How to manage a 62-year-old female with persistent hypertension despite high-dose lisinopril?

Management of Resistant Hypertension in 62-Year-Old Female

For a 62-year-old female with persistent hypertension (192/92 mmHg) despite high-dose lisinopril (40mg daily), add a thiazide-like diuretic such as chlorthalidone 12.5-25mg daily as the next step in management. 1

Assessment of Resistant Hypertension

This patient presents with:

• Persistent hypertension (192/92 mmHg) despite maximum dose of lisinopril (40mg daily)
• Intermittent headaches, likely related to uncontrolled blood pressure
• No diuretic in current regimen

This case meets criteria for resistant hypertension, defined as BP >140/90 mmHg despite treatment with ≥3 antihypertensive medications at optimal doses including a diuretic 1. However, this patient is only on one medication (lisinopril), suggesting an incomplete treatment regimen rather than true resistance.

Management Algorithm

Step 1: Rule out pseudoresistance

• Confirm BP measurement technique is correct
• Exclude white coat effect (consider ambulatory BP monitoring)
• Assess medication adherence
• Screen for substances that may elevate BP (NSAIDs, alcohol, stimulants)

Step 2: Optimize current regimen

• The patient is already on maximum dose of lisinopril (40mg daily)
• Add a thiazide-like diuretic as the next agent 1
  • Chlorthalidone 12.5-25mg daily (preferred) or
  • Indapamide 1.25-2.5mg daily
• Thiazide-like diuretics are more effective than thiazide diuretics and maintain efficacy down to eGFR of 30 mL/min/1.73m² 1

Step 3: If BP remains uncontrolled after 2-4 weeks

• Add a long-acting calcium channel blocker (e.g., amlodipine 5-10mg daily) 1
• This creates a three-drug regimen of:
  • ACE inhibitor (lisinopril)
  • Thiazide-like diuretic (chlorthalidone)
  • Calcium channel blocker (amlodipine)

Step 4: If BP still remains uncontrolled

• Add a mineralocorticoid receptor antagonist (spironolactone 25-50mg daily) 1
• Monitor potassium and renal function within 2-4 weeks of initiation 2
• Spironolactone is particularly effective in resistant hypertension 1

Evidence-Based Rationale

The International Society of Hypertension guidelines (2020) recommend a diuretic-based treatment regimen for resistant hypertension, with optimal choice being thiazide-like diuretics 1. The American Heart Association (2018) specifically recommends substituting a thiazide-like diuretic (chlorthalidone or indapamide) for prior diuretics in patients with resistant hypertension 1.

Studies have shown that the combination of an ACE inhibitor (like lisinopril) and a thiazide diuretic provides additive blood pressure-lowering effects 3. In fact, the FDA label for lisinopril states: "When given together with thiazide-type diuretics, the blood pressure lowering effects of the two drugs are approximately additive." 3

Important Considerations

• Monitor electrolytes and renal function within 2-4 weeks after adding a diuretic 2
• Check for orthostatic hypotension, especially when adding multiple agents
• Target BP should be <130/80 mmHg for most adults, including this 62-year-old patient 2
• Consider screening for secondary causes of hypertension if BP remains difficult to control despite a 3-4 drug regimen 1
• Potential secondary causes include renal parenchymal disease, renovascular hypertension, primary aldosteronism, and obstructive sleep apnea 1

Common Pitfalls to Avoid

1. Failing to add a diuretic to the regimen - diuretics are essential for most patients with resistant hypertension
2. Using hydrochlorothiazide instead of chlorthalidone - chlorthalidone has superior 24-hour BP control
3. Inadequate dosing of medications - ensure optimal dosing before adding new agents
4. Not allowing sufficient time between medication adjustments (2-4 weeks needed)
5. Overlooking medication adherence issues - non-adherence is common in resistant hypertension
6. Missing secondary causes of hypertension - consider screening if BP remains difficult to control

By following this evidence-based approach, the patient's blood pressure should improve significantly, reducing her risk of cardiovascular events and alleviating her headache symptoms.