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Chapter 43: Resistant Hypertension

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A 45-year-old woman is found to have mean office BP values around 154/96 mm Hg by her primary care doctor. She is receiving lisinopril 40 mg/day, amlodipine 10 mg/day, and hydrochlorothiazide 25 mg/day.

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Which ONE of the following is the most appropriate diagnosis at this time?

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A. Resistant hypertension

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B. Refractory hypertension

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C. Secondary hypertension

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D. Essential hypertension

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E. Normotension

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The answer is A. Resistant hypertension is defined as high blood pressure that remains uncontrolled (>140/90 mm Hg) despite the use of effective doses of three or more different classes of antihypertensive agents, including a diuretic. Refractory hypertension has been used to refer to an extreme phenotype of antihypertensive treatment failure, considering increased blood pressure levels (>140/90 mm Hg) despite the use of optimal doses of five or more different classes of antihypertensive agents, including chlorthalidone and a mineralocorticoid receptor antagonist.

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Which ONE of the following is not considered a cause of resistant hypertension?

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A. Noncompliance

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B. Isolated office hypertension

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C. Excessive sodium intake

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D. Sleep apnea

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E. Acetaminophen

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The answer is E. Drug-induced resistant hypertension is related with many pharmacologic classes, including nonsteroidal anti-inflammatory drugs, oral contraceptives, anticancer agents, sympathicomimetic agents, corticosteroids, cocaine, cyclosporine, erythropoietin, etc. The acetaminophen effects on BP is unclear.

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Noncompliance, isolated office hypertension, excessive sodium intake, sleep apnea are well-known causes of resistant hypertension.

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A 66-year-old woman is found to have mean office BP values around 158/92 mm Hg. Her home-BP measurements shows mean values of 136/82 mm Hg. She is receiving olmesartan 40 mg/day, amlodipine 10 mg/day, and chlorthalidone 25 mg/day.

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Which ONE of the following is the most appropriate approach at this time?

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A. Add bisoprolol 5 mg/day

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B. Add spironolactone 25 mg/day

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C. Perform an ambulatory BP monitoring

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D. Reevaluate secondary forms of hypertension

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E. Keep treatment and schedule a new visit in 6 months

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The answer is C. The white-coat effect is seen to a greater or lesser degree in most if not all hypertensive patients. Growing evidence now points to greater prognostic significance in determining risk for hypertensive end-organ damage compared with ...

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