Management of resistant hypertension

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Management of resistant hypertension : 

Management of resistant hypertension Shruthi Kodad

Definition : 

It is defined as BP measurement that exceeds 140/90mmHg in patients without DM/renal sufficiency or 130/80mmHg in patients diagnosed with DM/renal insufficiency Despite regular use of 3 or more antihypertensive drugs of different classes that should include 1 diuretic at max tolerated dose unchanged for atleast 1 month without interruption Definition

Pseudoresistant hypertension : 

Lack of control of BP with appropriate treatment in a patient who does not resistant hypertension Causes BP measurement not done by proper guidelines White coat HTN Calcified or atherosclerotic arteries as seen in elderly Poor adherence to medications Inadequate dosing / inappropriate combinations of antihypertensives Physician’s inertia to increase dose/no. of drugs even if targets are not reached Pseudoresistant hypertension

Prevalence : 

True prevalence : not known In a cross-sectional analysis of over 260,000 patients included in large primary care network in the south eastern United States, resistant hypertension was present in 16% 12.5% were uncontrolled on 3 or more medications 3.5% were controlled on 4 or more medications Prevalence

Risk factors : 

Suboptimal therapy Lifestyle and diet  Obesity Physical inactivity Excess alcohol intake High salt diet Risk factors

Contribution of dietary salt to resistant hypertension : 

Randomized trial : 12 patients with resistant hypertension were assigned to low (50 meq/day) or high (250 meq/day) sodium diet for 1 week After a two-week washout, the patients received the other diet Switching from the high to low salt diet was associated with Average reduction in office BP of 23/9 mmHg Reduction in the 24-hour ambulatory blood pressure of 20/10 mmHg Contribution of dietary salt to resistant hypertension Pimenta et al ;Hypertension unit, Australia

Risk factors (contd..) : 

Medications NSAIDS Glucocorticoids Herbal preparations Estrogen-containing contraceptives Calcineurin inhibitors Antidepressants Risk factors (contd..)

Slide 8: 

Extracellular volume expansion  Renal insufficiency Sodium retention due to therapy with vasodilators Ingestion of a high salt diet Secondary causes Primary aldosteronism Renal artery stenosis Chronic kidney disease Obstructive sleep apnea

Guidelines for the measurement of BP to diagnose & treat hypertension : 

Guidelines for the measurement of BP to diagnose & treat hypertension

Slide 13: 

Detailed medical history,drug history , examination Labs Serum electrolytes, glucose,creatinine and urinalysis Screening for primary hypoaldosteronism Pheochromocytoma Noninvasive imaging for renal artery stenosis

Treatment : 

Identify and reverse the cause of pseudo/true resistant HTN Salt intake <2.4g/day Avoid NSAIDs Exercise Treat aggressively with combinations of antihypertensive drugs Treatment

Slide 15: 

Thank you