ABC | Volume 114, Nº3, March 2020

Statement Brazilian Position Statement on Resistant Hypertension – 2020 Arq Bras Cardiol. 2020; 114(3):576-596 Figure 4 – Flowchart of RH treatment. CCB: calcium channel blocker; ARB: angiotensin receptor blocker; HR: heart rate; ACEI: angiotensin-converting enzyme inhibitor; CKD: chronic kidney disease; BP: blood pressure. Treatment flowchart Exclude: Pseudoresistance Poor adherence, White-coat effect, and Secondary hypertension Sodium consumption < 2.5 g/day Lifestyle changes Healthy diet Lose weight - Exercise Sleep > 6 hours Optimize triple regimen TZDs - ACEI/ARB - CCB Full dose Loop diuretic (CKD) BP > recommended target BP > recommended target BP > recommended target BP > recommended target BP > recommended target Replace/optimize thiazide diuretic Chlortalidone 12.5 - 50 mg, Indapamide 1.5 mg 4 th Drug - Mineralocorticoid antagonist, Spironolactone 25-50 mg or Amiloride 10-20 mg 5 th Carvedilol, Nebivolol (HR < 70 bmp avoid BB) Clonidine or Doxazosin 1-16 mg Other associations. Hydralazine 50-150 mg or Furosemide low dose Interventional therapy - Reference center bilaterally. 157,159 BAT has shown significant reductions in BP persisting for up to 3 years in randomized controlled trials. 157,159 However, this procedure is invasive and expensive and is associated with side effects, limiting its indication in clinical practice. 156,159 Another form of stimulation is the amplification of the endovascular baroreflex (implantation of an expandable device within the carotid artery), which has shown promising results with greater safety in controlling BP in RHTN. 156 These procedures are not available in Brazil. 10.3. Renal Sympathetic Denervation Renal sympathetic denervation (RSD) by ablation catheter reduces renal efferent activity and, consequently, increases renal blood flow and decreases activation of the renin- angiotensin-aldosterone system, water retention, and renal afferent activity, which through brain signaling, decreases sympathetic action on heart and vessels. 160 Data from uncontrolled studies have shown reductions of up to 30 mmHg in office systolic BP in patients with RHTN, without complications related to the procedure. 161 However, the SYMPLICITY HTN-3 trial, 162 a randomized sham-controlled study, showed no significantly superior effect of BP reduction after 6 months from RSD. A meta-analysis of 11 controlled studies comparing RSD with optimized pharmacological treatment or sham procedure in patients with RHTN showed that RSD was not superior in reducing BP, with heterogeneity of responses in the studies, mainly due to lack of a sham control in most publications and heterogeneity in assessment of treatment adherence. 163 The development of new circumferential catheters with distal renal artery applications may promote a more complete RSD, and their effects on BP reduction have been demonstrated in patients with untreated hypertension. 164 The 2018 European Society of Hypertension position paper does not recommend RSD for treatment of hypertension in general but includes a recommendation of this procedure in the context of controlled clinical studies with sham procedures and optimized therapy for safety and efficacy assessment in populations with a large number of individuals. 160 Based on this evidence, RSD is currently an alternative only for patients with UC-RHTN with optimized pharmacological treatment and proven therapeutic adherence or with important drug-related adverse effects, to be always performed at referral centers trained for the procedure. 164 10.4. Use of Continuous Positive Airway Pressure OSA is a clinical condition affecting more than half of the patients with RHTN 94 and is mainly treated with CPAP, an air compressor that applies continuous positive pressure to the patient’s airway. To date, seven randomized trials have analyzed the effect of treatment of OSA with CPAP in patients with RHTN. 165-171 Except for one of these studies, 170 the others found significant reductions in BP (5 mmHg on average; one study showed reductions ≥ 10 mmHg after CPAP use). 169 However, the proportion of patients who achieved the target BP (< 140/90 mmHg) with CPAP was low, possibly due to poor CPAP adherence. In clinical practice, the BP response to CPAP varies, even in patients with good adherence. A recent study showed predictive biomarkers of better BP response to CPAP in patients with RHTN. 172 Validation and large-scale application of these biomarkers could help select better those patients who benefit most from BP reduction. 590