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Expired CME Article

Resistant Hypertension: Identifying Causes and Optimizing Treatment Regimens

Cora Lynn B. Trewet, PharmD, MS, Michael E. Ernst, PharmD
Volume: 101 Issue: 2 February, 2008

Abstract:

Management of resistant hypertension (RH), defined as uncontrolled blood pressure on three or more antihypertensive medications including a diuretic, begins initially with identifying and addressing contributors such as medication adherence, lifestyle factors and the use of interfering substances. Evaluation for the “white-coat” phenomenon, or associated conditions and secondary causes such as sleep apnea, primary aldosteronism, chronic kidney disease or renovascular disease may be indicated. Inadequate dosing, lack of using long-acting diuretics, and suboptimal combinations are observed as causes in nearly half of patients with RH. Appropriate pharmacotherapy of RH begins first with insuring the patient is receiving appropriate therapy for compelling indications, as outlined by the JNC-7 guidelines. Specific regimen enhancements to achieve blood pressure control include the addition of aldosterone antagonists, dual renin-angiotensin system blockade, and dual calcium channel blockade. Addition of centrally acting agents, alpha blockers, or vasodilators may also be necessary.


Key Points


* Managing resistant hypertension (RH) begins initially with identifying and intervening on reversible contributing factors such as medication adherence, lifestyle factors and investigating the use of interfering substances.


* Further work-up to exclude secondary causes or assess for the “white-coat” phenomenon may be indicated.


* Ineffective regimens, including inadequate dosing, lack of using long-acting diuretics, and suboptimal combinations are observed as causes in nearly half of patients with RH.


* Appropriate pharmacotherapy of RH begins with insuring that the patient is receiving appropriate therapy for compelling indications as outlined by the JNC-7 guidelines.


* Specific regimen enhancements to achieve blood pressure control include the addition of aldosterone antagonists, dual renin-angiotensin system blockade, dual calcium channel blockade, alpha blockers, combined alpha/beta blockers, centrally acting agents, and vasodilators.

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