The objective of this study was to investigate if an increased intra-abdominal adipose tissue (IAAT)-subcutaneous adipose tissue (SAT) ratio was associated with difficult-to-treat hypertension (defined as an elevation of clinic blood pressure ≥140/90 mmHg) during treatment with at least three antihypertensive drugs. The study cohort included 572 patients who were under stable antihypertensive treatment. Results revealed that an increased IAAT/SAT ratio (measured by computed tomography) was a strong predictor of difficult-to-treat hypertension, independently of the presence of metabolic syndrome and insulin levels in men. However, this relationship became nonsignificant when diuretic use was included in the model. This finding suggests that insufficient diuretic use (i.e., volume retention) might be one of the underlying pathophysiological mechanisms to explain the relationship between an increased IAAT/SAT ratio and difficult-to-treat hypertension. The significant predictors of resistant hypertension in men were regular alcohol drinking habits and a decreased estimated glomerular filtration rate. In women, on the other hand, the IAAT/SAT ratio was not a significant predictor of difficult-to-treat hypertension. In their comment, Jordan J and Grassi G recognized that intra-abdominal adiposity appears to be an important risk factor for difficult-to-treat hypertension. They also qualified the observation concerning diuretic use as important because it supports the idea that volume expansion is a crucial mechanism in the pathogenesis of difficult-to-treat or resistant hypertension. They highlighted the fact that this complex issue is not sufficiently studied.
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