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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

HOSPITAL DISCHARGE CRITERIA

  • Blood pressure control

  • Resolution of complications

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