What is indicated for managing a patient with resistant hypertension whose blood pressure remains above the target after three antihypertensive therapies?

Managing resistant hypertension can be complex, especially when a patient’s blood pressure remains above target despite the use of three antihypertensive medications. In this context, initiating spironolactone is a well-supported strategy due to its effectiveness in managing resistant hypertension, particularly among those with treatment-resistant cases.

Spironolactone is a potassium-sparing diuretic that not only helps to lower blood pressure but also addresses the issue of volume overload, which can be a contributing factor to resistant hypertension. It is particularly beneficial in patients who may have secondary causes of hypertension, such as hyperaldosteronism, and has proven efficacy in reducing blood pressure by enhancing sodium excretion while retaining potassium. This dual action can significantly improve overall blood pressure control when standard therapy is insufficient.

The approach of increasing the dosage of the current diuretic could lead to diminished returns on efficacy and increase the risk of side effects. Similarly, switching to a different antihypertensive class might not address the specific mechanisms involved in resistant hypertension and could result in less effective blood pressure management compared to adding an agent like spironolactone, which targets different pathways. Discontinuing all but one medication is generally inadvisable, as it risks losing control over hypertension.