Curbside Consult Part I: Breaking the Bonds of Resistant Hypertension

Published Online: Wednesday, November 9, 2011

To comment on this article, scroll down.

Definition of Resistant Hypertension
Hypertension is the most common form of chronic disease, affecting over 25% of adults despite the accessibility of practice guidelines and availability of effective therapy. Failure to achieve blood pressure (BP) goals is attributed to many factors, including an aging population, higher prevalence of kidney disease and obesity, high salt intake, physician inertia resulting in hesitancy to increase dose and number of anti-hypertensive medications prescribed, and patient nonadherence to medication regimens.

Resistant hypertension is defined as a failure to achieve a BP goal of <140/90 mm Hg despite adherence to an appropriate anti-hypertensive regimen of three drugs that includes a diuretic. (This definition does not apply to patients with newly diagnosed hypertension.) The problem of resistant hypertension is projected to rise as the population ages. Patients with persistent hypertension despite multiple medications are at high risk for adverse cardiovascular events and are more likely than those with controlled hypertension to have a secondary (i.e., identifiable) cause, which is usually at least in part reversible. A concerted effort on the part of hospitals and other stakeholders in the health care industry indicates that a system can be implemented to help increase the percentage of patients who meet BP goals and reduce the prevalence of resistant hypertension.

Case Presentation
A 54-year-old black man with a 10-year history of diabetes and a 15-year history of hypertension presents to your office complaining of a headache. He has a blood pressure of 210/105 mm Hg, a heart rate of 78, and a body mass index (BMI) of 34. He had a 20-year history of smoking. Both his parents had hypertension, and his mother died of a stroke. He also has a family history of kidney disease, but none of his family members have gone on dialysis.

The patient has been prescribed a variety of anti-hypertension medications. Currently, he is supposed to be on amlodipine (10 mg per day), losartan (100 mg per day), and hydrochlorothiazide (25 mg per day). He has had problems with low potassium in the past. In fact, he is currently supposed to be taking a potassium supplement—KCl (20 meq per day). You notice his last recorded potassium level is 3.5 mmol/L. As for his kidney function, his GFR is estimated at 55 mL/min.

When asked if he is on a low-salt diet, the patient says he does not add salt to his food, but no one has ever really talked to him about the importance of limiting sodium intake. He has no allergies, though he does have some side effects from medication. He has experienced swelling from amlodipine, and he had a cough on an ACE inhibitor, though he doesn’t remember which one. He has been told that his cholesterol is elevated, but has not been put on medication to control it, nor has he been given any dietary counseling. He has been told to follow up with a primary care physician, which is what has brought him to this appointment.

George Bakris, MD, is professor of medicine and director of the hypertension center at the University of Chicago Medical Center.

To read the conclusion of this case discussion, click here.

Join the conversation: