When the Going Gets Tough, the Tough Get Going

Abstract

Patients with elevated blood pressure (BP) represent a major problem for primary care physicians, not only because of the large number of these patients, but also because BP can prove frustratingly difficult to control in some of them. The management of treatment-resistant hypertension (TRH) is indeed a topic of considerable interest over the last few years, particularly since novel, non-pharmacological interventions held out the prospect of helping these patients. The theme of this mini-symposium was how currently available therapeutic tools can be used to manage ‘difficult-to-control’ patients with persistently elevated BP who may have apparent treatment resistance. To ensure that this symposium was relevant and practical, invited experts used a patient case in which treatment fails to control BP. One option in such a case might be to assume that the patient has apparent TRH. However, by looking at the case in more detail and carrying out a thorough clinical work-up, other factors such as pseudo-resistance or poor adherence might be playing important roles. The case was used to highlight the importance of investigating the reasons behind a patient’s failure to achieve BP control and the steps that can be taken to address these issues. Professor Josep Redòn introduced the clinical case and discussed the selection of appropriate management strategies and therapies. Estimation of the risk, based on the European Society of Hypertension (ESH) and the European Society of Cardiology (ESC) treatment guidelines, and details of the ongoing difficulties in reducing the patient’s elevated BP were also covered during his presentation. Professor Michel Burnier discussed in detail difficult-to-control BP and the need for clinical assessment. Among the topics covered were the patient’s referral to a specialist treatment centre, apparent resistance to modification/intensification of treatment, detailed investigation to rule out spurious resistant hypertension, assessment of treatment adherence, and development of a plan or management strategy to educate and motivate the patient and improve adherence to treatment. Professor Massimo Volpe discussed the ongoing management of difficult-to-control patients using strategies designed to favour adherence, including single-pill, fixed-dose combination (FDC) therapy. The meeting was concluded with an interactive discussion, in which the audience raised issues arising from the case presented; these included poor adherence, spurious TRH as a misdiagnosis, and the need for a thorough clinical assessment in order to identify the true cause of the failure to control BP.