What are the next steps for a patient with uncontrolled hypertension despite being on esmolol (beta-blocker) and Cardene (nicardipine, calcium channel blocker)?

From the Guidelines

For a patient with uncontrolled hypertension despite being on esmolol and Cardene, the next step should be to reinforce lifestyle measures, especially sodium restriction, and consider adding low-dose spironolactone to existing treatment, as recommended by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. The patient's current regimen of esmolol (a beta-blocker) and Cardene (nicardipine, a calcium channel blocker) suggests that they are already on two different classes of antihypertensive medications, but their blood pressure remains uncontrolled. According to the 2024 ESC guidelines, the addition of spironolactone, a mineralocorticoid receptor antagonist, is a recommended next step for patients with resistant hypertension 1. This approach is based on the principle of using complementary mechanisms to block different pathways of blood pressure regulation, as resistant hypertension often requires multiple agents targeting different physiological systems to achieve adequate control. Some key points to consider when adding spironolactone include:

• Starting with a low dose to minimize the risk of hyperkalemia and other side effects
• Monitoring renal function and electrolytes regularly
• Adjusting the dose based on the patient's response and tolerance
• Considering alternative options, such as eplerenone, if spironolactone is not effective or tolerated 1. Additionally, the patient should be evaluated for secondary causes of hypertension, such as renal artery stenosis, primary aldosteronism, or pheochromocytoma, which might explain their resistance to treatment. Lifestyle modifications should also be reinforced, including regular physical activity, weight loss if overweight, limiting alcohol consumption, and ensuring medication adherence. If the patient's blood pressure remains uncontrolled despite these measures, further treatment options, such as catheter-based renal denervation, may be considered in a multidisciplinary setting 1.

From the Research

Uncontrolled Hypertension Despite Esmolol and Cardene

• The patient's blood pressure is still not controllable despite being on esmolol (beta-blocker) and Cardene (nicardipine, calcium channel blocker) 2, 3.
• Esmolol is an ultra-short-acting intravenous cardioselective beta-antagonist with a short elimination half-life, allowing for rapid titration and reversibility of effect 2, 4.
• Nicardipine is a calcium channel blocker that can cause vasodilation and reduce blood pressure 5.

Possible Reasons for Uncontrolled Hypertension

• The dose of esmolol or nicardipine may not be sufficient to control the patient's blood pressure 2, 6.
• The patient may have an underlying condition that is causing the hypertension, such as pain, anxiety, or hypoxemia, which needs to be addressed 5.
• The patient may be experiencing a rebound effect from the esmolol or nicardipine, which can cause an increase in blood pressure 3.

Next Steps

• Consider increasing the dose of esmolol or nicardipine, or adding another antihypertensive agent, such as labetalol or nitroglycerin, to the treatment regimen 6, 5.
• Monitor the patient's blood pressure and heart rate closely, and adjust the treatment regimen as needed 2, 3.
• Investigate and address any underlying conditions that may be contributing to the patient's hypertension, such as pain or anxiety 5.