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A Case of Hypertension:
Overcoming Resistance Requires
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Resistant Hypertension
Consider secondary hypertension
Results of the evaluation:
 Renal function normal
 Renal artery ultrasound- 70% left renal artery
stenosis
 Plasma aldosterone / renin activity ratio is normalno primary aldosteronism
 Hypertension is not episodic – no pheo
 No Cushings features
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Resistant Hypertension
Exam:
BMI 32
Afebrile
BP: 155/90 right and left arm (large cuff)
HR: 70 bpm
Lungs clear. Cardiac rhythm regular. Heart sounds normal. No murmur.
Abdominal exam: no mass or bruit.
Extremity exam is normal. No pulse delay
Labs
Electrolytes: Na 135, K 4.0
Cr 0.8
Plasma aldosterone / renin is normal
Renal artery doppler: 70% left renal artery stenosis
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Resistant Hypertension
 55 year-old man
 BP 155/90 and confirmed at home
 BMI 32
 Diuretic (hctz) + ACE-I (enalapril) + long acting
dihydropyrdine calcium channel blocker (amlodipine)
and compliant
 Left renal artery stenosis (70%)
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
Renal artery stenosis in up to 20% of patients
OSA in up to 70% of patients
Primary aldosteronism in up to 20% of patients
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Resistant Hypertension
 BP that remains above goal despite three
antihypertensive agents (one of which is a diuretic)
 20% of patients with hypertension
 So, what is the goal?
It depends who you ask…..
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*Calhoun DA et al. Resistant Hypertension: Diagnosis, Evaluation, and Treatment.
Hypertension. 2008 Jun;51(6):1403-19. doi: 10.1161/HYPERTENSIONAHA.108.189141. Epub 2008 Apr 7.
Age 60 or above: < 150/90
Below age 60: < 140/90
*James PA, Oparil S, Carter BL, et al. 2014 Evidence-Based Guideline for the Management of High Blood
Pressure in Adults: Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8).
JAMA. 2014;311(5):507-520. doi:10.1001/jama.2013.284427.
December 2014
< 140/90
*Go AS, Bauman MA, Coleman King SM, Fonarow GC, Lawrence W, Williams KA, Sanchez E.
An effective approach to high blood pressure control: a science advisory from the American Heart Association,
the American College of Cardiology, and the Centers for Disease Control and Prevention.
Hypertension. 2014;63:878–885.
December 2014
< 140/90
Age 80 or older : < 150/90
( if diabetic or CKD < 140/90)
*Weber MA, et al. Clinical Practice Guidelines for the Management of Hypertension
in the Community. The Journal of Clinical Hypertension, 16: 14–26. doi: 10.1111/jch.12237
May 2015
Stable patient
<140/90
Prior MI, stroke,
TIA
<130/80
*Rosendorff C, et al. and on behalf of the American Heart Association,
American College of Cardiology, and American Society of Hypertension. Treatment of
hypertension in patients with coronary artery disease: a scientific statement from the
American Heart Association, American College of Cardiology, and American Society of
Hypertension. Hypertension. 2015.
BP < 140/80
*The Sprint Group. N Engl J Med. 2015 Nov 9. [Epub ahead of print]
Our Patient
 Age 55
 No CAD
 Non-diabetic
 Left renal artery
stenosis
Target < 140 / 90
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Non-pharmacologic
 Diet
 Salt restriction
 Moderate reduction: 4mmHg lowering systolic BP
 Exercise
 40 minutes, three times weekly: systolic BP reduction 5 mmHg
 OSA?
 Treatment would only lower systolic BP approximately 3mm
Hg
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*Cooper CJ et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis
N Engl J Med 2014 Jan 2;370(1):13-22. doi: 10.1056/NEJMoa1310753. Epub 2013 Nov 18.
Coral Trial
 947 patients with RAS > 60% AND resistant
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


hypertension or > stage 3 CKD
Medical therapy with or without stenting mean stenosis
73%
43 month follow up
No difference in death, MI, stroke, hospitalization for
heart failure, renal insufficiency, need for permanent
dialysis
Systolic BP 2.3 mm Hg lower in the stent group
*Cooper CJ et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis
N Engl J Med 2014 Jan 2;370(1):13-22. doi: 10.1056/NEJMoa1310753. Epub 2013 Nov 18
Medications
 Diuretic key to the regimen
 Persistent volume expansion common

Even in the absence of edema
 HCTZ
 Consider replacing with chlorthalidone
Twice as potent as HCTZ in lowering blood pressure
 Within recommended doses probably a more potent
antihypertensive effect over 24 hours

 If GFR < 30 mL/min thiazide less effective
 Consider loop diuretic
Furosemide short acting so twice daily
 Torsemide once daily

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Medications
 In addition to diuretic:
 Angiotensin
converting
enzyme inhibitor
 Calcium channel
blocker
Add a fourth medication?
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Spironolactone
Pearls
• Know the target BP and confirm resistance with home BP
• Rule out confounding causes, life style causes and
•
•
•
•
•
noncompliance
Optimize the ACEI and calcium channel blocker
Switch from HCTZ to chlorthalidone
If remains resistant on three agents investigate for secondary
hypertension as clinically indicated
• No evidence that renal artery revascularization improves BP
• Don’t forget primary aldosteronism
Fourth agent: Add mineralocorticoid receptor antagonist
(spironolactone, eplerenone)
Follow potassium
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