a case of hypertension: overcoming resistance requires change copyright © 2015, all rights reserved...
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A Case of Hypertension: Overcoming Resistance Requires Change
COPYRIGHT © 2015, ALL RIGHTS RESERVED
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Copyright © 2015
Guys:
I am in our outpatient office and I need your help. It’s a case that you
will not be able to resist.
My patient is 55 years old and has a long history of hypertension.
During the past year an elevation of his blood pressure has prompted
that I increase his antihypertensive regimen and it now consists of
three antihypertensive agents: hydrochlorothiazide +enalapril+
amlodipine.
Despite titration to near maximum doses, his blood pressure taken at
home and in the office has been 155/90. His blood pressure control
has been resistant to three agents.
What do I do now ?
Guys:
I am in our outpatient office and I need your help. It’s a case that you
will not be able to resist.
My patient is 55 years old and has a long history of hypertension.
During the past year an elevation of his blood pressure has prompted
that I increase his antihypertensive regimen and it now consists of
three antihypertensive agents: hydrochlorothiazide +enalapril+
amlodipine.
Despite titration to near maximum doses, his blood pressure taken at
home and in the office has been 155/90. His blood pressure control
has been resistant to three agents.
What do I do now ?
Copyright © 2015
Resistant Hypertension
Consider secondary hypertension
Results of the evaluation:Renal function normalRenal artery ultrasound- 70% left renal artery stenosisPlasma aldosterone / renin activity ratio is normal- no primary aldosteronismHypertension is not episodic – no pheoNo Cushings features
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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 stenosisCopyright © 2015
Resistant Hypertension
Resistant Hypertension
55 year-old manBP 155/90 and confirmed at homeBMI 32Diuretic (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
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Resistant Hypertension
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BP that remains above goal despite three antihypertensive agents (one of which is a diuretic)
20% of patients with hypertensionSo, what is the goal?
It depends who you ask…..It depends who you ask…..
*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.
*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.
Age 60 or above: < 150/90Below age 60: < 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;63:878–885.
December 2014 < 140/90
*Weber MA, et al. Clinical Practice Guidelines for the Management of Hypertension in the Community. The Journal of Clinical Hypertension, 16: 14–26. doi: 10.1111/jch.12237
December 2014< 140/90Age 80 or older : < 150/90 ( if diabetic or CKD < 140/90)
*Rosendorff C, et al. and on behalf of the American Heart Association, American College of Cardiology, and American Society of Hypertension. Treatment ofhypertension 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.
May 2015
Stable patient<140/90
Prior MI, stroke, TIA<130/80
BP < 140/80
*The Sprint Group. N Engl J Med. 2015 Nov 9. [Epub ahead of print]
Our Patient
Age 55No CAD Non-diabeticLeft renal artery
stenosis
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Target < 140 / 90Target < 140 / 90
Non-pharmacologic
DietSalt 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
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*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 upNo 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
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Medications
In addition to diuretic: Angiotensin converting
enzyme inhibitor Calcium channel
blocker
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Add a fourth medication?Add a fourth medication?
Spironolactone
Pearls
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• 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• Don’t forget primary aldosteronism
• Fourth agent: Add mineralocorticoid receptor antagonist (spironolactone, eplerenone)
• Follow potassium
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