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100 Resistant Hypertension in Clinical Practice

mineralocorticoid receptor antagonist (spironolac- al in etiology with obesity, excessive dietary sodium
tone or eplerenone). intake, obstructive sleep apnea, and CKD being par-
ticularly common factors. Target-organ damage such
Renal Parenchymal Disease as retinopathy, CKD, and LVH supports a diagnosis
of poorly controlled hypertension and in the case of
CKD is both a common cause and complication of
poorly controlled hypertension. Most of this popu- CKD will influence treatment in terms of classes of
lation was receiving antihypertensive drug therapy , agents selected as well as establishing a blood pres-
but achievement of current goal levels (<130/85 mm sure goal of <130/80 mm Hg.
Hg) was uncommon. Treatment resistance in patients
with CKD is related in large part to increased sodium Medical History
and fluid retention and consequential intravascular The medical history should document duration, se-
volume expansion. verity, and progression of the hypertension; treat-
ment adherence; response to prior medications,
Renal Artery Stenosis including adverse events; current medication use,
Renovascular disease is a common finding in hyper- including herbal and over-the-counter medications;
tensive patients undergoing cardiac catheterization, and symptoms of possible secondary causes of hy-
with more than 20% of patients having unilateral or pertension. Daytime sleepiness, loud snoring, and
bilateral stenosis (with a degree of obstruction ≥70%). witnessed apnea are suspicious for sleep apnea. A
Studies of treatment-resistant hypertension com- history of peripheral or coronary atherosclerotic dis-
monly reveal a high prevalence of previously unrec- ease increases the likelihood of renal artery stenosis.
ognized renovascular disease, particularly in older Labile hypertension, in association with palpitations
patient groups. and/or diaphoresis, suggests the possibility of pheo-
chromocytoma.
More than 90% of renal artery stenosis are athero-
sclerotic in origin. The likelihood of atherosclerotic Assessment of Adherence
renal artery stenosis is increased in older patients; Ultimately, adherence can only be known by patient
in smokers; in patients with known atherosclerotic self-report. Patients should be specifically asked, in
disease, especially peripheral arterial disease; and in a nonjudgmental fashion, how successful they are
patients with unexplained renal insufficiency. Bilater- in taking all of their prescribed doses, including dis-
al renal artery stenosis should be suspected in pa- cussion of adverse effects, out-of-pocket costs, and
tients with a history of “flash” or episodic pulmonary dosing inconvenience, all of which can limit adher-
edema, especially when echocardiography indicates ence. Family members will often provide more objec-
preserved systolic heart function.
tive assessments of a patient’s adherence, but such
input should generally be solicited in the presence
Diabetes of the patient.
Diabetes and hypertension are commonly associ-
ated, particularly in patients with difficult-to-control Blood Pressure Measurement
hypertension. Pathophysiologic effects attributed to Use of good blood pressure measurement tech-
insulin resistance that may contribute to worsening nique is essential to the accurate diagnosis of re-
hypertension include increased sympathetic nervous sistant hypertension, including having the patient sit
activity, vascular smooth muscle cell proliferation, quietly in a chair with his or her back supported for
and increased sodium retention.
5 minutes before taking the measurement; use of
the correct cuff size with the air bladder encircling
Evaluation
at least 80% of the arm (the adult large cuff for the
The evaluation of patients with resistant hyperten- majority of patients); and supporting the arm at heart
sion should be directed toward confirming true treat- level during the cuff measurement. A minimum of
ment resistance; identification of causes contributing 2 readings should be taken at intervals of at least
to treatment resistance, including secondary causes 1 minute and the average of those readings should
of hypertension; and documentation of target-organ be taken to represent the patient’s blood pressure.
damage. Accurate assessment of treatment adher- The blood pressure should be measured carefully
ence and use of good blood pressure measurement in both arms and the arm with the higher pressures
technique is required to exclude pseudoresistance. generally should be used to make future measure-
In most cases, treatment resistance is multifactori- ments. Supine and upright blood pressures should

GCDC 2017