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Resistant Hypertension

Aka: Resistant Hypertension, Hypertension Combination Therapy, Combination Antihypertensive Therapy, Refractory Hypertension
  1. See Also
    1. Hypertension
    2. Hypertension Criteria
    3. Hypertension Evaluation
    4. Antihypertensive Selection
    5. Refractory Hypertensive Populations
  2. Epidemiology
    1. See Refractory Hypertensive Populations
    2. Prevalence: May approach 20-30% of hypertensive patients
  3. Definition: Resistant Hypertension
    1. Blood Pressure above goal despite adherance to antihypertensive regimen of 3 medications
  4. Indications for Combination Antihypertensive Therapy
    1. Failed Hypertension Monotherapy
    2. Hypertension
  5. Protocol
    1. Consider reasons for Resistant Hypertension (see below)
    2. Review Hypertension Risk Stratification
    3. Determine Hypertension Reduction Goal
    4. Advance to next step if BP>15/10 above goal
    5. Consolidate medications into combination agents and once daily regimens
  6. Efficacy
    1. Adding a medication to protocol has five fold greater efficacy over doubling dose of current medications
  7. Causes: Resistant Hypertension
    1. Noncompliance with current regimen (most common)
      1. Recent drug holiday
      2. Unfilled prescription
      3. Frequently missed doses (ask this in a non-judgemental way)
      4. Lifestyle modification (e.g. DASH Diet, Weight loss, Exercise) not employed
        1. See Lifestyle Modification in Hypertension
    2. Inaccurate Blood Pressure measurement (see BP Examination regarding pitfalls)
      1. Example: BP cuff that is too small will artificially inflate Blood Pressure readings
    3. White coat Hypertension
      1. Consider Ambulatory Blood Pressure Monitoring
      2. Increase regimen if average 24 hour BP > 129/79 or daytime average BP >134/84
    4. Pseudohypertension (elderly patients with atherosclerosis)
    5. Progression of disease
    6. Treatment program not optimized
      1. Example: Thiazide Diuretics are ineffective at GFR <30 ml/min (use Loop Diuretics instead)
    7. Medications or drugs counteracting antihypertensive (e.g. NSAIDS, Sympathomimetics)
      1. See Medication Causes of Hypertension
    8. Comorbid condition (e.g. Sleep Apnea, morbid Obesity, Alcohol Abuse, anxiety, Chronic Pain)
    9. Secondary Hypertension
      1. See Secondary Hypertension Causes
      2. Obstructive Sleep Apnea
        1. Very common cause of Resistant Hypertension
      3. Hyperaldosteronism
        1. Represents 20% of refractory cases (consider especially if Hypokalemia)
        2. Use Spironolactone or Eplerenone
        3. Check Serum Potassium and Serum Creatinine 2 weeks after start and then every 6 months
      4. Chronic Kidney Disease is common
        1. Follow a salt restricted diet
        2. Use Diuretics with an ACE Inhibitor or Angiotensin Receptor Blocker
        3. Check Serum Potassium and Serum Creatinine 2 weeks after start and then every 6 months
      5. Hyperuricemia
        1. Experimental lowering of serum Uric Acid with Allopurinol results in signficant lowering of Blood Pressure
    10. Reference
      1. O&#39;Rorke (2001) BMJ 322:1230
  8. Preparations: Combinations (assist with cost and compliance)
    1. Prinizide (Lisinopril 10-20 mg with Hydrochlorothiazide 12.5-25 mg)
    2. Diovan-Hct (Valsartan 80-160 mg with Hydrochlorothiazide 12.5 mg)
    3. Ziac (Bisoprolol with Hydrochlorothiazide 6.25)
    4. Lotrel (Benzapril 10-20 mg with Amlodipine 2.5-10 mg)
    5. Tarka (Trandolopril 1-2 mg with Verapamil 180-240 mg)
    6. Exforge (Valsartan and Amlodipine)
    7. Reserpine 1.25-2.5 mg with Hydrochlorothiazide 25 mg
    8. Tenoretic (Atenolol 50-100 mg with Chlorthalidone 25 mg)
  9. Protocol: Combinations that add 4 drugs in 2 pills for $50-60
    1. Tenoretic 100/25 with Lotrel 10/20
    2. Tenoretic 100/25 with Prinizide 20/12.5
  10. Protocol: Step 1
    1. Serum Creatinine <1.5 to 1.8 mg/dl
      1. ACE Inhibitor and Thiazide Diuretic (Hydrochlorothiazide, Chlorthalidone - more potent)
    2. Serum Creatinine >1.5 to 1.8 mg/dl (or GFR <30)
      1. ACE Inhibitor and Loop Diuretic (Lasix typically twice daily or Torsemide once daily)
    3. Alternative
      1. Angiotensin Receptor Blocker may be used if intollerant to ACE Inhibitor
  11. Protocol: Step 2
    1. Add Non-Dihydropyridine Calcium Channel Blocker (e.g. Diltiazem, Verapamil)
  12. Protocol: Step 3
    1. Heart Rate >83
      1. Add low dose Beta Blocker
    2. Heart Rate <84
      1. Add Dihydropyridine Calcium Channel Blocker (e.g. Amlodipine, Nifedipine)
  13. Protocol: Step 4
    1. Consider Spironolactone 12.5 to 50 mg orally daily (100 mg offers no added benefit compared with 50 mg dose)
    2. Consider Alpha-Beta Adrenergic blocker (Labetolol)
  14. Protocol: Step 5
    1. Consider Central Adrenergic Agonist (Clonidine)
    2. Consider Hydralazine (Apresoline)
    3. Consider Reserpine (risk of depression)
    4. Consider long acting Alpha adrenergic blocker at night (e.g. Terazosin)
  15. Protocol: Step 6
    1. Consult Nephrology or Cardiology
  16. Protocol: Additional Measures
    1. Consider Tekturna (Aliskiren), a Direct renin inhibitor
  17. References
    1. Woolley (2007) Park Nicollet Primary Care Conference, Minneapolis, MN
    2. Schwartz (2008) Mayo Selected Topics in Internal Medicine, Lecture
    3. Garg (2005) Am J Hypertens 18:619-626
    4. Moser (2006) N Engl J Med 355(4): 385-92
    5. Viera (2009) Am Fam Physician 79(10): 863-9

