In a “Clinical-Pathological Conference” feature in a recent issue of Hypertension, the authors discuss a patient on 5 antihypertensive agents and still above target blood pressure (195/110 mm Hg).1 The patient is described as having resistant hypertension—ie, she is adherent to a 3-drug regimen including a diuretic and her blood pressure remains above target. Clinical aspects of this particular variety of hypertension are debated. The authors navigate some choppy, but important waters, and it is worth revisiting selected points of their discussion.
#1. Their first statement is critical, “I think without having checked adherence of your patient, you cannot talk about resistant hypertension. It is as simple as that.”1
The question of medication adherence is crucial. Twenty-five percent of patients referred to resistant hypertension clinics are not taking their medications as prescribed.1 Patients who are not taking their medicines appropriately should not be labeled as resistant. A diuretic has to be part of the regimen and 12.5 mg of hydrochlorothiazide does not qualify. The authors were committed enough to the role adherence plays in such a scenario that they did not label this patient as “resistant” until her blood pressure remained elevated on directly observed therapy.
#2. Regarding the workup for secondary causes of hypertension when medication resistance is diagnosed, the practice of screening renin and aldosterone levels and calculating the ratio of aldosterone/renin is not without controversy. The authors recount the uncontroversial steps in their work-up to eliminate secondary causes and report normal electrolytes and renal function, normal catecholamines (serum and urine), normal imaging of the adrenal glands and renal arteries. No discernable secondary cause found. Then came the controversial renin and aldosterone screens. What was the problem?
The patient’s antihypertensive regimen was: enalapril 40 mg/day, bisoprolol 10 mg daily, lercanidipine 10 mg (a dihydropyridine calcium channel blocker), losartan 50 mg daily, (this author strongly disagrees with dual blockade of the renin-angiotensin system), and indapamide 2.5 mg/day. Her renin value was maximally suppressed (0.17nmol/L/hour) and the aldosterone was low.
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1. George MJ, Marks DJB, Rezk T, et al. Resistant hypertension: trials and tribulations. Hypertension. 2018;71:772-780.
2. Wolley MJ, Stowasser M. New advances in the diagnostic workup of primary aldosteronism. J Endocrine Soc. 2017;1:149-161.
3. Stowasser M., Ahmed AH. Pimenta PJ, et al. Factors affecting the aldosterone/renin ratio. Hormone Metab Res. 2012;44:170-176