; orange: high risk; red: very high risk. CKD prognosis according to GFR category and albuminuria: KDIGO 2012 Categories of persistent albuminuria Description and intervals A1 Normal to slightly increased A2 Moderately increased A3 Severely increased GFR categories (ml/min/1,73m 2 ) Description and interval Normal or high Slightly decreased Mild to moderately decreased Moderate to extremely decreased Extremely decreased Terminal renal disease 584