Hypertensive disease (C0020538)

Definition (NCI) A disorder characterized by a pathological increase in blood pressure; a repeatedly elevation in the blood pressure exceeding 140 over 90 mm Hg.
Definition (MEDLINEPLUS)

Blood pressure is the force of your blood pushing against the walls of your arteries. Each time your heart beats, it pumps out blood into the arteries. Your blood pressure is highest when your heart beats, pumping the blood. This is called systolic pressure. When your heart is at rest, between beats, your blood pressure falls. This is the diastolic pressure.

Your blood pressure reading uses these two numbers, the systolic and diastolic pressures. Usually they are written one above or before the other. A reading of

  • 120/80 or lower is normal blood pressure
  • 140/90 or higher is high blood pressure
  • Between 120 and 139 for the top number, or between 80 and 89 for the bottom number is prehypertension

High blood pressure usually has no symptoms, but it can cause serious problems such as stroke, heart failure, heart attack and kidney failure. You can control high blood pressure through healthy lifestyle habits and taking medicines, if needed.

NIH: National Heart, Lung, and Blood Institute
Definition (NCI) A blood pressure of 140/90 or higher. High blood pressure usually has no symptoms. It can harm the arteries and cause an increase in the risk of stroke, heart attack, kidney failure, and blindness.
Definition (CSP) persistantly high arterial blood pressure.
Definition (MSH) Persistently high systemic arterial BLOOD PRESSURE. Based on multiple readings (BLOOD PRESSURE DETERMINATION), hypertension is currently defined as when SYSTOLIC PRESSURE is consistently greater than 140 mm Hg or when DIASTOLIC PRESSURE is consistently 90 mm Hg or more.
Definition (NCI) Pathological increase in blood pressure; a repeatedly elevated blood pressure exceeding 140 over 90 mmHg.
Concepts Disease or Syndrome (T047)
MSH D006973
ICD9 997.91, 401-405.99
ICD10 I10-I15.9, I10, I10-I15
SnomedCT 38341003, 155295004, 194756002, 155302005, 266287006, 195537001, 194794002, 194757006, 194760004
English Hypertension, BLOOD PRESSURE HIGH, HYPERTENSION, HYPERTENSION ARTERIAL, HYPERTENSIVE DISEASES, Hypertension, NOS, Hypertensive disease, NOS, Hypertensive disease NOS, Hypertensive diseases, [X]Hypertensive diseases, hypertension, Hypertension, arterial, Hypertensive cardiovascular disease or syndrome, Systemic hypertension, Hypertensive disorder, systemic arterial, hyperpiesia, hyperpiesis, systemic HTN, systemic hypertension (diagnosis), systemic hypertension, hypertensive disorder, vascular hypertension, 3-02 HYPERTENSIVE DISEASES, hbp, high bp, htn, (Hypertensive disease) or (hypertension) (disorder), Hypertensive disease (disorder), Hypertensive disease NOS (disorder), Hypertension arterial, Blood pressure high, HBP, HT, Hypertension NOS, [X]Hypertensive diseases (disorder), Surg comp - hypertension, HTN, HIGH BLOOD PRESSURE, PRESSURE, HIGH BLOOD, BLOOD PRESSURE, HIGH, High Blood Pressure, INCREASED BLOOD PRESSURE, BLOOD PRESSURE, INCREASED, Hypertension [Disease/Finding], hypertensive vascular disease, arterial hypertension, arterial hypertension systemic, blood high pressure, high blood pressure disorder, systemic