Resistant hypertension? A hypertensive emergency? Select your strategy and then find out if the evidence supports it.
You are seeing a 66-year-old woman with hypertension that has been hard to control. The patient has non-proteinuric CKD-3 (GFR, 40 cc/min by MDRD calculation) and is on a 3 drug-regimen for blood pressure control: amlodipine 10 mg/day; valsartan 320 mg/day; hydrochlorthiazide 12.5 mg/day.
Comparing home monitoring blood pressure readings with office values demonstrates that she is consistently above her target blood pressure. You should:
A. Increase the amlodipine to 20 mg/day
B. Consider an alternative diuretic regimen before classifying her as resistant (chlorthalidone 12.5 to 25 mg/day, indapamide 5 mg/day, or triamterene-hydrochlorothiazide).
C. Add furosemide once a day.
D. Consider the patient resistant and initiate spironolactone at 25 mg/day.
Answer: B. Consider an alternative diuretic regimen before classifying her as resistant.
Hydrochlorothiazide at 12.5 mg/day is not a potent antihypertensive. In fact, some specialists explicitly say at this dose the drug does not lower blood pressure and adds nothing to the regimen.1 Consider diuretic alternatives.2 Another important point is that with CKD 3 or worse, diuretic potency declines. As a result, chlorthalidone or furosemide (dosed twice daily) have to be considered as important alternatives.2
You see a 56-year-old man who was previously diagnosed with hypertension and treated with an angiotensin converting enzyme inhibitor, chlorthalidone, and amlodipine. His blood pressure readings have been below target, but today his blood pressure is 190/112 mm Hg. He admits that he stopped his medications. He denies chest pain, shortness of breath, neurologic changes, and visual disturbances.
His examination does not reveal funduscopic changes or neurologic findings, and his heart examination and ECG are normal. You order lab studies for electrolyte levels and renal function; they return later and are normal. You should:
A. Send him to the emergency department (ED) immediately.
B. Start treating him in the office and do not let him leave until blood pressure is less than 160 100 mm/Hg.
C. Have him restart his medications and recheck his blood pressure in the next 24 to 72 hours.
D. Admit him to the hospital.
Answer: C. Have him restart his medications and recheck his blood pressure in the next 24 to 72 hours.
This patient has severe hypertension (>180/110 mm Hg). Patients with severe hypertension are divided into 2 categories: those with target organ injury (heart, brain, kidney, and fundus), who are classified as a hypertensive emergency and should be admitted to the hospital to have their blood pressure reduced immediately; and those without target organ injury, who are classified as a hypertensive urgency and are often sent to the ED or admitted. But, can the latter group be managed as outpatients?
A retrospective cohort study which included patients with blood pressure >180 110 mm Hg identified 58 583 ambulatory physician visits in which there was a hypertensive urgency.3 A comparison was made between those who received hospital care (ED and/or admission) and those undergoing continued ambulatory management for hypertension, with an endpoint of major adverse cardiovascular events (MACE) such as acute coronary syndrome, stroke, TIA. There were no differences in occrence of MACE between hospital-managed urgencies versus those sent home with the hypertensive urgency. Uncontrolled hypertension on follow up, at 7 days and at 30 days, was more common in the outpatient group, but control was equal in both groups at 6 months.3
The rate of MACE in hypertensive urgency patients is low. Outcomes are no better in patients referred to the hospital ED and/or admitted as compared to those followed closely as outpatients.
1. Pareek AK, Messerli FH, Chandurkar NB, et al. Efficacy of low dose chlorthalidone and hydrochlorothiazide as assessed by 24-h ambulatory blood pressure monitoring. JACC. 2016; 67:379-389.
2. Roush GC, Ernst ME, Kostis JB, Kaur R, Sica DA. Not just chlorthalidone: evidence-based, single tablet diuretic alternatives to hydrochlorothiazide for hypertension. Curr Hypertens Rep. 2015; 17:540. doi: 10.1007/s11906-015-0540-6.
3. Patel KK, Young L, Howell EH, Hu B, Rutecki G, Rothberg M. Characteristics and outcomes of patients presenting with hypertensive urgency in the office setting: a retrospective cohort study. JAMA Internal Medicine [In press]