michigan hypertension core curriculum - State of Michigan

Learning objectives:
226 Hypertension Core Curriculum
Resistant hypertension
Ziad Arabi, MD
1-To recognize resistant hypertension and to differentiate it from psuedoresistasnce;
2-To review the factors that might contribute to BP resistance including life style factors, suboptimal
therapy, drugs related and secondary causes of HTN; and
3- To review nonpharmacological and pharmacological treatments including the proper use of diuretics
and medications combinations.
Pretest: JJ is a 58 year old African American female with history of HTN, DM, hyperlipidemia, and
osteoarthritis. Her last BP readings in the clinic over the last 6 months were 175/94, 184/78 and
192/105 mm Hg. Her estimated glomerular filtration rate is 40 ml/min/1.73 m 2 . Medications include
atenolol 50 mg BID, lisinoprol 40 mg daily, amlodipine 5 mg daily, simvistatin 40 mg at bed time and
ibuprofen 400 mg TID PRN for knee pain. Her physical exam and labs are otherwise unremarkable.
The best first step to improve her BP control would be: A) to increase amlodipine to 10 mg daily, B)
change lisinopril to 20 mg BID, C) increase atenolol to 10 mg BID, D) - add clonidine 0.1 mg BID and
titrate up as needed, or E) - add Furosemide 20 mg BID. (Correct answer)
Definition: Resistant hypertension (RH) is defined as persistently elevated BP despite adherence to
a regimen of three optimally dosed antihypertensive agents of different classes including a diuretic or
controlled BP on 4 or more antihypertensive medications. Optimal dosing is reasonably considered
to be at least half of the FDA approved maximal dose of an antihypertensive agent given the known
relatively flat BP dose-response curve for most drugs
Blood Pressure Goals: The BP goal according to JNC 7 for most hypertensive patients is < 140/90
mm Hg. However, in individuals with CKD (DGFR < 60 ml/min/1.73 m 2 or spot albumin:crea ratio >
200) or DM, the BP goal is < 130/80 mm Hg.
Prevalence: The exact prevalence of RH is unknown yet. 1 However, it is estimated that RH is relatively
common affecting 10 to 15% of the patients with HTN 2 and. 3