arterial hypertension, hypertensive disease, Hypertensive diseases (I10-I15), high blood pressure, High blood pressure, Hyperpiesia, Hyperpiesis, Hypertensive vascular degeneration, Hypertensive vascular disease, BP - High blood pressure, High blood pressure disorder, Systemic arterial hypertension, HBP - High blood pressure, BP+ - Hypertension, HT - Hypertension, Hypertensive disorder, systemic arterial (disorder), Hypertensive disorder, HTN - Hypertension, blood pressure; high, high; arterial tension, high; blood pressure, (Hypertensive disease) or (hypertension), Raised blood pressure (disorder), Blood Pressure, High, Blood Pressures, High, High Blood Pressures, Vascular Hypertensive Disorder, Hypertensive disease, HYPERTENSIVE DISEASE
French HYPERTENSION ARTERIELLE, Pression artérielle élevée, PAH, Hypertension SAI, TH, HYPERTENSION, TENSION ARTERIELLE E, Hypertension chronique, Hypertension permanente, Hypertension artérielle, Hypertension
Portuguese HIPERTENSAO, Hipertensão arterial NE, Hipertensão arterial, Pressão arterial alta, HYPERTENSAO ARTERIAL, PRESSAO SANGUINEA ELEVADA, Pressão Arterial Alta, Pressão Sanguínea Alta, Hipertensão
Spanish HIPERTENSION, PRESION SANGUINEA ALTA, Presión sanguínea alta, HTA, Hipertensión NEOM, Hipertensión arterial, HT, Hypertension, Hypertensive disease, High blood pressure, (Hypertensive disease) or (hypertension), Hypertension NOS, HIPERTENSION ARTERIAL, [X]enfermedades hipertensivas (trastorno), [X]enfermedades hipertensivas, Hypertensive disease NOS, degeneración vascular hipertensiva, enfermedad hipertensiva, SAI (trastorno), enfermedad hipertensiva, SAI, enfermedad hipertensiva, enfermedad vascular hipertensiva, hiperpiesia, hiperpiesis, hipertensión arterial (trastorno), hipertensión arterial, presión arterial alta, tensión arterial alta, tensión arterial elevada, Hipertension, Hipertensión, Presión Sanguínea Alta, Presion Sanguinea Alta
German HYPERTONIE, Hypertonie, arteriell, Blutdruck, hoch, HBP, HT, Hypertonie NNB, BLUTDRUCK HOCH, HYPERTONIE ARTERIELL, Hypertension, Hypertonie
Dutch hypertensie NAO, hoge bloeddruk, arteriële hypertensie, bloeddruk; hoog, hoog; arteriële druk, hoog; bloeddruk, hypertensie, Bloeddruk, hoge, Hypertensie
Italian Ipertensione (HT), Ipertensione NAS, Pressione del sangue elevata, Ipertensione, Pressione sanguigna alta, Ipertensione arteriosa
Japanese 動脈性高血圧, 高血圧ＮＯＳ, ｺｳｹﾂｱﾂ, ｺｳｹﾂｱﾂNOS, ﾄﾞｳﾐｬｸｾｲｺｳｹﾂｱﾂ, 高血圧, 高血圧症
Swedish Högt blodtryck
Czech hypertenze, Arteriální hypertenze, Vysoký krevní tlak, Hypertenze NOS, Hypertenze, vysoký krevní tlak
Finnish Kohonnut verenpaine
Russian GIPERTENZIIA, GIPERTONICHESKAIA BOLEZN', KROVIANOE DAVLENIE VYSOKOE, ГИПЕРТЕНЗИЯ, ГИПЕРТОНИЧЕСКАЯ БОЛЕЗНЬ, КРОВЯНОЕ ДАВЛЕНИЕ ВЫСОКОЕ
Croatian HIPERTENZIJA
Polish Nadciśnienie
Hungarian Arteriás hypertonia, Hypertensio, HT, RR magas, Hypertonia k.m.n., Magas vérnyomás
Sources
Derived from the NIH UMLS (Unified Medical Language System)


ANTIHYPERTENSIVE COMBINATIONS (C1874305)

Concepts Pharmacologic Substance (T121)
English ANTIHYPERTENSIVE COMBINATIONS, antihypertensive combinations (medication), antihypertensive combinations, [CV400] ANTIHYPERTENSIVE COMBINATIONS
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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