Treatment resistant hypertension

It is estimated that in the United States, approximately 10% of persons with hypertension, have treatment resistant hypertension (10-12 million) defined as elevated blood pressure, despite concurrent use of at least three antihypertensive, drugs of different classes, including a diuretic.

Defined as the inability to control office blood pressure despite optimal therapy with at least 3 antihypertensive drugs at full dosages.

TRH may be attributable to volume overload, obstructive, sleep, apnea, and renovascular disease.

TRH may occur with hormonal dysregulation related hyperparathyroidism, thyroid disease, pheochromocytoma, paraganglioma, reninoma, undiagnosed, primary aldosteronism, and hypercortisolism.

Using 2017 blood pressure guidelines cancel accounts for nearly one in six US adults.

Patients with treatment related resistant hypertension are often prescribed at least four anti-hypertensive agents with the goal of systolic blood pressures of less than 130 mmHg and diastolic blood pressures of 80 mmHg or less.

Treatment resistant hypertension is associated with high cardiovascular risk and renal adverse events.

Current guidelines, recommend the addition of spironolactone, a mineralocorticoid receptor antagonist as a fourth line agent.

It is  suggested that treatment resistant hypertension is associated with autonomous aldosterone production.

Many patients with TRH have salt sensitive hypertension, in which increase sodium intake results in increase blood pressure through sodium and water retention.

This process occurs due to the activation of the sympathetic nervous system impairing the suppression of the renin-angiotensin-aldosterone system with consequent increase in aldosterone levels.

Increased aldosterone increases sodium reabsorption and passive water absorption across the distal tubule of the nephron contributing to hypertension.

Spironolactone is effective in treating treatment resistant hypertension.

Surgical sympathectomy was an effective treatment for some patients, but profound orthostatic hypotension has made the procedure obsolete.

Patients with treatment resistant hypertension should be evaluated for poor adherence to lifestyle in antihypertensive medications, and for the use of drugs that interfere with antihypertensive drug effectiveness, such as nonsteroidal anti-inflammatory agents, oral contraceptives, hormone therapy, or glucocorticoids.

Patients with resistant hypertension should be screened for secondary hypertension and assess target organ damage.



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