Sequential nephron blockade vs . sequential renin–angiotensin system blockade on central and ambulatory blood pressure in resistant hypertension: A randomized clinical trial

AIMS: This study compares sequential nephron blockade (SNB) and renin-angiotensin system sequential blockade (RASSB) in patients with resistant hypertension (RHTN), evaluating central systolic pressure, arterial stiffness, pulse pressure and ambulatory blood pressure monitoring (ABPM). METHODS: A total of 72 patients with resistant hypertension were recruited from the Hypertension Outpatient Clinic and randomly allocated to two treatment groups: SNB (n = 35; 22 women, 13 men) and RASSB (n = 37; 22 women, 15 men). Central systolic blood pressure (CSBP), augmentation index (AI) and AI75 were assessed using validated non-invasive tonometry. ABPM was performed over 24 h to evaluate systolic, diastolic and pulse pressure changes. RESULTS: Office blood pressure reductions were significant in both groups (p < .0001). SNB: SBP from 174.5 to 127.0 mmHg; DBP from 105.3 to 78.11 mmHg. RASSB: SBP from 178.4 to 134.4 mmHg; DBP from 102.7 to 77.33 mmHg. ABPM confirmed 24-h reductions (p < .0001). SNB showed greater pulse pressure reduction (Δ = 22.99 vs. 15.93 mmHg, p = .024) and central systolic pressure reduction (Δ = -10.3 vs. -5.1 mmHg, p = .036). RASSB elicited a significant decrease in heart rate (Δ = -12.4 bpm, p < .0001). No treatment-related discontinuations occurred. CONCLUSION: SNB demonstrated superior efficacy in reducing CSBP and pulse pressure, while RASSB more effectively lowered heart rate. These distinct haemodynamic responses support individualized treatment strategies for patients with RHTN.