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Black Patients with Apparent Treatment-Resistant Hypertension May be at Risk for Underutilizing Evidence-Based Pharmacologic Treatments

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A review of historical data from several recent landmark clinical trials found that, when applying current treatment recommendations for apparent treatment-resistant hypertension (aTRH), very few Black patients were taking the optimal pharmacologic treatment. This suggests a significant opportunity to change the prescribed therapy for Black patients to match current evidence-based guidelines.

Resistant hypertension (RH) is defined by the American Heart Association (AHA) as above-goal blood pressure (BP) in a patient despite the use of ≥ 3 classes of antihypertensive medication or the use of ≥ 4 classes regardless of BP level.

The qualifying term, apparent treatment-resistant hypertension, is used when criteria for RH are met, but when pseudoresistance cannot be excluded due to factors such as white coat effect or medication nonadherence. A 2018 AHA Scientific Statement provided a comprehensive update on RH management, which includes evidence-based lifestyle interventions and preferential use of two antihypertensive classes: changing the preferred diuretic to a long-acting thiazide-like diu-retic (chlorthalidone or indapamide) and adding a mineralocorticoid receptor antagonist (spirono-lactone or eplerenone).1

A recent Hypertension 2 article analyzed data from the JHS 3 (Jackson Heart Study) and RE-GARDS 4 (Reasons for Geographic and Racial Differences in Stroke) studies, conducted prior to 2016, to determine if self-identified Black adults with aTRH in these large study populations had received the lifestyle and pharmacologic treatments recommended by the 2018 AHA Scientific Statement. The authors found that 28% of Black adults taking antihypertensive medication met criteria for RH, but were unable to entirely exclude pseudoresistance in the original studies; those patients were categorized as having aTRH. Less than 6% of the patients with aTRH re-ported taking a long-acting thiazide-like diuretic and <10% reported taking a mineralocorticoid receptor antagonist.

The authors conclude that recommended pharmacologic and evidence-based lifestyle interven-tions for aTRH were underutilized; low use of the optimized regimen presents an opportunity to improve care; and “achieving higher rates of BP control among Black adults may have an im-portant role in reducing disparities in hypertension-related morbidity and mortality.”


  1. Carey RM, Calhoun DA, Bakris GL, et al; on behalf of the American Heart Association. Resistant hyper-tension: detection, evaluation, and management: a scientific statement from the American Heart Asso-ciation. Hypertension. 2018;72:e53–e90. doi: 10.1161/HYP.0000000000000084.
  2. Langford AT, Akinyelure OP, Moore TL Jr, et al. Underutilization of treatment for black adults with ap-parent treatment-resistant hypertension: JHS and the REGARDS study. Hypertension. 2020;76(5):1600-1607. doi:10.1161/HYPERTENSIONAHA.120.14836.
  3. National Heart, Lung, and Blood Institute. Jackson Heart Study (JHS). https://www.nhlbi.nih.gov/science/jackson-heart-study-jhs. Updated 2020. Accessed October 26, 2020.
  4. Shimbo D, Levitan EB, Booth JN 3rd, et al. The contributions of unhealthy lifestyle factors to apparent resistant hypertension: findings from the Reasons for Geographic And Racial Differences in Stroke (RE-GARDS) study. J Hypertens. 2013;31:370–376. doi: 10.1097/HJH.0b013e32835b6be7.
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