Management of Resistant Hypertension with BP 180/90 mmHg
For a patient with BP 180/90 mmHg already on lisinopril 40 mg and hydrochlorothiazide 25 mg daily, the addition of spironolactone should be considered as the next step in management, as this patient has resistant hypertension. 1
Current Medication Assessment
The patient is currently on:
- Lisinopril 40 mg daily (ACE inhibitor)
- Hydrochlorothiazide 25 mg daily (thiazide diuretic)
- Atorvastatin 20 mg daily (statin)
- Clopidogrel 75 mg daily (antiplatelet)
- Diltiazem ER 240 mg daily (calcium channel blocker)
- Aspirin 81 mg daily (antiplatelet)
- Levothyroxine 112 mcg daily (thyroid replacement)
Despite being on three antihypertensive medications (lisinopril, hydrochlorothiazide, and diltiazem), the patient's blood pressure remains elevated at 180/90 mmHg, meeting the definition of resistant hypertension. 1
Diagnosis: Resistant Hypertension
Resistant hypertension is defined as blood pressure that remains above goal despite the concurrent use of three antihypertensive agents of different classes, one of which should be a diuretic. 1
This patient meets this definition as they are on:
- An ACE inhibitor (lisinopril)
- A thiazide diuretic (hydrochlorothiazide)
- A calcium channel blocker (diltiazem)
Management Algorithm
Step 1: Verify adherence and proper BP measurement
- Confirm medication adherence
- Ensure proper BP measurement technique
- Consider ambulatory or home BP monitoring to confirm diagnosis 1
Step 2: Add spironolactone
- Add spironolactone 25 mg daily as the fourth antihypertensive agent 1
- Spironolactone has shown superior efficacy in resistant hypertension compared to other fourth-line agents 1
- Monitor serum potassium and renal function after initiation 1
Step 3: If spironolactone is not tolerated or contraindicated
- Consider eplerenone as an alternative mineralocorticoid receptor antagonist 1
- Alternative options include:
- Higher dose of thiazide diuretic
- Addition of a loop diuretic if GFR is reduced
- Addition of bisoprolol (beta-blocker)
- Addition of doxazosin (alpha-blocker) 1
Step 4: If BP remains uncontrolled
- Consider adding a centrally acting agent (e.g., clonidine) 1
- Consider hydralazine as a vasodilator 1
- Consider referral to a hypertension specialist 1
Target Blood Pressure
- The recommended target BP for most adults is 120-129/70-79 mmHg 1
- For this patient with multiple cardiovascular risk factors, aim for a target of <130/80 mmHg 1
- At minimum, aim to reduce BP by at least 20/10 mmHg from current levels 1
Important Considerations
Medication Optimization
- Ensure all medications are taken at optimal doses
- Consider converting to single-pill combinations where possible to improve adherence 1
- Verify that diltiazem is at maximum tolerated dose before adding additional agents 1
Lifestyle Modifications
- Reinforce sodium restriction (<2g sodium/day) 1
- Encourage weight loss if applicable
- Recommend regular physical activity
- Limit alcohol consumption 1
Monitoring
- Schedule follow-up within 2-4 weeks after medication changes 1
- Monitor electrolytes, especially potassium and renal function, when adding spironolactone 1
- Target BP control should be achieved within 3 months 1
Potential Pitfalls and Caveats
Dual antiplatelet therapy: The patient is on both aspirin and clopidogrel, which may indicate recent cardiovascular event. Consider the timing of any recent events when adjusting BP medications. 1
Drug interactions: Monitor for potential interactions between diltiazem and other medications, as diltiazem inhibits CYP3A4 and may increase levels of atorvastatin. 1
Pseudoresistance: Consider white coat hypertension, improper BP measurement technique, or medication non-adherence as potential causes of apparent treatment resistance. 1
Secondary hypertension: Consider screening for secondary causes of hypertension if BP remains difficult to control despite optimal therapy. 1
Avoid dual RAS blockade: Do not add an ARB to the current ACE inhibitor (lisinopril) as combining two RAS blockers is not recommended. 1