Sunteți pe pagina 1din 23

From the Publishers of

A Case of Hypertension: Overcoming


Resistance Requires Change

COPYRIGHT 2015, ALL RIGHTS RESERVED


Terms of Use
The Consult Guys slide sets are owned and copyrighted by the American College
of Physicians (ACP). All text, graphics, trademarks, and other intellectual property
incorporated into the slide sets remain the sole and exclusive property of ACP.

The slide sets may be used only by the person who downloads or purchases them
and only for the purpose of presenting them during not-for-profit educational
activities. Users may incorporate the entire slide set or selected individual slides
into their own teaching presentations but may not alter the content of the slides in
any way or remove the ACP copyright notice.

Users may make print copies for use as hand-outs for the audience the user is
personally addressing but may not otherwise reproduce or distribute the slides by
any means or media, including but not limited to sending them as e-mail
attachments, posting them on Internet or Intranet sites, publishing them in meeting
proceedings, or making them available for sale or distribution in any unauthorized
form, without the express written permission of the ACP. Unauthorized use of the
Consult Guys slide sets constitutes copyright infringement.

Copyright 2015
Guuyyss::
G
s a ca s
s e
e t
t hh aa wililll
tt yyoouu w
I t
lp.. Its a ca
o f fi ce
ce aann d
d I
I nneeeedd yyoouurr hheelp
tpaati t
tieennt offi
II aam m inin oouurr oouutp
nnoott bbee aabblele ttoo reressisistt..
h y p ee rt
rt e
e n
n s
s io
io nn.. D ingg
Duurrin
isttoory
ry ofo f h yp
e a rs oo ld
ld aann d
d hh aass aa lolonngg hhis m tedd th
ppte thaatt II
pa ti e
e n
n t
t is
is 55 55 y
y e a r s pre ss uure
re h
h as
as ppro
r o m
y
My pa
M ti oonn ooff hhisis bblolooodd pre ss
e p a
a s
s t
t ye
ye aarr an
a n eele
levv a
a ti
ti
n a n d
d it
it nnooww c
c o
o nnssis
is ts ooff tthhrreeee
ts
th
the p reggim
sivvee re
nnsi imeen an lo ddipipininee..
e h is
is a
a n
n ti
tihh y
y p
p e
e rrte
te id e +e nn a
a la
la pprril
il+
+ aam
m lo
reaasse h
inccre
in
n t s: hhyyddrroocchhlolorrooththiaiazzide +e
s iv e a
a g
g e
e n ts:
ihyp
anttih
an ypeertrteennsive at hhoom mee
lo o d pprreesssu
su rree ttaakkeenn at
m a x im
im uumm oseess,, hhis
ddos is bblood ll hhaass bbeeeenn
tr a t io
io n
n t
t o
o n
n eeaa rr m a x r e s su
su r
ree ccoo n
nttro
ro
D titrat
itee ti
Deessppit 15 5 //9900.. HHisis bblolooodd ppres
e h a ss bb ee e
e n
n 1 5 5
andd in
an thee oofffi
in th ficce ha
s is ta nntt to
to tt hhre
re ee aaggeenntts.s.
re
res is ta

w ??
do noow
Whhaatt ddoo II do n
W

Copyright 2015
Resistant Hypertension

Consider secondary hypertension


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

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

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
<140/90

Prior MI, stroke,


TIA
<130/80
*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
No CAD
Non-diabetic
Left renal artery
stenosis

Target < 140 / 90

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

947 patients with RAS > 60% AND resistant


hypertension or > stage 3 CKD
Medical therapy with or without stenting mean stenosis
73%
43 month follow up
No difference in death, MI, stroke, hospitalization for
heart failure, renal insufficiency, need for permanent
dialysis
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
Medications

Diuretic key to the regimen


Persistent volume expansion common
Even in the absence of edema
HCTZ
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
Medications

In addition to diuretic:
Angiotensinconverting
enzyme inhibitor
Calcium channel
blocker

Add a fourth medication?

Copyright 2015
Spironolactone
Pearls

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
Produced by

and

Copyright 2015 COPYRIGHT 2015, ALL RIGHTS RESERVED