Comparison of the efficacy of different treatment regimens for resistant hypertension: A system review and network meta-analysis

Resistant hypertension (RH) is associated with poor prognosis and high mortality, making it crucial to identify its effective treatment strategies. So we perform a network meta-analysis to compare the effect of different treatments on RH. A systematic search was conducted in databases up to January 10, 2025. We conducted a network meta-analysis using random effects to compare the change of systolic/diastolic blood pressure (SBP/DBP) between the following interventions: second-generation renal denervation (RDN), aldosterone receptor antagonist (MRA), endothelin receptor antagonist, aldosterone synthase inhibitor, sodium-glucose cotransporter-2 inhibitors, baroreflex activation therapy, central arteriovenous anastomosis, lifestyle, and control group. 26 eligible studies were included in the final analysis. After conducting sensitivity analyses, MRA significantly lowered both office and 24-h blood pressure (BP) compared to control group (mean difference, -10.3, [95% confidence interval, -12.74 to -8] for office SBP; -4.36, [-5.97 to -2.84] for office DBP; -9.73, [-12.18 to -7.19] for 24-h SBP; -3.22, [-5 to -1.44] for 24-h DBP). RDN effectively reduced both office and 24-h BP, and it caused a large reduction in DBP compared to control group (-6.09, [-9.04 to -3.08] for office DBP; -3.34, [-5.6 to -1.6] for 24-h DBP). Lifestyle modification effectively reduced office SBP and 24-h BP, and it as well as MRA were almost all in the top three treatments. In conclusion, MRA is the priority treatment for RH. RDN is also a good alternative to MRA, especially in individuals characterized by uncontrolled DBP. A combination of lifestyle interventions alongside pharmacological/device-based therapies may represent the optimal approach.