Resistant Hypertension Flashcards
Define Resistant Hypertension
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)
Common RH Patient Characteristics/RF
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
Define Pseudo-Resistance
“perceived” resistant hypertension
- Needs to be ruled out
Causes of Pseudo-Resistance
Poor adherence
Bad BP technique
White coat HTN
Poor adherence in Pseudo-Resistance
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
Bad BP Technique in Pseudo-Resistance
Rest before obtaining
Validate BP device/monitor
Recent tobacco abuse/caffeine intake within 30 minutes
White Coat HTN in Pseudo-Resistance
- 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
Lifestyle Cause of RH: Obesity
Impaired Na excretion
Increased RAAS and sympathetic CNS activity
Lifestyle Cause of RH: Dietary Salt Intake
Volume overload
Elderly/AA/CKD patients are more susceptible
Ideally 2300 mg of Na per day
Lifestyle Cause of RH: Alcohol Intake
Female less than 1 per day
Male less than 2 per day
Medication-Related Factors for RH
NSAIDs
Stimulants
Oral contraceptives
Herbals
Secondary Causes of HTN
Obstructive Sleep Apnea
Primary aldosteronism
Renal artery stenosis
Renal parenchymal disease
Systemic Approach to RH
Medical History Exclude Pseudoresistance Assess lifestyle factors Minimize interfering substances Rule out secondary causes LAST- treat!
Medical History in RH
Duration of severity HTN Current medication use Previous medication use and doses Previous side effects CI to medications
Exclude Pseudo-resistance
Elevated clinic BP
Repeat BP and assure technique
Obtain valid home BP readings
Improve adherence
How do you improve adherence?
Use agents with a low side effect profile and low cost
Once daily
Communicate importance of control and ADRs/cost
Assess lifestyle factors
Salt, alcohol
Obesity, exercise
Minimize interfering substances
D/c meds and find alternatives
Example: tylenol instead of NSAIDs
Rule out Secondary Causes
Sleep apnea (daytime tiredness, snoring) Primary Hyperaldosteronism (increased aldosterone/renin ratio) CKD: CrCl less than 30 mL/min Renal Artery Stenosis: worsening renal function
Non-pharmacologic Treatments
Reduce sodium intake to less than 2300 mg
Weight loss
Moderation of EtOH
Increased activity (30 minutes most days of the week)
Pharmacologic Treatment
Optimize Diuretic Therapy Take at least 1 BP at night Attempt appropriate combos Add aldosterone antagonists Use alternatives Alter or add
Optimize diuretic therapy
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
Attempt appropriate combinations?
ACEi/ARB + diuretics
ACEi/ARB + CCB
Add aldosterone antagonists- drugs and risk
Spironolactone or eplerenone
Risk: Hyperkalemia
