Truly Refractory Hypertension

What really is refractory or resistant hypertension? Twenty years ago, Setaro and Black defined the condition as blood pressure >140/90 mm Hg, no evidence of secondary hypertension, maximal doses of at least 2 appropriate antihypertensive agents, and sufficient treatment duration to allow the treatments to be effective.1 Today, we would probably expand the definition to at least 3 agents2 or patients who do not respond to 3 agents, including a thiazide diuretic plus mineralocorticoid-receptor inhibition. Thirty years ago, Swales et al performed a trial of regimens for such patients.3 One of the following 4 regimens was used: oral diazoxide, minoxidil, captopril, or quadruple therapy (diuretic+β-adrenoceptor blocker+hydralazine+prazosin). Despite the severity of hypertension, blood pressure could be controlled in almost all these patients. Since then, sleep apnea has come under scrutiny as a common unappreciated cause. Ruttanaumpawan et al found that about half of their 42 therapy-resistant patients with hypertension were suffering from obstructive sleep apnea.4 Of course, there is always the lingering possibility that the patients are just not ingesting their medicines, and novel strategies have been developed to deal with that issue.5 The advent of device-related treatments has pretty well laid the issue of refractory hypertension to rest. Typing the condition into search engines invariably leads the searcher to articles on catheter-based renal denervation.6 We present a case that we believe is an example for truly resistant hypertension, and we like to coin in the term device-resistant hypertension into the debate about uncontrollable hypertension. Our patient, who kindly provided written consent for this report, is a slender (body mass index, 17.4 kg/m2) 51-year-old woman, who was normotensive until age 36 years. By that time, she had had 4 uneventful pregnancies without complications. Her mother was hypertensive, and her father also had elevated blood pressure …