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Chapter 43: Resistant Hypertension

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.

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

A. Resistant hypertension

B. Refractory hypertension

C. Secondary hypertension

D. Essential hypertension

E. Normotension

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.

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

A. Noncompliance

B. Isolated office hypertension

C. Excessive sodium intake

D. Sleep apnea

E. Acetaminophen

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.

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

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.

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

A. Add bisoprolol 5 mg/day

B. Add spironolactone 25 mg/day

C. Perform an ambulatory BP monitoring

D. Reevaluate secondary forms of hypertension

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

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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