Some patients have pseudoresistant hypertension due to errors in blood pressure measurement or white coat hypertension. Resistant hypertension can only be distinguished from white coat hypertension by out of office blood pressure measurement. This is best accomplished with 24-hour ambulatory monitoring, although home and workplace assessments can be utilized if one is confident that the blood pressure is being measured accurately. Ambulatory measurements should ideally be attained in all patients with resistant hypertension.
Ambulatory monitoring is also a better predictor than office blood pressure measurements of cardiovascular morbidity (i.e. end-organ damage) and mortality in patients with resistant hypertension
Step 3: Treatment Recommendations
- Non-pharmacological treatment – More strict enforcement by the physician and adherence of the patients about non-pharmacological measures is needed. Recommendations include smoking cessation, reduction in alcohol intake, dietary sodium restriction, healthy eating plans, increased physical activity and weight loss. Lifestyle interventions complement the efficacy of drug therapy and, alone, are often satisfactory in uncomplicated essential hypertension.
- Constructing a potent Antihypertensive Regimen
- Revisit the initial regimen and ensure optimal dosed drug & combination
- Do not keep adding medications
- appropriate & optimally dosed 3 drug regimen should suffice for BP control
- adding multiple additional drug has potential for serious side effects
- attempt to find an underlying cause and tailoring treatment for that cause is necessary.
- See if dose Titrations is appropriate?
e.g.: Carvedilol should be maximized to 25-50 mg twice a day. Low dose Diuretics 12.5 mg HCTZ will not work in chronic renal disease and may have a substandard effect in others.
- Adding a complementary agent from another class of antihypertensives may be superior to “maxing out” single agent first.
- Doubling the dose of one drug (or monotherapy) had approximately one-fifth of the equivalent incremental blood pressure lowering effect of adding another drug class before trying to max-out.
- Perform a “Diuretic Review”
- Diuretics is the mainstay of the resistant hypertension patient medication regimen & should be optimized to see full therapeutic benefit.
- Studies indicate that patients with resistant HT – Frequently have inappropriate volume expansion contributing to their treatment resistance such that a diuretic is essential to maximize BP control. In most patients, use of a long acting thiazide diuretic will be most effective.
- Chlorthalidone may give more “bang for the buck” than HCTZ
- Chlorthalidone is more patent than HCTZ (50mg HTCZ = 25 – 37 mg CHTD).
- It has longer duration of action (16 – 24 hrs Vs 48-72 hrs)
- Gives better lowering of BP
- 1 month of chlorthalidone use translates into 1 day of additional life.
- 23 year follow up of Cohort – Chlorthalidone can be a “gift that keeps on giving”.
- Thiazide Diuretic may lack effect at lower GFR (Stage 3 Kidney disease).
- Frusemide may a better option than thiazide for BP control.
- Because of shorter half life, Frusemide may be dosed twice.
- Is patient taking Beta-blockers?
- Betablockers are no longer acceptable first line therapies, unless there are compelling indications like CAD, CHF etc.
- One agent specifically Atenolol may increase central aortic pressure
- Switch to a optimal dose of dual acting Beta blocker (Carvedilol or Labetalol).
- additional lowering of BP due to ∞ blockade.
- better LV / Vascular coupling
- carvedilol does not increase Insulin resistance.
- Antihypertensives at night - “When you snooze you lose”
- Controlling BP in chronic renal disease “Night time is the right time”
- Use a long half life agent at night rather than in the morning
- α1-Adrenergic Receptor Blockers
- Not to be used for monotherapy: ALLHAT (class effect)
- May be used as an add-on for resistant hypertension
- May cause urinary incontinence, especially in females, due to bladder outlet relaxation
- The Use of last line agents viz. Clonidine lacks outcome data and may add adverse drug reaction & decreased adherence because of dosing frequency.
- Value of Hydralazine - Hydralazine does not have much evidence of efficacy for prevention of cardiovascular benefit when used for essential hypertension.
- MINOXIDIL Should be a last Resort
- Potent vasodilator and should be used with betablocker & diuretics.
- Difficult to use & fraught with many serious side effects (Edema, anasarca, pericardial effusion & hirsutism).
- Can be used for select patients by physicians who are comfortable with dosing & side effects
- Mineralocorticoid Receptor Antagonists
- Consistent with reports of a high prevalence of primary aldosteronism in patients with resistant HT have been studies demonstrating that;
- Mineralocorticoid receptor antagonists provide significant antihypertensive benefit when added to existing multidrug regimens
- Switch to a regimen relying on a spironolactone backbone.
- Multiple studies attested efficacy of spironolactone in patients with RHTN, especially those with OSA.
- Dose of spironolactone may be titrated upwards, needs serial K+ monitoring especially in CKD.
- Used for resistant HT with normal aldosterone levels, 12.5-50mg/daily
- Additional benefits: antiproteinuric, improves heart failure survival (RALES)
- 10% gynecomastia
- Not when creatinine > 2.5, K > 5.0
- Chlorthalidone 25mg + spironolactone 12.5-50 mg
- Excellent diuretic maximization, also vs hypokalemia
- Chlorthalidone, can
- ↓ s. K+ enough to cause cardiac arrest
- Aldosterone blockers spironolactone eplerenone can
- Protect vulnerable patients and
- Significantly reduce BP resistant to ≥ 3 drugs,
- A logical way to provide maximal anti-HT efficacy and to prevent hypokalemia might be a
- Combination of chlorthalidone and spironolactone 12.5/25.0 mg/d
- Use Appropriate Combinations:-
- Preferred Antihypertensive Combinations
- A RAAS inhibitor & a Calcium Channel Blocker
- A RAAS inhibitor & a Diuretics (especially a thiazide)
- A RAAS inhibitor & a Calcium Channel Blocker plus a Diuretic
- Acceptable Combinations
- Betablockers & Diuretics
- Calcium Channel Blockers & Diuretics
- Dual Calcium Channel Blockade (DHP & NDHP agent)
- Unacceptable Combinations
- Dual RAAS blockade
- RAAS inhibitors plus betablockade
- Betablockers plus antiadrenergic drugs
When to refer a specialist?
Indication for specialist referral in hypertensive patients are:-
- Suspected secondary hypertension
- Hypertension with target organ damage
- eGFR < 30 ml/min/1.73 cm2
- eGFR decline of 15%, within 3 months
- Proteinuria > 1 g/day
- Requiring > 4 medications for pressure control
FOR MORE INFORMATION CALL AT
Dr Vinod Sharma
National Heart Institute
49-50, Community Centre,
East Of Kailash,New Delhi - 110065
For appointments: (+91) 9818020014, 9810131739
Email : email@example.com
Website : www.drvinodsharma.in
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