Hypertension Management of the “Difficult Patient” - PowerPoint PPT Presentation

Hypertension management of the difficult patient l.jpg
1 / 57

  • Updated On :
  • Presentation posted in: General

Hypertension Management of the “Difficult Patient”. Clay A. Block, M.D. 12-6-2004. What is the “difficult patient”?. The “Difficult Patient”. Resistant Hypertension Intolerant of Multiple Medicines. Definition of Hypertension. Normal<= 120/80 Prehypertensive 120-139/80-89

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.

Download Presentation

Hypertension Management of the “Difficult Patient”

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -

Presentation Transcript

Hypertension management of the difficult patient l.jpg

HypertensionManagement of the “Difficult Patient”

Clay A. Block, M.D.


Slide2 l.jpg

What is the “difficult patient”?

The difficult patient l.jpg

The “Difficult Patient”

  • Resistant Hypertension

  • Intolerant of Multiple Medicines

Definition of hypertension l.jpg

Definition of Hypertension

  • Normal<= 120/80

  • Prehypertensive 120-139/80-89

  • Stage 1 Htn 140-159/90-99

  • Stage 2 Htn >= 160/100

Resistant hypertension l.jpg

Resistant Hypertension

  • Failure to reach goal BP in a patient adhering to full doses of an appropriate three drug regimen that includes a diuretic

What are the goals of therapy l.jpg

What are the goals of therapy?

  • <140/90 for patients without diabetes or renal disease

    • Most patients who achieve their systolic goal will also achieve their diastolic goal

  • <130/80 for patients with diabetes or renal disease

    • (JNC 7)

What is the benefit l.jpg

What is the Benefit?

  • Stroke Incidence Reduction 35-40%

  • Heart Failure Reduction > 50%

  • Myocardial Infarction Reduction 20-25%

What is the benefit8 l.jpg

What is the Benefit?

  • Number Needed to Treat to Prevent 1 Death Over 10 Years by Lowering Systolic Pressure by 12 mmHg in Stage 1 Hypertension: 11

  • In the Presence of CV Disease or Target Organ Damage the NNT falls to 9

Approach to the patient with potentially resistant htn l.jpg

Approach to the Patient With Potentially Resistant Htn

  • Review Diagnosis

  • Review Goals

  • Get on Same Page:

    • Most Patients Will Require Multiple Agents to Achieve Control

    • All Medicines Have Side Effects and Costs

    • Don’t Forget Lifestyle Modification and Nonpharmacologic Approaches

Approach to resistant hypertension l.jpg

Approach to Resistant Hypertension

  • Establish “true resistance”

    • Measure BP accurately

    • Consider “White Coat Hypertension”

    • Consider “pseudoresistance”

    • Consider secondary causes

Accurate bp measurement l.jpg

Accurate BP Measurement

  • “Persons should be seated quietly for 5 minutes with feet on the floor and the arm supported at heart level”

  • Cuff must be appropriately sized (cuff bladder must encircle 80% of the arm)

  • Check both arms and a leg (or palpate pulses carefully)

  • Caffeine and Tobacco can transiently raise BP substantially

Approach to resistant hypertension13 l.jpg

Approach to Resistant Hypertension

  • Establish “true resistance”

    • Measure BP accurately

    • Consider “White Coat Hypertension” (WCH)

    • Consider “pseudoresistance”

    • Consider secondary causes

White coat hypertension needs attention l.jpg

'White-coat hypertension' needs attention

  • Q.My doctor wants to start both me and my husband on blood-pressure pills, and his blood pressure is only 145/95. And my blood pressure is fine at home and only high in my doctor's office — isn't this just "white-coat hypertension"? We don't have headaches, tiredness, dizziness or anything

    • 2002 Honolulu Newspaper Column

White coat hypertension l.jpg

White Coat Hypertension

  • 20-30% of Apparently Resistant Hypertension May be due to “White-Coat Hypertension”

  • Patients with WCH have an increased risk of CV events and often have some degree of end organ damage

  • Use home or ambulatory monitoring to sort out

Home and ambulatory bp monitoring abpm l.jpg

Home and Ambulatory BP Monitoring (ABPM)

  • Often lower than office readings

  • Useful to “calibrate” home monitors

  • Nocturnal Dip (10-20% fall during the night) is physiologically important (Dippers vs. Non-Dippers)

  • Can identify “windows of poor control” or windows of low BP and correlate with perceived symptoms

Dippers vs non dippers l.jpg

Dippers vs. Non-Dippers

  • More LVH

  • More silent cerebrovascular disease

  • More albuminuria

  • More progression of CKD

  • More CV mortality

Additional information from ambulatory monitoring l.jpg

Additional Information From Ambulatory Monitoring

  • Heart rate: For each 10% less reduction in heart rate, cardiovascular mortality increases by 30% (J Htn 16, 1335-1343, 1998)

