michigan hypertension core curriculum - State of Michigan

4-Direct vasodilators (e.g.minoxidil) may be necessary in some cases – typically in men (causes
fine vellus hair growth and is thus usually avoided in women). The use of minoxidil will necessitate
concomitant beta-blockerade or the use of nonDHP calcium channel blockers to slow the pulse rate
down and loop diuretics such as furosemide to counterbalance the minoxidil-induced fluid retention. .
5-Dual calcium-channel blockers (a dihydropyridine, such as amlodipine, plus a nonDHP calcium
antagonist such as verapamil. 37
Summary and Recommendations
White coat HTN and therapeutic noncompliance should be considered in persons suspected of
having resistant HTN. Resistant HTN is typically multi factorial. Obesity and excessive alcohol and salt
might exacerbate HTN resistance. Suboptimal dosing, the use of too few drugs, and inadequate use of
diuretics are the most common causes of RH in primary care. Secondary causes (including exogenous
substances) must also be considered.
Post test
RR is 48 year old man with history of uncontrolled HTN and a myocardial infarction ~ 6 months
ago. His BP readings at his last three clinic visits were 179/95, 164/89 and 183/72 mm Hg while his
pulse ranged from s 87 to 96 beats/min. His weight has been stable at 207 lbs. BUN and creatinine
were 25 and 1.5, respectively. He continues to smoke but he does not exercise. His medication list
includes metoprolol 25 mg BID, HCTZ 25 mg daily, and lisinopril 10 mg daily. He states that he has
been compliant with medication for the last three months.
Which one of the following choices represents the best approach to improve his BP control: 1) intensify
life style modification, including smoking cessation and weight loss, 2) noncompliance is very likely and
no medication adjustment is needed at this time, 3) screen for pheochromocytoma, 4) increase lisinopril
to 20 mg/d, or 5) increase metoprolol to 50 mg BID and add amlodipine 5 mg/d. (Correct answer)
References
1. Hyman DJ, Pavlik VN. Characteristics of patients with uncontrolled hypertension in the United
States. N Engl J Med. Aug 16 2001;345(7):479-486.
2. Calhoun DA, Jones D, Textor S, et al. Resistant hypertension: diagnosis, evaluation, and
treatment: a scientific statement from the American Heart Association Professional Education
Committee of the Council for High Blood Pressure Research. Circulation. Jun 24 2008;117(25):
e510-526.
232 Hypertension Core Curriculum