Transcript Difficult to control Hypertension


A 59F diagnosed with HTN 8 years ago comes to the clinic for
BP check. She is currently taking HCTZ 25 mg/d, lisinopril 40
mg/d and amlodipine 10 mg/d. While she reports good
compliance, she submits that her home BP ranges between
150-162/95-100 mmHg. She is also a diagnosed diabetic and
is taking metformin. She has no other medications. The
lowest BP in the clinic (after 3 measurements) is 155/90. Latest
lab work showed normal kidney function. What is the best
diagnosis for this patient’s condition?

A.
B.
C.
D.



Essential HTN, well controlled
Secondary HTN
“Difficult-to-control” HTN
Resistant HTN

Define resistant HTN

Identify etiologic factors

Discuss treatment strategies and options

Resistant HTN
› failure to achieve goal BP
› with maximum doses of 3 anti-HTN meds,
including a diuretic, taken with good
adherence
› not synonymous with “uncontrolled” HTN
› does not apply to recently diagnosed HTN

Only 58% of treated hypertensives reach
BP <140/90 mmHg

Only <40% of patients with DM and CKD
achieve good BP control
Sarafidis and Bakris.
J Am Coll Cardiol. 2008;52:1749-57.

Increase BP by a mean of 5 mmHg

Inhibit renal prostaglandin  decrease
renal blood flow  sodium and fluid
retention

Also interfere with action of BP meds
(except CCB)

Large amounts (i.e. >3 drinks/day) have
a dose-dependent effect on BP, in both
hypertensive and normotensive people

A 64M presents to the clinic for follow up; he has missed his last 2
appointments. Medical history is remarkable for HTN and OA of
both knees. His medication list includes metoprolol 25 mg BID,
losartan 50 mg/d, amlodipine 10 mg/d and hydralazine 50 mg
QID and ibuprofen 800 mg TID. However, he cannot confirm
taking all of them and adds that “my meds have been changed
so many times”. Upon being told by the nurse that his present BP
is 165/98 mmHg, he reports that his BP when taken at the
pharmacy 4 months ago was 130/85. Physical exam is
unremarkable aside from bilateral ankle pitting edema. What is
the most appropriate diagnosis?
A.
 B.
 C.
 D.

Uncontrolled HTN
Pseudo-resistant HTN
Resistant HTN
“Difficult-to-control” HTN

Lack of BP control with appropriate
treatment in a patient who does not
have resistant HTN
Sarafidis and Bakris. J Am Coll Cardiol. 2008;52:1749-57.







Inadequate rest prior to BP check
Taking single instead of triple readings
Using cuffs that are too small
Recent smoking
Not fully holding arm at heart level (i.e.
midpoint of the sternum while seated)
Not baring the arm
Back not supported and legs crossed

Ambulatory BP reading (ABP)
› Validated equipment
› BP measured Q15-30 mins.; 50-100 total
readings/24 hours
› Mean daytime, nightime, 24-hr. BP
› Approved for use by Medicare and
Medicaid for suspected WCH
› Evaluates diurnal BP rhythm
• Nightime BP drops by at least 10% from daytime BP
• Patients with non-dipping patern may be at increased risk
for HTN complications
• Nightime BP may be best predictor of CV risk
Pickering ,et al. Circulation. 2005;111:697-716.
Sarafidis and Bakris.
J Am Coll Cardiol. 2008;52:1749-57.

A 76F hypertensive presents for follow up. She was diagnosed
approx. 15 years ago and has achieved good control (usual
home BP =130/80 mmHg) with HCTZ 25 mg/d, diltiazem 180
mg BID and nifedipine XL 90 mg/d. She has no other medical
conditions and takes her medications with good adherence.
Vital signs are: BP 142/95 mmHg, HR 65 beats/min; the rest of
her physical exam is unremarkable. Review of recent labs
showed an estimated GFR of 38 mL/min (it was 50 mL/min
about 1 year ago). What is the most appropriate treatment
approach for this patient?

A.
B.
C.
D.



Add lisinopril 10 mg/d
Add metoprolol 25 mg BID
D/C HCTZ and start bumetanide 1 mg/d
Continue HCTZ and increase dose to 50 mg/d
Sarafidis and Bakris. J Am Coll Cardiol. 2008;52:1749-57.

Volume expansion is the most frequent
pathogenetic finding in resistant HTN

Diuretics can help >60% of patients
achieve good control

Note kidney function

HCTZ: effective from doses of 12.5 mg/d (in
normal kidney function); increases up to 50
mg/d may improve BP

Chlorthalidone: 25 mg/d may be superior
to HCTZ 50 mg/d; instant benefit

Study: Switch from HCTZ to chlorthalidone
resulted in 8 mmHg drop in SBP
 HCTZ
>
50 mL/min
 Chlorthalidone
=
40 mL/min
 Loop
 <40
diuretics
mL/min

Vasodilating BB may be added to 3-drug
combo (if pulse rate not too low)

May add complementary CCB to 3-drug
combo with another CCB

Adding ARB to ACE-I less effective than
adding diiuretic or CCB; adding DRI results
in small BP drop

Adding spironolactone as 4th drug may
lead to mean 25/12 mmHg reduction,
especially in obese patients

As 5th drug, consider cenrtal alpha-agonists
(clonidine) or vasodilators (hydralazine or
minoxidil)
› No positive long-term outcome data
Hirsch. Cleve Clin J Med. 2007;52:449-56.

A 70M with resistant HTN is back in the clinic for close follow
up. He also has PAD and well-controlled COPD. Since his
diagnosis, medications have been added incrementally to
include valsartan 320 mg/d, diltiazem 360 mg/d and HCTZ 50
mg/d. Other meds include ASA 81 mg/d, cilostazol 100 mg
BID, fluticasone + salmeterol and tiotropium inhalers. His clinic
and home BP readings are consistently between 145-151/9297 mmHg; HR is 85-90 beats/min. On exam, he has no JVD,
rales or wheezes, and edema. Blood markers are within
normal. What is the best treatment strategy?

A.
B.
C.
D.



Start metoprolol 15 mg BID
Start lisinopril 10 mg/d
Start torsemide 10 mg/d
Start amlodipine 5 mg/d

Recognize resistant and pseudo-resistant HTN

Check contributory factors, with emphasis on
medications, diet (i.e. salt, alcohol) and patient
adherence

Perform a new physical exam at every visit

Consider different and appropriate drug
combinations

Know when to refer