Resistant & Refractory Hypertension: 9 Questions for Primary Care
How are you managing your patients with resistant or refractory hypertension? How do your strategies align with current guidelines? Try these 9 questions and find out.
1. Resistant hypertension is usually defined as inability to achieve BP control despite administration of which of the above?
Answer
Resistant hypertension is characterized by poor BP control despite maximum doses of ≥3 antihypertensives or BP that requires ≥4 antihypertensives for maintenance.
2.The usual 3-drug antihypertensive regimen prescribed prior to considering hypertension resistant is which of the above?
Answer
An regimen of a renin-angiotensin system inhibitor, calcium channel blocker, and thiazide diuretic should be optimally dosed before making a diagnosis of resistant hypertension.
3. Which of the factors above should be ruled out when determining whether or not hypertension is resistant?
Answer
If any/all of these factors listed are present (improper BP measurement technique, white-coat effect on BP, non-adherence to antihypertensive medication regimen), the hypertension might be categorized as "pseudoresistant."
4. Match the deficiency above with the tactic for assessing adherence to an antihypertensive Rx regimen.
Answer
A. Time consuming, nonhygenic -- 4. Pill counting
B. Inaccurate when tested -- 3. Questionnaire
C. Notoriously inaccurate -- -- 1. Physician perception
D. Inaccuracies -- 2. Self-report, diary
5. Which of the above pairs of hypertension type and pathophysiology are correct?
Answer
“Resistant hypertension is predominantly mediated by sodium retention, volume overload and aldosterone. Refractory hypertension appears to be mediated by enhanced sympathetic tone, not excessive volume.”
6. True or False: Higher urinary norepinephrine, higher heart rate, and reduced heart rate variability are characteristic of resistant hypertension.
Answer
False. “Compared with patients with controlled resistant hypertension, refractory cases were shown to have higher urinary norepinephrine, higher heart rate, reduced heart rate variability, higher system vascular resistance, but not increased left atrial volume, left ventricular volume or natriuretic peptide levels.”
7. Which of the conditions above can be secondary causes of resistant hypertension?
Answer
Secondary causes of resistant hypertension can include chronic kidney disease, obstructive sleep apnea, primary hyperaldosteronism and renovascular hypertension.
8. True or False: Reserpine is more likely to be of benefit in treatment of refractory than resistant hypertension.
Answer
True. Because refractory hypertension may be mediated by enhanced sympathetic tone, therapy should target alpha-, beta- adrenergic blockade, followed by centrally acting sympatholytics, vasodilators or both.
9. True or False: In addition to steroidal MRAs like spironolactone, nonsteroidal MRAs are being investigated for treatment of resistant hypertension.
Answer
True. Nonsteroidal MRA formulations being investigated to treat resistant hypertension include esaxerenone, available in Japan for hypertension, and finerenone, available in the US for diabetic kidney disease.
Source: Filippone EJ, Naccarelli GV, Foy AJ. Controversies in hypertension V: Resistant and refractory hypertension. Am J Med. 2024; 137:12-22. doi: 10.1016/j.amjmed.2023.09.015
This quiz poses questions for primary care professionals on treating a condition defined by its resistance to prior treatment. Among the patients you see every day, the prevalence of hypertension is increasing with age. Estimates are that approximately 7% of US young adults aged 18–39 have hypertension. The prevalence increases more than 9-fold to 65% among those aged 60 and over. In your panel, are there individuals with persistent uncontrolled hypertension?
The questions are based on a Patient Care Guideline Topline that summarizes a review on assessment and management of resistant and refractory hypertension published in The American Journal of Medicine. Try the quiz first, then click through the Topline for a quick update.
