Comparison of the Efficacy of Different Treatment Regimens for Resistant Hypertension: A Systematic Review and Network Meta-Analysis.

PURPOSE: Our study tends to perform a network meta-analysis to compare the effect of different treatments on resistant hypertension (RH).

METHODS

A systematic search was conducted in databases up to April 1, 2026. 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), mineralocorticoid receptor antagonist (MRA), endothelin receptor antagonist, aldosterone synthase inhibitor (ASI), sodium-glucose cotransporter-2 inhibitors, baroreflex activation therapy, central arteriovenous anastomosis, lifestyle, and control group.

RESULTS

Thirty-three 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 -9.11, [95% confidence interval -10.44 to -7.79] for office SBP; -4.97 [-5.83 to -4.11] for office DBP; -9.64 [-11.73 to -7.54] for 24-h SBP; -3.75 [-5.08 to -2.42] for 24-h DBP). RDN effectively reduced both office and 24-h BP, and it caused a large reduction in office DBP compared to control group (-6.63 [-8.58 to -4.68] for office DBP; -3.36 [-4.57 to -2.14] for 24-h DBP). Lifestyle and ASI effectively reduced office and 24-h BP, and it as well as MRA were almost in the top three treatments.

CONCLUSION

MRA can be the priority treatment for RH. ASI and RDN are also optimal alternatives to MRA, particularly suitable for 24-h BP and uncontrolled DBP management, respectively. A combination of lifestyle alongside pharmacological/device-based therapies may represent the optimal approach. More trials concerning other treatments for RH are needed.