Chobanian AV et al. JNC 7 Report. Hypertension 2003;42;1206-52

Chobanian AV et al. JNC 7 Report. Hypertension 2003;42;1206-52

Hajjar I and Kotchen TA. JAMA 2003;290:199-206

Sarafidis P and Bakris G. JACC 2008;52:1749-57

Chobanian AV et al. JNC 7 Report. Hypertension 2003;42;1206-52

Kaplan NM. J Hypertens 2005;23:1441-4

Schlaich M et al. Curr Hypertens Rep. 2010;12:296-302

Step 1: Confirm Treatment Resistance ● Office BP >140/90 or >130/80 mmHg in patients with CKD or DM and ● Patient prescribed 3 or more meds at optimal doses, including a diuretic or ● Office BP at goal but patient requires 4 or more medications

Step 1: Confirm Treatment Resistance

Step 2: Exclude Pseudo-Resistance

Sarafidis P and Bakris G. JACC 2008;52:1749-57

Step 1: Confirm Treatment Resistance

Step 3: Identify Factors that Contribute to Treatment Resistance

● Lifestyle factors ● Interfering substances ● Secondary causes of hypertension

Step 2: Exclude Pseudo-Resistance

Bramlage P et al. Am J Hypertens 2004;17:904-10

Chobanian AV et al. JNC 7 Report. Hypertension 2003;42;1206-52

Chobanian AV et al. JNC 7 Report. Hypertension 2003;42;1206-52

Singer et al. Hypertension. 1991;17:798-803

Conlin PR et al. Hypertension 2000;36:461-5

Bakris GL et al. Am Fam Physician 1989;40:199-204

Sarafidis P and Bakris G. JACC 2008;52:1749-57

Logan et al. J Hypertens. 2001;19:2271-2277

Grote et al. J Hypertens. 2000;18:679-685

Somers et al. J Clin Invest. 1995;96:1897-1904

Cushman et al. J Clin Hypertens. 2002;4:393-404

Singer et al. Hypertension. 2002;40:464-9

Step 1: Confirm Treatment Resistance

Step 2: Exclude Pseudo-Resistance

Step 3: Identify Factors that Contribute to Treatment Resistance

Step 4: Nonpharmacologic Treatment ● Reverse contributing lifestyle factors ● Discontinue or minimize interfering substances ● CPAP

Step 1: Confirm Treatment Resistance

Step 2: Exclude Pseudo-Resistance

Step 3: Identify Factors that Contribute to Treatment Resistance

Step 4: Nonpharmacologic Treatment

Step 5: Pharmacologic Treatment

Ernst et al. Hypertension 2006;47:352-8

Townsend RR et al. Clin Pharmacol Ther. 1990;48:665-675

Chapman et al. Hypertension 2007;49:839-45

Eide et al. J Hypertens 2004;22:2217-26

ONTARGET Investigators NEJM 2008;358:1547-1559; Mann et al. Lancet 2008;372:547-553

Start RAS based combination therapy (ACEi or ARB) plus CCB and diuretic

Add vasodilating β-blocker or Aldosterone Antagonist

Refer to Clinical Hypertension Specialist

If BP still not at goal

Recheck in 3-4 weeks

Recheck in 3-4 weeks

If BP still not at goal