A64-year-old man with hypertension presents for routine follow-up of his blood pressure. His home blood pressure log reveals readings in the 150/70 range. His home monitor had previously been verified by clinic BP readings. He denies any complaints. His current medications include HCTZ 25 mg daily, metoprolol 100 mg twice daily, enalapril 20 mg twice daily, and amlodipine 10 mg daily. He states he is adherent to his medication, drug, and exercise regimen as you recommended. At this time, how would you advise the patient?
- You need to take another blood pressure medication.
- I need to order some tests to look for secondary causes of high blood pressure.
- In spite of your efforts, you need to exercise more and lose more weight.
- Your blood pressure is acceptable where it is. Continue your current regimen.
- I need to refer you to a cardiologist.
Answer(s): B
Explanation:
Resistant hypertension is defined as blood pressure not at goal despite adequate doses of a three-drug regimen including a diuretic. One of the first considerations is medication compliance and white coat hypertension. White coat hypertension can be assessed by the use of ambulatory blood pressure monitoring. A patient's home monitor should be assessed for accuracy against the office monitor. The patient's technique should also be verified. One should also assess for other agents that may lead to resistant hypertension despite pharmacologic therapy (e.g., tobacco use, NSAIDs, steroids, recreational drugs, oral decongestants, herbal medications). If the above are ruled out, one should initiate a workup to assess for a secondary cause for the hypertension, which may include chronic kidney disease, coarctation of the aorta, Cushing syndrome, steroid treatment, drug-induced hypertension, pheochromocytoma, primary aldosteronism, renovascular hypertension, sleep apnea, and thyroid/ parathyroid disease.
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