Resistant Hypertension

Question 1

Define Resistant Hypertension

Answer 1

o Not at Goal despite concurrent use of 3 antihypertensives at MAX tolerated doses (ideally one of these BP drugs should be a diuretic but doesn’t have to be)

Question 2

Common RH Patient Characteristics/RF

Answer 2

o	Obesity**
o	Sleep apnea**
o	Female sex
o	Black race
o	Older age >75 years old
o	Long-standing poorly controlled hypertension
o	Diabetes
o	Kidney disease
o	High salt intake
o	High alcohol intake

Question 3

Define Pseudo-Resistance

Answer 3

“perceived” resistant hypertension

- Needs to be ruled out

Question 4

Causes of Pseudo-Resistance

Answer 4

Poor adherence
Bad BP technique
White coat HTN

Question 5

Poor adherence in Pseudo-Resistance

Answer 5

Up to 40% of patients stop taking BP meds within the first year
Due to: side effects, complicated regimens, drug cost. poor patient education, cognitive/psychiatric issues

Question 6

Bad BP Technique in Pseudo-Resistance

Answer 6

Rest before obtaining
Validate BP device/monitor
Recent tobacco abuse/caffeine intake within 30 minutes

Question 7

White Coat HTN in Pseudo-Resistance

Answer 7

• Elevated BP in clinic but home readings normal or at goal
• Always validate patient’s BP monitor by checking against clinic BP
• Can use 24 hour BP monitoring

Question 8

Lifestyle Cause of RH: Obesity

Answer 8

Impaired Na excretion

Increased RAAS and sympathetic CNS activity

Question 9

Lifestyle Cause of RH: Dietary Salt Intake

Answer 9

Volume overload
Elderly/AA/CKD patients are more susceptible
Ideally 2300 mg of Na per day

Question 10

Lifestyle Cause of RH: Alcohol Intake

Answer 10

Female less than 1 per day

Male less than 2 per day

Question 11

Medication-Related Factors for RH

Answer 11

NSAIDs
Stimulants
Oral contraceptives
Herbals

Question 12

Secondary Causes of HTN

Answer 12

Obstructive Sleep Apnea
Primary aldosteronism
Renal artery stenosis
Renal parenchymal disease

Question 13

Systemic Approach to RH

Answer 13

Medical History
Exclude Pseudoresistance
Assess
lifestyle factors
Minimize interfering substances
Rule out secondary causes
LAST- treat!

Question 14

Medical History in RH

Answer 14

Duration of severity HTN
Current medication use
Previous medication use and doses
Previous side effects
CI to medications

Question 15

Exclude Pseudo-resistance

Answer 15

Elevated clinic BP
Repeat BP and assure technique
Obtain valid home BP readings
Improve adherence

Question 16

How do you improve adherence?

Answer 16

Use agents with a low side effect profile and low cost
Once daily
Communicate importance of control and ADRs/cost

Question 17

Assess lifestyle factors

Answer 17

Salt, alcohol

Obesity, exercise

Question 18

Minimize interfering substances

Answer 18

D/c meds and find alternatives

Example: tylenol instead of NSAIDs

Question 19

Rule out Secondary Causes

Answer 19

Sleep apnea (daytime tiredness, snoring)
Primary Hyperaldosteronism (increased aldosterone/renin ratio)
CKD: CrCl less than 30 mL/min
Renal Artery Stenosis: worsening renal function

Question 20

Non-pharmacologic Treatments

Answer 20

Reduce sodium intake to less than 2300 mg
Weight loss
Moderation of EtOH
Increased activity (30 minutes most days of the week)

Question 21

Pharmacologic Treatment

Answer 21

Optimize Diuretic Therapy
Take at least 1 BP at night
Attempt appropriate combos
Add aldosterone antagonists
Use alternatives
Alter or add

Question 22

Optimize diuretic therapy

Answer 22

Add thiazide if mild edema
Add loop if moderate to severe edema
Switch from thiazide to loop when CrCl is less than 30 mL/min

Question 23

Attempt appropriate combinations?

Answer 23

ACEi/ARB + diuretics

ACEi/ARB + CCB

Question 24

Add aldosterone antagonists- drugs and risk

Answer 24

Spironolactone or eplerenone

Risk: Hyperkalemia

Question 25

When NOT to use aldosterone antagonists?

Answer 25

Renal impairment is known (Cr greater than 1.6 or elder with CrCl less than 30 mL/min
Baseline potassium greater than 5