Tips for Treating Difficult Resistant Hypertension Cases

In an upcoming presentation, Michael J. Bloch, MD, an associate professor in the department of internal medicine at the University of Nevada School of Medicine, plans to offer primary care physicians an outline for treating difficult cases of resistant hypertension.

In “Resistant Hypertension: How to Manage Challenging Cases in Primary Care,” Bloch plans to discuss the condition’s definition and its prevalence relative to other groups of patients with poorly controlled hypertension, as well as the development of a treatment strategy—both pharmacological and non-pharmacological—for patients with resistant hypertension.

Bloch will detail a diagnostic and treatment algorithm for resistant hypertension, in a series of 7 steps including confirming treatment resistance; identifying and reversing contributing lifestyle factors; discontinuing or minimizing interfering substances; screening for a secondary cause of resistant hypertension; intensifying pharmacological treatment; and referring the patient to a clinical hypertension specialist.

In terms of when to assess for secondary cause, Bloch advises evaluating when a patient presents with severe or sudden hypertension, or is very old or very young or resistant. Common etiologies of secondary hypertension, he says, include sleep apnea, intrinsic renal disease, thyroid disease, coarctation of the aorta, Cushing’s syndrome, primary aldosteronism, Pheochromocytoma, and renal artery disease.

He also intends to touch on the importance of excluding “pseudo resistance” when evaluating for resistant hypertension, which he says should be suspected when a patient displays marked hypertension without target organ damage, and/or blood pressure therapy produces symptoms consistent with hypotension without much decrease in blood pressure.

“Resistant hypertension has a very specific definition, and a specific treatment algorithm,” says Bloch.

“Despite the fact that it is quite common, most primary care providers are not fully comfortable treating resistant hypertension,” he continues. “However, if they approach barriers to control in systematic fashion, the evidence demonstrates that the majority of these patients’ blood pressure can be controlled.”

—Mark McGraw