ABC | Volume 114, Nº3, March 2020

Statement Brazilian Position Statement on Resistant Hypertension – 2020 Arq Bras Cardiol. 2020; 114(3):576-596 Table 1 – Prevalence, clinical findings, and additional tests for the most common causes of secondary hypertension in patients with resistant hypertension Secondary cause Overall prevalence Prevalence in RHTN Clinical findings Diagnostic investigation Obstructive sleep apnea 94,107,109 > 5 to 15% > 30% Snoring, daytime sleepiness, morning headache, metabolic syndrome Berlin questionnaire, STOP-Bang questionnaire, Epworth sleepiness scale, polysomnography (gold standard) or home polysomnography with five or more episodes of sleep apnea and/or hypopnea per hour of sleep Renal parenchymal disease 113 1.6 to 8% 2 to 10% Edema, anorexia, nocturia, fatigue, anemia, increased urea and creatinine, changes in urinary sediment Urinalysis (low density, glomerular hematuria or albuminuria), calculation of estimated GFR, renal US, screening for albuminuria and protein/ creatinine ratio in random urine sample Renal artery stenosis 115,116 1 to 8% 2.5 to 20% Abdominal murmur, acute pulmonary edema, impaired renal function by RAAS blockers, asymmetric kidneys Screening: renal artery Doppler US (operator dependent) and/or renogram with or without captopril, magnetic resonance angiography, computed tomography, conventional renal arteriography (gold standard) Primary hyperaldosteronism 119-121 1.4 to 10% 6 to 23% Mostly asymptomatic RH hypokalemia (not required and unusual) Incidental adrenal nodule ARR > 30 in the absence of aldosterone antagonists. Confirmatory tests (suppression with fludrocortisone or saline infusion) Imaging tests: thin-slice helical computed tomography (preferred) or resonance magnetic imaging Thyroid diseases 32 Hypothyroidism 1 to 2% 1 to 3% Fatigue, weight gain, hair loss, systolic hypertension, muscle weakness. TSH and free T4 Hyperthyroidism Heat intolerance, weight loss, diastolic hypertension, palpitations, exophthalmos, tremors, tachycardia Cushing’s syndrome 32 0.5% < 1% Weight gain, fatigue, hirsutism, amenorrhea, “moon facies,” “buffalo hump,” purple striae, central obesity, hypokalemia Salivary cortisol 24-hour urinary cortisol Morning cortisol (8 AM) and 8 hours after administration of dexamethasone (1 mg) at 12 AM. Magnetic resonance Pheochromocytoma 127,128 0.2 to 0.5% < 1% Episodic, labile or resistant hypertension, episodic headache, profuse sweating and palpitations, pallor Free plasma and/or 24-hour urinary metanephrines (values twice or thrice above the normal), 24-hour plasma and/or urinary catecholamines and/or computed tomography and magnetic resonance Coarctation of aorta 129 < 1% < 1% SBP/DBP difference > 20/10 mmHg between upper and lower limbs; ejection murmur in the interscapular region Lower rib notching on chest X-ray, screening with Doppler echocardiography, magnetic resonance imaging or thoracic aorta angiography Adapted from Rimoldi SF et al. 105 PA/PRA: plasma aldosterone/plasma renin activity; RHTN: resistant hypertension; DBP: diastolic blood pressure; SBP: systolic blood pressure; GFR: glomerular filtration rate; RAAS: renin-angiotensin-aldosterone system; US: ultrasonography. number of antihypertensive drugs in 84% of operated patients, compared with 12.4% in the clinically treated group. 134 8.2. Salt Restriction Control of salt intake is especially effective in the elderly, in individuals of African descent, and in those with decreased glomerular filtration. 135 These situations restrict the ability of water and sodium excretion by the kidneys, and BP becomes more dependent on volume variations. Not surprisingly, sodium sensitivity and volume overload account for the primary pathophysiological mechanism in most cases of RHTN. 136 A systematic review and meta-analysis involving 34 studies with 3,230 participants on the effect of long-term reduction in sodium intake revealed a decrease in systolic BP of 5.8 mmHg (2.5 to 9.2; p = 0.001) associated with a decrease in urinary sodium excretion of up to 100 mmol in 24 h, which corresponds to a reduction in salt intake of approximately 6 g/day. 137 In patients with RHTN, a low- sodium diet with 2.5 g of salt daily reduced BP by up to 23.0/9.0 mmHg, clearly demonstrating the efficacy of this measure, despite the possibility of compromising the long-term adherence to such markedly restricted salt consumption. 79 8.3. Alcohol Intake Due to the direct relationship between the amount of alcohol consumed and BP levels, excessive alcohol consumption 588