michigan hypertension core curriculum - State of Michigan

controlled BP to have been victimized by “therapeutic inertia”. That is, to have repeated clinic visits with
elevated BP levels noted, but with no intensification of therapy being undertaken. Also, utilization of
ineffective drug combinations – beta blockers plus RAAS blockers, beta blockers and clonidine, or ACE
inhibitors and ARBs – contributes to poor BP control.
Drug -related factors
A variety of medications and substances can raise the BP and, contribute to treatment
resistance. 10 Examples include nonsteroidal anti-inflammatory drugs (NSAIDs), Selective COX-2
inhibitors, sympathomimetic drugs, oral contraceptives, and some herbal preparations. 11 While the use
of these agents is fairly common, their effects are highly individualized and these agents account for
only less than 2 percent of cases of resistant hypertension. 9
Nonsteroidal anti-inflammatory drugs and cyclooxygenase-2 inhibitors, impair the excretion of sodium,
cause volume retention, and also inhibit the production of local renal vasodilatory prostaglandins.
The therapeutic action of angiotensin-converting–enzyme (ACE) inhibitors and loop diuretics (but
not calcium-channel blockers) depends on the availability of these prostaglandins. 12 At equally
effective doses for osteoarthritis management, the ability on NSAID and COX2 inhibitors to
destabilize hypertension control is not universally equal among all agents used 12 and. 13 The effect of
acetaminophen on BP medications seems almost inert when compared to piroxicam and Ibuprofen. 14
Sulindac is one NSAID that has not been shown to affect renal prostaglandin synthesis and raise BP.
Disease related factors (or secondary hypertension)
Secondary causes of HTN accounts of less than 5 percent of all HTN causes 15 and up to 10 percent
of cases of RH. 16 Blood pressure elevations are often more challenging to treat until the underlying
secondary cause is identified and treated. Secondary causes of HTN are addressed separately under
the Chapter of Secondary Hypertension.
1- Renal Parenchymal Disease: Only less than 15% of the patients with CKD who are followed
in nephrology clinics achieve blood pressure control (of