What is the next step in controlling resistant hypertension in a 69-year-old male with a history of peripheral vascular disease, peripheral edema, and hypertension, currently on Angiotensin Receptor Blocker (ARB) and Furosemide (Lasix)?

Management of Resistant Hypertension in a 69-Year-Old Male with PVD and Peripheral Edema

Adding spironolactone (mineralocorticoid receptor antagonist) as a fourth agent is the recommended next step for controlling resistant hypertension in this patient currently on ARB and furosemide. 1, 2

Assessment of Current Situation

This 69-year-old male presents with:

• Resistant hypertension (uncontrolled BP despite ARB and furosemide)
• Peripheral vascular disease (PVD)
• Peripheral edema
• Currently on ARB and loop diuretic (Lasix/furosemide)

Recommended Treatment Algorithm

Step 1: Optimize Current Medications

• Ensure optimal dosing of current ARB and furosemide
• Consider switching to chlorthalidone if eGFR allows (provides 7-8 mmHg greater SBP reduction than hydrochlorothiazide) 2
• Ensure medication adherence and proper BP measurement technique

Step 2: Add Third-Line Agent

• Add a long-acting dihydropyridine calcium channel blocker (CCB) such as amlodipine 1, 2
  • Amlodipine is particularly beneficial as it has documented efficacy in coronary artery disease 3
  • Start with 5 mg daily and titrate as needed

Step 3: Add Fourth-Line Agent (Key Recommendation)

• Add spironolactone 12.5-25 mg daily as the fourth agent 1, 2, 4
  • Spironolactone is specifically indicated for resistant hypertension 4
  • Mineralocorticoid receptor antagonists are more successful than α- or β-blockers for resistant hypertension 1
  • Particularly beneficial for patients with peripheral edema 5

Monitoring and Follow-up

• Check serum potassium and renal function within 1-2 weeks of starting spironolactone 2
• Monitor for gynecomastia and erectile dysfunction with prolonged use of spironolactone 1
• Consider switching to eplerenone if these side effects occur 1
• Schedule follow-up within 2-4 weeks to assess BP response 2

Special Considerations for This Patient

Peripheral Vascular Disease

• Continue ARB therapy as it provides vascular protection 6
• Avoid high-dose beta-blockers which may worsen claudication symptoms 6
• Consider adding a statin if not already prescribed 6

Peripheral Edema

• Spironolactone is particularly beneficial as it addresses both resistant hypertension and edema 4, 5
• The combination of loop diuretic (furosemide) and spironolactone is effective for managing edema while controlling BP 5

Potential Pitfalls and Cautions

• Monitor potassium closely when adding spironolactone to ARB therapy due to increased risk of hyperkalemia 1, 2
• Use caution if eGFR <45 mL/min/1.73m² or baseline potassium >4.5 mEq/L 1
• Avoid combining ACE inhibitors with ARBs as this increases adverse events without additional benefit 1, 2
• Consider secondary causes of resistant hypertension, particularly primary aldosteronism, which responds well to mineralocorticoid receptor antagonists 7, 8

If BP Remains Uncontrolled

If BP remains uncontrolled after adding spironolactone:

1. Consider alpha-blockers (doxazosin) or vasodilators (hydralazine) 1, 9
2. Consider referral to a hypertension specialist for further evaluation 1, 2