Description
Managing resistant hypertension, a condition where blood pressure remains elevated despite treatment, requires a comprehensive approach. Resistant hypertension is typically defined as high blood pressure that remains uncontrolled despite the use of three or more different antihypertensive medications. The first step in managing resistant hypertension involves lifestyle changes, including adopting a low-sodium diet, regular exercise, weight management, and reducing alcohol intake. Healthcare providers should review current medications to ensure optimal dosing and assess for potential drug interactions or contributing factors. Identifying and treating underlying causes of secondary hypertension, such as kidney disease or hormonal disorders, is crucial. Patients are often encouraged to monitor their blood pressure at home to assess its variability and ensure accurate readings. Using combination therapies that include different classes of antihypertensive drugs can be more effective in controlling resistant hypertension.
Résumé
- A 22-year-old male presented with pulmonary edema, uncontrolled hypertension (170/110 mmHg), and concentric left ventricular hypertrophy despite multiple antihypertensives. A 55-year-old obese female complained of headache, fatigue, daytime sleepiness, and irritability, with uncontrolled hypertension (above 160/100 mmHg) despite multiple medications. A 45-year-old male with 12 years of hypertension was managed with minimal doses of antihypertensives and had normal creatinine levels.
- Resistant hypertension is defined as seated office blood pressure that remains above goal despite the concurrent use of three different antihypertensive classes, including a diuretic if tolerated, at maximum recommended or maximally tolerated doses and appropriate dosing frequency. Controlled resistant hypertension is achieved with more than four antihypertensive medications, while uncontrolled resistant hypertension persists despite three antihypertensives. Refractory hypertension is uncontrolled even with five or more drugs.
- Apparent treatment-resistant hypertension, also known as pseudo-resistant hypertension, must be excluded by verifying medication dosages and adherence, ruling out white-coat hypertension, and ensuring proper blood pressure monitoring. Incorrect cuff size, inadequate rest before measurement, and rapid cuff deflation can falsely elevate readings. Physician inertia can also contribute to sub-optimal therapy.
- The most common causes of resistant hypertension include chronic kidney disease, certain medications, obstructive sleep apnea, obesity, and older age. Factors associated with resistant hypertension are obesity, female sex, black race, obstructive sleep apnea, diabetes, chronic kidney disease, alcohol, and smoking. Addressing modifiable factors like obesity, high salt intake, alcohol consumption, and smoking is crucial.
- Secondary hypertension, present in about 10% of hypertension cases, can result from obstructive sleep apnea, renal parenchymal diseases, primary hyperaldosteronism, renal artery stenosis, pheochromocytoma, Cushing's disease, and thyroid diseases. Absence of nocturnal dipping on ambulatory blood pressure monitoring, unexplained hypokalemia, and metabolic alkalosis can suggest specific underlying conditions. Obese patients should be evaluated for obstructive sleep apnea, hypothyroidism, and Cushing's syndrome.
- Lifestyle modifications, including weight reduction, a low-salt diet (less than 2.3 grams per day), and increased physical activity, can significantly reduce blood pressure. CPAP therapy has shown short- and long-term benefits for blood pressure reduction in patients with obstructive sleep apnea and resistant hypertension. Pharmacological therapy typically involves a combination of ACE/ARB, calcium channel blocker, and a thiazide-like diuretic.
- If blood pressure remains uncontrolled, mineralocorticoid receptor blockers like spironolactone or eplerenone can be added. Spironolactone is more potent but has more side effects. Other options include vasodilator beta-blockers, central-acting agents like clonidine, and direct vasodilators like hydralazine or minoxidil. Newer drugs in development include aprocitentin and baxdrostat.
- Device-based interventions for resistant hypertension include renal denervation, carotid baroreceptor stimulation, and central AV fistulas. Renal denervation involves catheter-based radiofrequency or ultrasound ablation. Carotid baroreceptor stimulation involves implanting a device to stimulate the carotid baroreceptors. Existing trials have shown varying degrees of success.
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