Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ KEY FEATURES +++ ESSENTIALS OF DIAGNOSIS ++ Blood pressure > 140/90 mm Hg in patients adhering to a triple-drug regimen (including a diuretic) at near-maximal doses +++ GENERAL CONSIDERATIONS ++ Resistant or refractory hypertension is usually due to patient factors, such as: – Excessive sodium, alcohol, and calories – Noncompliance with medications Occasionally, the patient ingests other substances that interfere with the effectiveness of treatment, such as: – Nonsteroidal anti-inflammatory drugs – Oral contraceptives Another common problem is underdosing of medications, especially diuretics +++ CLINICAL PRESENTATION +++ SYMPTOMS AND SIGNS ++ Patient may report being under increased stress Nonspecific symptoms such as headaches, nose bleeds, fatigue, dyspnea +++ PHYSICAL EXAM FINDINGS ++ Elevated blood pressure Evidence of left ventricular hypertrophy such as a precordial lift or fourth heart sound +++ DIFFERENTIAL DIAGNOSIS ++ Inaccurate blood pressure measurement (eg, cuff too small) Stimulant exposure (eg, nasal sprays, diet pills, alcohol) Aggravating medical conditions (eg, sleep apnea) Secondary hypertension (eg, renal artery stenosis) Medication noncompliance +++ DIAGNOSTIC EVALUATION +++ ELECTROCARDIOGRAPHY ++ ECG findings: left ventricular and atrial hypertrophy +++ DIAGNOSTIC PROCEDURES ++ Ambulatory blood pressure monitoring: to confirm resistance and document temporal trends in relation to medication ingestion +++ TREATMENT +++ CARDIOLOGY REFERRAL ++ Suspected cardiac disease Refractory hypertension +++ HOSPITALIZATION CRITERIA ++ Severe hypertension (> 220/120 mm Hg) Heart failure Stroke Myocardial infarction Aortic dissection Renal failure +++ MEDICATIONS ++ Maximize medications, especially diuretics – If estimated glomerular filtration rate (GFR) is > 50 mL/min/1.73 m2, use a thiazide diuretic (eg, chlorthalidone) – If GFR is 30–40 mL/min/1.73 m2 or less, use a loop diuretic (eg, furosemide) Use the most efficacious combinations of drugs first (eg, a diuretic, an angiotensin-converting enzyme inhibitor, and a calcium channel blocker) Spironolactone 12.5–25 mg/day added to the above is often quite effective Then consider adding a beta blocker or a central alpha2-receptor agonist, such as clonidine, or a combined adrenergic inhibitor such as labetalol If the resting heart rate is > 70 bpm, consider beta blockers or rate-lowering calcium blockers such as diltiazem or verapamil +++ THERAPEUTIC PROCEDURES ++ Carotid baroreceptor stimulation is under investigation Catheter-based renal artery denervation studies have had mixed results, and the role of this procedure is unclear at this time +++ MONITORING ++ ECG and blood pressure in hospital +++ DIET AND ACTIVITY ++ Intensify lifestyle modifications (eg, low-salt diet or DASH diet, exercise, weight loss) +++ ONGOING MANAGEMENT ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth