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Management of Resistant Hypertension in Primary Care Image
Dec 08, 2020

Management of Resistant Hypertension in Primary Care

Ben Taylor Photo

Ben Taylor PA-C, PhD, DFAAPABen Taylor, PA-C, PhD, DFAAPA

We all understand that hypertension remains the world\u2019s leading risk factor for cardiovascular disease, stroke, disability, and ultimately, death. Even with a multitude of updates from the Joint National Committee and steady improvement in hypertension awareness, treatment, and control rates, a vast majority of adults with hypertension still fail to achieve their recommended blood pressure treatment targets, even with three antihypertensive medications, and they have to be placed on four or more medications to achieve their targets. These patients are designated as having resistant hypertension (RH), and they remain at increased risk for morbidity and mortality.<\/p>\r\n

The typical characteristics of a patient with RH include African American race, older age, and male sex. Comorbidities associated with RH include obesity, left ventricular hypertrophy, albuminuria, diabetes mellitus, chronic kidney disease, and a higher Framingham 10-year risk score. All are more common in patients with RH than in those without RH.<\/p>\r\n

So, what do we do if we cannot get a patient\u2019s blood pressure under control? Remember that the goal blood pressure for patients with RH is the same as that in patients with hypertension without treatment resistance. Try the following measures in your patient before referring to a hypertension specialist:<\/p>\r\n

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  1. Identify and treat any secondary causes:<\/strong> The most common of these are obstructive sleep apnea, primary aldosteronism, and renal artery stenosis.<\/li>\r\n
  2. Stop medications that raise blood pressure:<\/strong> A variety of medications increase blood pressure; most commonly implicated are nonsteroidal anti-inflammatory drugs (NSAIDs).<\/li>\r\n
  3. Reinforce lifestyle modification:<\/strong> Weight loss, exercise, and eating a healthy diet have demonstrated health benefits and lower blood pressure values.<\/li>\r\n
  4. Check for nonadherence:<\/strong> Adherence needs to be addressed at every visit. This is a major contributor to inadequate blood pressure control and is commonly seen in patients who have treatment resistance.<\/li>\r\n
  5. Consider changes to pharmacologic therapy:<\/strong><\/li>\r\n<\/ol>\r\n
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      Switch to a more potent diuretic:<\/strong><\/p>\r\n<\/li>\r\n

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      If estimated glomerular filtration rate (eGFR) is \u226530 mL\/min\/1.72 m2, start chlorthalidone at 12.5 mg daily with titration up to 25 mg daily. If indapamide is used, start at 1.25 mg daily, titrating up to 5 mg daily as needed.<\/p>\r\n<\/li>\r\n

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      If eGFR <30 mL\/min\/1.72 m2, try switching to a loop diuretic; furosemide and bumetanide are relatively short acting and usually require BID dosing.<\/p>\r\n<\/li>\r\n

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      Add a mineralocorticoid receptor antagonist:<\/strong> A mineralocorticoid receptor antagonist (eg, spironolactone 12.5 mg daily then titrating to 25 mg, or eplerenone 50 mg daily) can yield significant antihypertensive benefit when added to existing multiple-drug regimens in patients with RH.<\/p>\r\n<\/li>\r\n<\/ul>\r\n

      I recommend referral to a hypertension specialist if blood pressure remains elevated despite 6 months of intensive treatment with at least three drugs classes. Other specialists may need to be consulted if you suspect a specific secondary cause of hypertension.<\/p>

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Reference
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  • Braam B, et al. Recognition and management of resistant hypertension. Clin J Am Soc Nephrol.<\/em> 2017;12:524-535.<\/li>\r\n
  • Carey RM, et al. Resistant hypertension: Detection, evaluation, and management. A scientific statement from the American Heart Association. Hypertension.<\/em> 2018;72:e53-e90.<\/li>\r\n
  • Unger T, et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension.<\/em> 2020;75:1334-1357.<\/li>\r\n
  • Williams B, et al. 2018 ESC\/ESH guidelines for the management of arterial hypertension. Eur Heart J.<\/em> 2018;39:3021-3104.<\/li>\r\n<\/ul>
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