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102 Resistant Hypertension in Clinical Practice

Dietary Salt Restriction: The benefit of dietary salt re- excess of 20% of patients after 1 year.Endovascular
duction is well documented in general hypertensive angioplasty, with or without stenting, should be con-
patients with observed reductions in systolic and di- sidered when drug therapy alone is unsuccessful.
astolic blood pressure. However, in an evaluation of However, if the blood pressure remains poorly con-
patients whose blood pressure was uncontrolled on trolled in spite of optimal medical therapy, revascu-
a combination of an ACE inhibitor and hydrochloro- larization is recommended.
thiazide, a reduced-salt diet lowered systolic and dia-
stolic blood pressure.A dietary salt restriction, ideally Pharmacological Treatment
to less than 100 mEq of sodium/24-hour, should be Withdrawal of Interfering Medications
recommended for all patients with resistant hyper-
tension. Medications that may interfere with blood pressure
control, particularly NSAIDs, should be avoided or
Moderation of Alcohol Intake: Cessation of heavy al- withdrawn in patients with resistant hypertension
cohol ingestion can significantly improve hyperten- or lowest effective dose should be used with sub-
sion control. Daily intake of alcohol should be limited sequent down titration whenever possible. When ini-
to no more than 2 drinks (1 ounce of ethanol) per tiating treatment with these agents, blood pressure
day (eg, 24 ounces of beer, 10 ounces of wine, or 3 should be monitored closely while recognizing that
ounces of 80 proof liquor) for most men and 1 drink adjustments to the antihypertensive regimen may
per day for women or lighter-weight persons.
become necessary.
Increased Physical Activity: Aerobic exercise regimen Therefore, if analgesics are necessary, acetamino-
(stationary cycling 3 times a week) lowers both di- phen may be preferable to NSAIDs in subjects with
astolic & systolic BP. Reductions in diastolic blood resistant hypertension, recognizing, however, that
pressure are maintained after 32 weeks of exercise, acetaminophen will provide little if any antiinflam-
even with withdrawal of some antihypertensive med- matory benefit.
ications. Based on these observed benefits, patients
should be encouraged to exercise for a minimum of Diuretic Therapy
30 minutes on most days of the week.
Evaluation of patients with resistant hypertension
Ingestion of a High-Fiber, Low-Fat Diet: Ingestion of have been consistent that treatment resistance was
a diet rich in fruits and vegetables; high in low-fat a lack of, or underuse of, diuretic therapy. Blood
dairy products, potassium, magnesium, and calci- pressure control was improved primarily through the
um; and low in total saturated fats (i.e., the Dietary use of increased doses of diuretics. Lack of blood
Approaches to Stop Hypertension or DASH diet) re- pressure control was attributed most often to the use
duced systolic and diastolic blood pressure. of a suboptimal medical regimen, which was modi-
fied most frequently by adding a diuretic, increas-
Treatment of Secondary Causes of ing the dose of the diuretic, or changing the class
Hypertension: of prescribed diuretic based on the underlying renal
When primary aldosteronism, pheochromocytoma, or function.
Cushing’s disease is suspected or confirmed, treat- In most patients, use of a long-acting thiazide diuret-
ment will be specific for that particular disorder. Ef- ic will be most effective. Chlorthalidone 25 mg daily
fective management of these diseases may require provided greater 24-hour ambulatory blood pres-
referral to an appropriate specialist. sure reduction. Given the outcome benefit demon-
strated with chlorthalidone and its superior efficacy
Treatment of Obstructive Sleep Apnea compared with hydrochlorothiazide, chlorthalidone
Treatment of sleep apnea with continuous positive should be preferentially used in patients with resis-
airway pressure (CPAP) likely improves blood pres- tant hypertension. In patients with underlying CKD
sure control. (creatinine clearance <30 mL/min), loop diuretics
may be necessary for effective volume and blood
Treatment of Renal Artery Stenosis pressure control. Furosemide is relatively short acting
and requires twice-daily dosing. Alternatively, loop
Angioplasty of fibromuscular lesions almost always diuretics with a longer duration of action, such as
benefits, and is often curative, of the associated hy- torsemide, can be used.
pertension and therefore is the recommended treat-
ment of choice. Restenosis, however, may occur in

GCDC 2017