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From the Publishers of

A Case of Hypertension: Overcoming

Resistance Requires Change


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Copyright 2015
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Copyright 2015
Resistant Hypertension

Consider secondary hypertension

Results of the evaluation:
Renal function normal
Renal artery ultrasound- 70% left renal artery
Plasma aldosterone / renin activity ratio is normal-
no primary aldosteronism
Hypertension is not episodic no pheo
No Cushings features

Copyright 2015
Resistant Hypertension

BMI 32
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
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

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..

Copyright 2015
*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;63:878885.
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

Prior MI, stroke,

*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
Left renal artery

Target < 140 / 90

Copyright 2015

Salt restriction
Moderate reduction: 4mmHg lowering systolic BP

40 minutes, three times weekly: systolic BP reduction 5 mmHg
Treatment would only lower systolic BP approximately 3mm

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

947 patients with RAS > 60% AND resistant

hypertension or > stage 3 CKD
Medical therapy with or without stenting mean stenosis
43 month follow up
No difference in death, MI, stroke, hospitalization for
heart failure, renal insufficiency, need for permanent
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

Diuretic key to the regimen

Persistent volume expansion common
Even in the absence of edema
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

Copyright 2015

In addition to diuretic:
enzyme inhibitor
Calcium channel

Add a fourth medication?

Copyright 2015

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

Dont forget primary aldosteronism

Fourth agent: Add mineralocorticoid receptor antagonist

(spironolactone, eplerenone)
Follow potassium

Copyright 2015
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