Resistant Hypertension: Four Pearls for Your Practice

A panel of experts presented a general strategy for evaluating patients with refractory hypertension, but ultimately cautioned the audience to assume non-compliance until proven otherwise! Highlights included:

1. JNC-7 defines “resistant hypertension” as the inability to achieve blood pressure goals despite maximum or near-maximum dosing of three or more anti-hypertensive agents.

2. In the workup of secondary hypertension, consider primary hyperaldosteronism and/or the presence of an adrenal tumor, which is more common than generally appreciated.  Other causes include renal insufficiency, coarctation of the aorta, Cushing’s Syndrome, thyroid/parathyroid disease, drug-induced (prescribed or illicit), pheochromocytoma, or renovascular disease.

3. Adrenal tumor may be incidental to non-compliance: The patient presented had extensive workup for adrenal tumor before having serum levels checked for amlodipine, doxazosin, and labetalol; all were non-detectable despite patient assurances that she was using the medication as directed. Serum tests now exist for many anti-hypertensives; if they’re not available from your lab, the panel recommends a trial of supervised administration in the hospital before embarking on a workup, especially an invasive one.

4. Combination therapies are more effective than single-agent therapies because patients are more likely to consume their doses: Citing the non-compliance literature, the panel agreed that single-pill approaches are invariably more effective than multi-pill regimens, especially when they need to be taken multiple times daily. Once-a-day therapy is the panel's unanimous first choice, except when cost considerations make it impossible for a given patient.

Resistant Hypertension: highlights from a presentation at ACC.11, April 3, 2011, New Orleans.
Chair:  Suzanne Oparil, MD
Panel: Wanpen Vongpatansin, MD, William Elliot, MD, Ronald Victor, MD, William White, MD

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