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Copyright 2015
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Copyright 2015
Resistant Hypertension
Copyright 2015
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
Copyright 2015
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%)
Renal artery stenosis in up to 20% of patients
OSA in up to 70% of patients
Primary aldosteronism in up to 20% of patients
Copyright 2015
Resistant Hypertension
*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;63:878885.
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: 1426. doi: 10.1111/jch.12237
May 2015
Stable patient
<140/90
Age 55
No CAD
Non-diabetic
Left renal artery
stenosis
Copyright 2015
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
Copyright 2015
*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
Copyright 2015
Medications
In addition to diuretic:
Angiotensinconverting
enzyme inhibitor
Calcium channel
blocker
Copyright 2015
Spironolactone
Pearls
Copyright 2015
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