ABC | Volume 114, Nº3, March 2020

Statement Brazilian Position Statement on Resistant Hypertension – 2020 Arq Bras Cardiol. 2020; 114(3):576-596 contributes significantly to hinder BP control. 138 After all, daily consumption of more than two drinks (about 24 g/day) is associated with increased BP levels. 139 A recent meta-analysis of 36 studies with 2865 participants revealed that a 50% reduction in daily alcohol intake among consumers of six or more drinks (72 g) led to a decrease of 5.50 mmHg in systolic BP (95% CI; 6.70 to 4.30) and 3.97 mmHg in diastolic BP (95% CI; 4.70 to 3.25). 140 No studies have been published on patients with RHTN; however, based on available information, daily alcohol consumption is recommended to be restricted to less than two standard drinks (about 24 g) or even interrupted. 8.4. Physical Activity Despite having been evaluated only in small groups of patients with RHTN, physical activity is probably as much – or evenmore – beneficial in these individuals compared with those with non-resistant hypertension. 40,141 Regular aerobic exercise decreases office and ambulatory BP in patients with RHTN 142-145 and attenuates the characteristic neurohumoral activation. 146 Despite the lack of studies on resistance exercise in this subgroup, it is assumed that there is at least an advantage similar to that observed in patients with non-resistant hypertension. 147 Furthermore, the improved cardiorespiratory capacity obtained with physical activity appears to reduce mortality in patients with RHTN. 148 Therefore, this category of patients should be encouraged to perform regular physical activity of moderate intensity under proper supervision. In patients with very high BP (systolic BP ≥ 180 mmHg or diastolic BP ≥ 110 mmHg), physical activity should be delayed until the optimization of pharmacological treatment promotes BP reduction. 40,141 9. Pharmacological Treatment of Resistant Hypertension Coordinator: Rui Manoel dos Santos Póvoa. Authors: Marcus Vinícius Bolívar Malachias, Armando da Rocha Nogueira, and Paulo César Brandão Veiga Jardim. The objective of pharmacological treatment in RHTN is to identify the causes of lack of control and find the best combination of drugs, aiming at achieving the target BP with few adverse effects and greater adherence. In general, triple treatment optimization is attempted with preferred drugs, namely, ACEIs or ARBs, dihydropyridine CCBs, and TZDs. 33,149 Because they are better tolerated, ACEIs or ARBs must be increased to maximum doses in RHTN. Long-acting, higher potency TZDs, such as chlorthalidone instead of hydrochlorothiazide, should be used at appropriate doses for volume control, from 12.5 to 50 mg in a single dose in the morning. 1,33,40,150 Indapamide is a second TZD option in RHTN. 150 Furosemide should be used in cases of CKD with a eGFR of 30 mL/min or less. 1,33 In RHTN, CCB should preferably be taken at night to alternate the peaks of action of the antihypertensive drugs. 40 Intolerance to CCBs due to side effects is often one of the causes of treatment resistance. In such cases, lipophilic CCBs (manidipine, lercanidipine, manidipine) or levamlodipine, at low doses, may be attempted or, in selected cases, a non- dihydropyridine CCB such as diltiazem and verapamil. 33 If a CCB cannot be used, introduction of a beta-blocker may be considered, preferably one with vasodilatory action, such as nebivolol or carvedilol. 33,151 Beta-blockers may also be considered in association with one or more preferred antihypertensive drugs – ACEI or ARB, TZD, CCB – in special conditions such as heart failure, CAD, and increased basal heart rate, among others. 33,150,151 Failure to reach the target BP with triple therapy requires the use of a fourth drug, which current preferred option is spironolactone, 25 to 50 mg daily. 13,152-154 In cases of intolerance to spironolactone, which main adverse effect is gynecomastia in men, 12.5 mg daily may be attempted. As eplerenone is not available in our country, if intolerance to spironolactone persists even at low doses, replacement with a central sympatholytic agent should be considered, preferably clonidine, between 0.100 and 0.200 mg twice daily, 152 or a potassium-sparing diuretic, preferably amiloride (only available sparingly in our country in compounded formulations), from 10 to 20 mg; 155 or a beta-blocker, preferably with vasodilatory action, if not yet used; 40 or an alpha-blocker, preferably doxazosin 1 to 16 mg in one (nighttime) or two daily doses. 33,40,155 All these antihypertensive agents may be used in combination when necessary for BP control. 33 When no control is obtained with the addition of the fourth drug or combinations of the following options, a direct vasodilator must be used, preferably hydralazine, at doses between 50 and 150 mg administered twice or thrice daily. 40 Due to frequent adverse effects, the vasodilator minoxidil should be reserved for situations of extreme resistance when all previous alternatives fail 40,150 (Figure 4). In RHTN treatment, attention must be given to possible adverse effects of each drug used, along with their possible interactions. 10. New Treatments of Resistant Hypertension Coordinator: Luiz Aparecido Bortolotto. Authors: Luiz Aparecido Bortolotto, Luciano Ferreira Drager, and Thiago de Souza Veiga Jardim 10.1. Introduction In recent years, new types of interventional treatment have been evaluated in patients with RHTN, including: 10.2. Direct Carotid Sinus Stimulation Stimulation of carotid baroreceptors increases their activity and, consequently, reduces sympathetic flow, resulting in decreased BP. 156 Interventions promoting this stimulation have been used to treat patients with RHTN lacking response to clinical treatment. 156-159 Baroreflex activation therapy (BAT) is a surgical procedure in which electrodes are surgically implanted on the external portion of the carotid sinus unilaterally or 589