From the Guidelines
The next step for this patient with resistant hypertension should be to reinforce lifestyle measures, especially sodium restriction, and consider the addition of further diuretic therapy or alternative agents as the current treatment regimen is not effective in controlling blood pressure. The patient is already on a combination of antihypertensive medications including losartan, doxazosin, amlodipine, metoprolol ER, and spironolactone-HCTZ, yet the blood pressure remains elevated at 200/100 mmHg. According to the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, the recommended treatment of resistant hypertension includes reinforcement of lifestyle measures and addition of low-dose spironolactone to existing treatment, or further diuretic therapy if intolerant to spironolactone. Some key considerations in managing this patient's resistant hypertension include:
- Evaluating medication adherence, as non-compliance is a common cause of apparent treatment resistance
- Considering secondary causes of hypertension, such as obstructive sleep apnea, primary aldosteronism, renal artery stenosis, or pheochromocytoma
- Implementing home blood pressure monitoring to assess for white coat hypertension and track response to therapy
- Reinforcing lifestyle modifications, including sodium restriction to less than 2g daily, regular physical activity, weight loss if overweight, limiting alcohol consumption, and following the DASH diet The 2020 International Society of Hypertension global hypertension practice guidelines 1 also recommend optimizing the current treatment regimen, including health behavior change and diuretic-based treatment, and considering the addition of a low dose of spironolactone as the 4th line agent in those whose serum potassium is <4.5 mmol/L and whose eGFR is >45 ml/min/1.73m2. Given the patient's current medication regimen and lack of control, referral to a hypertension specialist may be warranted to further optimize treatment and consider alternative therapies such as catheter-based renal denervation, as recommended by the 2024 ESC guidelines 1.
From the Research
Patient Assessment
- The patient is a 48-year-old with high blood pressure, currently on losartan 100mg, doxazin 2mg, amlodipine 10mg, metoprolol ER 25mg, and spironolactone-HCTZ 25-25.
- The patient's blood pressure is high, at 200/100 mmHg.
Diagnosis and Treatment
- According to 2, poorly controlled hypertension is a common finding in the outpatient setting, and severely elevated blood pressure requires differentiation between hypertensive emergency and severe asymptomatic hypertension.
- The patient's blood pressure reading of 200/100 mmHg indicates severe asymptomatic hypertension, as there are no signs or symptoms of end-organ damage mentioned.
- As stated in 3, hypertensive urgency is defined as an acute elevation in blood pressure without evidence of end-organ damage, and blood pressure control can be achieved with oral medications within 24-48 hours.
Treatment Options
- The patient is already on multiple antihypertensive medications, including losartan, amlodipine, metoprolol, and spironolactone-HCTZ.
- According to 4, the target blood pressure for patients with hypertension is <140/90 mmHg, and treatment should be guided by the patient's absolute cardiovascular disease risk and evidence of end-organ damage.
- The study 5 found that amlodipine/losartan-based single-pill combination therapy was effective in achieving target blood pressure in patients with hypertension.
- Another study 6 compared the efficacy and tolerability of a fixed-dose combination of metoprolol extended release/amlodipine with losartan plus amlodipine in patients with mild-to-moderate hypertension, and found that both treatments were effective and well-tolerated.
Next Steps
- The patient's blood pressure should be closely monitored, and adjustments to their medication regimen may be necessary to achieve better blood pressure control.
- As recommended in 2, a cardiovascular risk profile should be assessed to guide treatment, and oral agents may be initiated or adjusted before discharge.
- The patient's medication adherence and potential side effects should be monitored, as stated in 5.