Resistant or Difficult-to-Control Hypertension

Abstract

clinical practice T h e ne w e ngl a nd jou r na l o f m e dic i ne n engl j med 355;4 www.nejm.A 70-year-old woman with a long-standing history of hypertension comes for follow-up. Her medications include atenolol (100 mg daily), hydrochlorothiazide (12.5 mg daily), lisinopril (40 mg daily), and ibuprofen (400 mg twice daily for osteoarthritis). She does not smoke or drink alcohol. Her body-mass index (the weight in kilograms divided by the square of the height in meters) is 32. Her systolic and diastolic blood pressures (measured three times while she was seated) range from 164 to 170 mm Hg and 92 to 96 mm Hg, respectively, and the pulse rate is 72 per minute. Examination of her ocular fundi reveals arteriolar narrowing. The results of cardiovascular examination are normal. There are no abdominal bruits. The serum potassium level is 3. 8 meq per liter, and the serum creatinine level is 1.2 mg per deciliter (106 μmol per liter); there is no microalbuminuria. How should this patient be further evaluated and treated?This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the authors' clinical recommendations.

Treatment of hypertension: mono-therapy versus [Zofenopril and Hydrochlorothiazide] combined therapy: A review

“…In high-risk hypertensive patients, adequate blood pressure (BP) control is difficult to achieve with a single antihypertensive drug [22,23,35]. This is the reason way various studies have tested the combination of ACE inhibitors with other antihypertensive drugs.…”

Resistant hypertension: Definition, evaluation, and new therapeutic approaches to treatment

“…Sympathomimetic agents (nasal decongestants, anorectic pills, cocaine, amphetamine-like stimulants), oral contraceptives, glucocorticoids, anabolic steroids, erythropoietin, and cyclosporine are also commonly used agents that can interfere with BP control. Black licorice, included in some oral tobacco products, and herbal supplements (e.g., ma huang and ginseng), also raise BP [11,20,22]. The effect of these agents varies; most people manifest little or no effect, but certain persons may experience severe BP elevations.…”

“…Reasonable algorithms to identify people with pseudo-resistant hypertension have been proposed [11,20]. In general, these approaches adopt a 2-step approach: first, confirmation of true resistance (by simultaneous recognition and correction of factors related to pseudoresistance); and second, identification of the factors that contribute to treatment resistance in a given patient ( Table 2).…”

“…Older patients with memory deficits or psychiatric illness can benefit from using pill boxes. Clinical inertia can be described as a physician's ignorance of treatment guidelines or reluctance to adhere to them due to lack of training or inexperience in antihypertensive medication, underestimation of cardiovascular risk, and overestimation of the treatment provided [20][21][22][23][24][25][26][27][28][29][30]. This results in suboptimal dosing or inappropriate combinations of agents.…”

“…Several factors contribute to elevated BP readings and produce the perception of resistant hypertension [20][21][22] (Table 1). Such factors include the following: 1. suboptimal BP measurement technique; 2. the white-coat effect; and 3. poor adherence to prescribed therapy and other causes described in the following text [11,21].…”