16. Treatment of hypertension. Resistant hypertension

Question 1

What are the non-pharmacological treatments of HTN?

Answer 1

It is the 1st line approach in mild hypertension

• Weight loss
• Diet:
  
  • Dietary salt reduction
  • DASH diet (Dietary Approaches to Stop HTN)
    
    • Fruits, vegetables, low-fat dairy products with reduced saturated and total fat, fish, meat
• Moderation of alcohol consumption
  
  • ≤ 2 drinks/day in men; ≤ 1 drink/days in women
• Physical activity
• Smoking cessation

Question 2

What is the pharmacological treatment of HTN?

Contraindications?

Answer 2

1st line treatment:

• ACEI (ramipril, enalapril) –x bilateral renal artery stenosis, hyperkalemia, pregnancy
• ARB (lozartan) –x same
• Ca²⁺-channel blockers (amlodipin) –x heart block
• Diuretics (thiazide [Inhibition of Na/Cl channel in dct]) –x Gout

Others:

• Beta blockers (metoprolol, carvedilol, labetolol, nebivolol) –x asthma, COPD
• Alpha blockers (prazosin, doxazosin)
• Alpha-2 agonists (clonidine, methyldopa)
• Direct vasodilators (nitrate, minoxidil)

Choosing a drug depends on the coexisting diseases:

• Angina/IHD –> beta blocker
• HF –> ACEI+diuretics
• Prostate hyperplasia –> alpha blockers
• Raynaud phenomenon –> Ca²⁺-channel blockers

Question 3

What is the instrumental treatment of HTN?

Answer 3

• Electronic baroreceptor reflex of carotid body
• Ablation of SY nerves running in the renal arteries
  
  • Increased SY stimulation ==> increased renin excretion –> increased Na⁺ reabsrption in the kidneys
  • Done by catheterization through radial/femoral artery using radiofrequency

Question 4

What is resistant hypertension? Different types?

Answer 4

BP remains above goal in spite of concurrent use of at least 3 antihypertensive agents over a period of 3 months.

• Refractory HTN:
  
  • Resistant HTN that can’t be controlled even with maximal medical therapy (≥ 5 drugs)
• Apparent resistant HTN:
  
  • Uncontrolled BP despite being prescribed ≥ 3 antihypertensive drugs (non-compliance)
• True resistant HTN:
  
  • Uncontrolled BP depsite being compliant with hypertensive regimen (≥ 3 drugs)
  • Confirmed by 24h ambulatory BP monitoring
• Pseudoresistant HTN:
  
  • ​Poorly controlled HTN that appears resistant but is attributable to different factors:
    
    • Inacurate measurement of BP, poor adherence to antihypertensice therapy, suboptimal antihypertensive therapy, poor adherence, …
• White coat HTN