Differential Diagnosis for Resistant Hypertension in the Evenings
Single Most Likely Diagnosis
- Non-adherence to medication regimen: The patient may not be taking the losartan as prescribed, leading to inadequate blood pressure control in the evenings.
- Volume overload: Excessive fluid intake or decreased renal function in the evening could lead to volume overload, causing resistant hypertension.
Other Likely Diagnoses
- Sleep apnea: This condition is common in older adults and can cause nocturnal hypertension due to intermittent hypoxia and increased sympathetic activity.
- White coat effect reversal: The patient may experience a reverse white coat effect, where blood pressure is higher at home in the evenings than in the clinic.
- Losartan dosage or timing: The current dosage of 100 mg losartan daily may be insufficient, or the timing of the dose may not be optimal for controlling evening blood pressure.
Do Not Miss Diagnoses
- Pheochromocytoma: Although rare, this condition can cause resistant hypertension and would be catastrophic if missed.
- Renal artery stenosis: This condition can lead to resistant hypertension and would require prompt intervention to prevent kidney damage.
- Hyperaldosteronism: Excess aldosterone production can cause resistant hypertension and would require specific treatment.
Rare Diagnoses
- Cushing's syndrome: This rare endocrine disorder can cause resistant hypertension due to excess cortisol production.
- Hyperparathyroidism: Elevated parathyroid hormone levels can lead to resistant hypertension, although this is a rare cause.
- Coarctation of the aorta: This congenital condition can cause resistant hypertension, although it is unlikely in a 76-year-old male without a previous diagnosis.