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ChatGPT said: Resistant hypertension, defined as blood pressure uncontrolled despite optimal doses of three antihypertensives including a diuretic, often has an underlying endocrine cause. Common etiologies include primary aldosteronism, pheochromocytoma, Cushing’s syndrome, thyroid and parathyroid disorders. A systematic endocrine evaluation is crucial to identify secondary hypertension and tailor therapy. Biochemical screening with renin-aldosterone ratio, plasma metanephrines, dexamethasone suppression test, and thyroid/parathyroid function tests help establish diagnosis. Imaging may be required for localization. Treating the root endocrine disorder, such as adrenalectomy for aldosteronoma or medical therapy for hormone excess, can normalize blood pressure and reduce cardiovascular risk, offering a targeted approach.
Summary Listen
- Resistant hypertension is defined as blood pressure above the target despite adherence to three anti-hypertensive agents of different classes, one of which is ideally a diuretic, or controlled blood pressure requiring four agents or more. It's often misdiagnosed due to pseudo-resistant hypertension (poor measurement technique, white-coat syndrome) and should be distinguished from refractory hypertension, which remains uncontrolled despite five or more agents.
- The condition affects 10-20% of treated hypertensives and is strongly associated with stroke, myocardial infarction, heart failure, and chronic kidney disease. It's crucial to recognize that resistant hypertension is almost always multifactorial, involving mechanisms like volume overload, chronic kidney disease and obstructive sleep apnea, sympathetic overactivity linked to obesity, chronic stress, and arterial stiffness, which is mainly caused by aging and diabetes.
- Endocrine causes of resistant hypertension include primary aldosteronism (excess aldosterone leading to sodium retention), pheochromocytomas and paragangliomas (excess catecholamine production), Cushing's syndrome (excess cortisone), thyroid disorders (hypothyroidism causing diastolic hypertension, hyperthyroidism causing systolic hypertension), primary hyperparathyroidism (calcium-induced vasoconstriction), and acromegaly (excess growth hormone).
- Diagnostic algorithms emphasize confirming true resistance, ruling out pseudo-resistance, evaluating contributing lifestyle factors like high sodium intake, alcohol consumption, and obesity, and assessing contributing drugs like oral contraceptives and NSAIDs. Screening for secondary causes like renal disease through urine analysis and creatinine assessment, and endocrine causes through specific hormone testing is essential.
- Management principles prioritize lifestyle modifications, especially salt restriction (5 grams/day), weight loss (5-10%), physical activity, alcohol moderation, and sleep hygiene. Pharmacological therapy typically involves a standard three-drug combination (ACE inhibitor/ARB, CCB, and thiazide diuretic), with spironolactone added in refractory cases. Treat the specific endocrine causes of resistant hypertension.
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About the Speakers
Dr. Sammer Ramadan
Senior Consultant Endocrinologist, Chief Of Medicine, Stockholm Primary Healthcare, Sweden
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