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Luiz Tadeu Giollo-Junior,1,2 Luciana Neves Cosenso-Martin,2 Valquiria da Silva Lopes,2 Manoel Paz Landim,2 Leticia Aparecida Barufi Fernandes,2 Kleber Aparecido de Oliveira,2 Amanda Oliva Spaziani,2 Aleandra Polegati Santos,2 Marco Antonio Silva,2 Juan Carlos Yugar-Toledo,2 Jose Fernando Vilela-Martin2 1General Hospital at Brazilian Army, Curitiba, Parana, Brazil; 2Hypertension Clinic - Internal Medicine Department, State Medical School in Sao Jose do Rio Preto (FAMERP), Sao Jose do Rio Preto, São Paulo, BrazilCorrespondence: Jose Fernando Vilela-Martin, Hypertension Clinic - Internal Medicine Department, State Medical School in Sao Jose do Rio Preto (FAMERP), Ave Brig. Faria Lima 5416, São Jose do Rio Preto, 15090-000, São Paulo, Brazil, Email vilelamartin@uol.com.brAbstract: Resistant hypertension (RH) is characterized by being difficult to control, even with the use of various antihypertensive drugs and is associated with target organ lesions and other comorbidities. Thus, new treatment alternatives such as transcutaneous electrical nerve stimulation (TENS) can offer benefits to resistant hypertensive patients by reducing blood pressure (BP) in a non-invasive way and without the need for the association of more antihypertensive drugs. In this case, a patient with RH was submitted to three weekly applications of TENS on the stellate ganglion lasting 40 min each for 1 month. Peripheral and central hemodynamic assessments were performed by 24-h ambulatory BP monitoring (ABPM) before and after TENS applications. After completion of the TENS applications, significant reductions in office systolic (SBP) and diastolic BP (DBP) were observed. There was also a decrease in peripheral SBP and DBP in the 24‐h ABPM and sleep and SBP during wakefulness. Additionally, central parameters including central SBP and pulse wave velocity presented a significant reduction in the 24‐h ABPM, during the wakefulness and sleep. TENS is able to attenuate the sympathetic hyperactivity present in RH cases and decrease the peripheral and central hemodynamic parameters of a resistant hypertensive patient.Keywords: resistant hypertension, blood pressure, central hemodynamic, arterial stiffness, non-pharmacological therapy

Elizabeth do Espirito Santo Cestario,1,&ast; Jose Fernando Vilela-Martin,1,&ast; Luciana Neves Cosenso-Martin,1 Tatiane Azevedo Rubio,1 Jessica Rodrigues Roma Uyemura,1 Valquiria da Silva Lopes,1 Letícia Aparecida Barufi Fernandes,1 Lucia Helena Bonalume Tacito,2 Heitor Moreno Junior,3 Juan Carlos Yugar-Toledo1,&ast; 1Hypertension Clinic, Internal Medicine Department, Medical School in São José Do Rio Preto (FAMERP), São Paulo, Brazil; 2Endocrinology Division, Internal Medicine Department, Medical School in São José Rio Preto (FAMERP), São Paulo, Brazil; 3Cardiovascular Pharmacology Laboratory, Faculty of Medical Sciences, State University of Campinas (UNICAMP), São Paulo, Brazil&ast;These authors contributed equally to this workCorrespondence: Jose Fernando Vilela-Martin, Ave Brig Faria Lima 5416, Sao Jose do Rio Preto, São Paulo, SP, 15090-000, Brazil, Tel +55 17 32015727, Email vilelamartin@uol.com.brIntroduction: Hypertension is the most important modifiable risk factor for cardiovascular disease and a leading public health concern.Objectives: The primary aim was to compare sequential nephron blockade (SNB) versus dual renin-angiotensin system blockade (DRASB) plus bisoprolol in patients with resistant hypertension to observe reductions in systolic and diastolic blood pressure (SBP and DBP) levels after 20 weeks of treatment.Material and Methods: This trial was an open-label, prospective, randomized, parallel-group, clinical study with optional drug up-titration. Participants were evaluated during five visits at 28-day intervals.Results: The mean age was 55.5 years in the SNB and 58.4 years in the DRASB + bisoprolol group (p=NS). Significant office BP reductions were observed in both groups. SNB group, SBP decreased from 174.5± 21.0 to 127.0± 14.74 mmHg (p< 0.0001), and DBP decreased from 105.3± 15.5 to 78.11± 9.28 mmHg (p< 0.0001). DRASB group, SBP decreased from 178.4± 21.08 to 134.4 ± 23.25 mmHg (p< 0.0001) and DBP decreased from 102.7± 11.07 to 77.33± 13.75 mmHg (p< 0.0001). Ambulatory blood pressure monitoring (ABPM) showed also significant SBP and DBP reductions in both groups (p< 0.0001).Conclusion: In patients with RHTN adherent to treatment, SNB and DRASB plus bisoprolol showed excellent therapeutic efficacy, although SNB was associated with earlier SBP reduction.Keywords: resistant hypertension, natriuretic agents, dual blockade of the renin-angiotensin system, bisoprolol

João Marcos de Menezes Zanatta, Luciana Neves Cosenso-Martin, Valquíria da Silva Lopes, Jéssica Rodrigues Roma Uyemura, Aleandra Marton Polegati Santos, Manoel Ildefonso Paz Landim, Juan Carlos Yugar-Toledo, José Fernando Vilela-Martin Internal Medicine Department, State Medical School at Sao Jose Do Rio Preto (FAMERP), Sao Jose Do Rio Preto, Sao Paulo, BrazilCorrespondence: José Fernando Vilela-MartinInternal Medicine Department, State Medical School at Sao Jose Do Rio Preto (FAMERP), 5416 Avenida Brigadeiro Faria Lima, Sao Jose Do Rio Preto, SP, 15090-000, BrazilTel +55 17 3201-5727Email vilelamartin@uol.com.brAbstract: Resistant hypertension (RH) is characterized by the use of three or more antihypertensive drugs without reaching the goal of controlling blood pressure (BP). For a definitive diagnosis of RH, it is necessary to exclude causes of pseudoresistance, including the white-coat effect, errors in BP measurement, secondary hypertension, therapeutic inertia, and poor adherence to lifestyle changes and pharmacological treatment. Herein, we report the history of a patient with long-standing uncontrolled BP, even when using seven antihypertensive drugs. Causes of secondary hypertension that justified the high BP levels were investigated, in addition to the other causes of pseudo-RH. In view of the difficult-to-control BP situation, it was decided to hospitalize the patient for better investigation. After 5 days, he had BP control with practically the same medications previously used. Finally, all factors related to the presence of pseudo-RH are discussed, especially poor adherence to treatment. Poor adherence to antihypertensive treatment is common in daily medical practice, and its investigation is of fundamental importance for better management of BP.Keywords: hypertension, resistant hypertension, medication adherence