RESISTANT HYPERTENSION Robert J Herman, MD FRCPC University of - - PowerPoint PPT Presentation

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RESISTANT HYPERTENSION Robert J Herman, MD FRCPC University of - - PowerPoint PPT Presentation

Jan 12, 2024 338 likes •543 views

RESISTANT HYPERTENSION Robert J Herman, MD FRCPC University of Calgary Learning Objectives Know the definition of resistant hypertension Have an approach to the work up and effective treatment of a patient with resistant hypertension

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RESISTANT HYPERTENSION

Robert J Herman, MD FRCPC University of Calgary

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Learning Objectives

Know the definition of resistant hypertension Have an approach to the work up and effective treatment of a patient with resistant hypertension Understand the benefits and limitations to new alternatives such as renal denervation

No disclosures

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Definition:

Blood pressure that remains above goal in spite of the concurrent use of 3 antihypertensive agents

  • f different classes. Ideally, 1

should be a diuretic and all agents should be prescribed at

  • ptimal doses.

AHA Scientific Statement. Hypertension 2008;51:1403-1419

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Resistant Hypertension

Inadequate medication 45-60%

Improper use of diuretics

Secondary hypertension 5-20%

Chronic Kidney Disease Renal artery stenosis Hyperaldosteronism Thyroid disease Hyperadrenalism Pheochromocytoma

Non-compliance/non-adherence 16-60% Whitecoat Hypertension 20-35% Sleep apnea 83%

Various sources, including Larochelle CHC 2011

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Resistant Hypertension

Pseudo-Resistant HTN

Error in BP Measurement

Improper cuff size Improper measurement technique

Whitecoat Hypertension Non Adherence / Non Compliance Patient factors Physician factors

True Resistant HTN

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Resistant Hypertension

Pseudo-Resistant HTN

Error in BP Measurement

Improper cuff size Improper measurement

Whitecoat Hypertension Non Adherence/Non Compliance

Patient factors Physician factors

True Resistant HTN Secondary HTN

OSA Drugs that cause BP Renal vascular or parenchymal disease Primary Aldo Other endocrine HTN

Other

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Primary Aldosteronism

Primary Aldo is common in RHTN (20%) Obesity and metabolic syndrome are very common in IHA, but not APA

  • Secretory products from human adipocytes

strongly stimulate aldosterone release in human adrenocortical NCI-H295R cells.

  • 3 hydroxysteroid dehydrogenase type 6 is
  • ver-expressed in zona glomerulosa cells of

adrenals from Cry1/Cry2 knockout mice.

  • GPR30
  • MR antagonists are effective Rx of HTN in

patients with the metabolic syndrome and substantially reduce the severity of OSA

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Nishizaka MK, et al. Am J Hypertens 2003; 16:925-30.

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Sympathetic Activation Metabolic Syndrome Salt Overload PA

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Sympathetic Activation Metabolic Syndrome Salt Overload PA OSA DM CKD

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Shibata H and Itoh H. Am J Hypertens 2012; 25:514

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C Blais IRCM

Salt country…..

Food Sodium Commercial Broth 900 mg/cup Canned Soup 550-1000 mg/cup Canned Tomato Sauce 1000 mg/cup Frozen Meals Up to 1500 mg/portion Delicatessen 500-1000 mg/2-3 cuts Pasta with seasoning 500-1000 mg/cup

Sodium recommended: 2300

mg/day or less

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Optimize The Diuretic Treatment with Chlorthalidone

Chlorthalidone PK properties:

longer t1/2, 3-fold greater potency/duration of action

Clinical trials:

HDFP, ALLHAT, SHEP with chlorthalidone; multiple trials with HCTZ in a combination product

Comparison chlorthalidone vs HCTZ:

greater 24 hour BP lowering effect at night

Ernst ME et al. Hypertension 2006;47:352-8

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Chapman N et al. Hypertension 2007; 49: 839-845

2010 Cochrane Review:

  • five crossover RCTs
  • mean BP decreases of 20/7 mmHg
  • no DRAE at Spironolactone doses below 100 mg/day
  • no data on clinical outcomes
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RHTN Rx: Lower on the List but Worthy of Consideration

Increase dose of the CEB Clonidine

Low dose, 0.1 mg bid

Beta-blockers

These are renin blockers Labetalol has added 1-blockade

Alpha blockade

Doxazosin: Caveat - withdrawn from ALLHAT

Adapted from Resistant Hypertension, presented by Zarnky Rocky Mountain/ACP Internal Medicine Meeting 2011

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Renal Denervation

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Symplicity HTN-1 (n=50) Symplicity HTN-2 (n=106) Symplicity Registry (n=153)

Generally well tolerated

No RAS, no change in renal function Severe hypotension (3), bradycardia (15), dissections, pseudo-aneurisms

Greatly exaggerate BP lowering response Most people have no reduction in meds No hard outcome data Concern over irreversible block of an important regulated pathway

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Steps in the Investigation and Treatment of RHTN

  • 1. Confirm the BP measurement
  • 2. Evaluate non-adherence
  • 3. Identify interfering medications, other agents
  • 4. Screen for secondary causes (esp OSA, PHA)
  • 5. Identify abnormal lifestyle issues
  • 6. Optimize antihypertensive therapy

Add or switch to chlorthalidone 25 mg/d Add an aldosterone antagonist (12.5-50 mg/d spironolactone)

  • 7. Follow, follow and follow up, again …
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