  • Increase in average 24 hour pulse pressure of >= 53 mmHg confers high risk

Why and when abpm l.jpg

Why and When ABPM

  • Suspected WCH

  • Excessive Variability

  • Apparent Drug Resistance

  • Symptoms Suggesting Hypotensive Episodes

Slide20 l.jpg

Explanation of ABPM plots

Slide21 l.jpg

An Example of “White Coat Hypertension”

Approach to resistant hypertension22 l.jpg

Approach to Resistant Hypertension

  • Establish “true resistance”

    • Measure BP accurately

    • Consider “White Coat Hypertension”

    • Consider “pseudoresistance”

    • Consider secondary causes

Pseudoresistance l.jpg


  • Pseudohypertension

  • Non-adherence may account for up to 50% of resistant cases

  • Inadequate Regimen

    • Especially inadequate diuretic component

  • Interfering medicines and substances also need to be considered

    • NSAIDs

    • Excessive Alcohol, Caffeine, or Tobacco

    • Excessive Salt Intake

    • Drugs of Abuse

    • Oral contraceptives

Critical importance of adequate diuretic therapy l.jpg

Critical Importance of Adequate Diuretic Therapy

  • 23/32 patients referred for management of “resistant hypertension” had evidence of expanded extracellular volume by nuclear study

    • None had clinical evidence of expanded extracellular volume

    • All were already on diuretic therapy

      • Am J Med Sci 1989; 298: 361-365

Critical importance of adequate diuretic therapy25 l.jpg

Critical Importance of Adequate Diuretic Therapy

  • Control improved in patients treated with potent thiazide diuretics (indapamide, metolazone, or larger doses of hctz, etc.) or given multiple daily doses of loop diuretics

  • Patients with co-existent renal disease may require more intensive diuretic therapy

Pseudohypertension l.jpg


  • Calcification of the arteries resulting in failure of the BP cuff to compress and occlude flow

  • Suspect if:

    • severe hypertension by cuff but no end organ injury

    • Antihypertensive rx results in sx of Hypoperfusion/hypotension without measurable hypotension

    • Pipe stem calcification on x-ray

Pseudohypertension29 l.jpg


  • Osler’s Maneuver (the radial artery remains palpable due to calcification and thickening despite inflation of cuff above systolic pressure)

    • Poorly reproducible

  • “Dynamap”-like devices may be more accurate in this setting

  • Direct Intra-arterial measurement is the only definitive way to establish the diagnosis, but this is uncommonly done

The importance of adherence l.jpg

The Importance of Adherence

  • Only 1/2 to 2/3 of patients take at least 75% of prescribed antihypertensive medicines

    • Of those taking < 75%, only 37% achieved BP goal

    • Of those taking >= 75%, 81% achieved goal

      • Arch Int Med 1987; 147:1393-1396

The importance of adherence31 l.jpg

The Importance of Adherence

  • In a more recent BMJ study, the same rate of adherence was found in both responsive and resistant patients (82%)

    • BMJ 2001; 323:142

Techniques to improve adherence l.jpg

Techniques to Improve Adherence

  • Education of the patient

    • Increases awareness but less effect on behavior

  • Minimize the number of pills

    • Combination pills (acei/diuretic, arb/diuretic, arb/ca-blocker, etc.)

  • Increase the frequency of visits

    • Use of care managers

Approach to resistant hypertension33 l.jpg

Approach to Resistant Hypertension

  • Establish “true resistance”

    • Measure BP accurately

    • Consider “White Coat Hypertension”

    • Consider “pseudoresistance”

    • Consider secondary causes

Important secondary causes of hypertension l.jpg

Important Secondary Causes of Hypertension

  • Obstructive Sleep Apnea

  • Obesity (Metabolic Syndrome)

  • Endocrinopathies

    • Hyperaldosteronism, thyroid problems, pheochromocytoma

  • Kidney Disease

    • Renal Insufficiency and Renal Artery Stenosis

Slide35 l.jpg

All Htn


JAMA 2000



Card 1999

Drug Resistant Htn


J Htn 2001

Stroke or TIA


Sleep, 1999



Circ 1999

Sleep apnea and hypertension l.jpg

Sleep Apnea and Hypertension

  • Clear dose response between severity of OSA and the incidence of hypertension

    • May relate to the “Non-dipping”

  • Clear improvement in hypertension of approximately 10mmHg with effective CPAP therapy (and no effect with ineffective CPAP)

Obesity and the metabolic syndrome l.jpg

Obesity and the Metabolic Syndrome

  • According to the Framingham Heart Study, 65-78% of the risk for hypertension can be related to obesity

  • Obesity is linked to:

    • OSA

    • Insulin resistance

    • Resistance to antihypertensive effect of medicines

    • Activation of the RAAS and the SNS

Slide38 l.jpg

Table 1. Forms of primary aldosteronism

Slide39 l.jpg

Table 2. Prevalence of unrecognized primary aldosteronism in patients with hypertension

Renal artery stenosis l.jpg

Renal Artery Stenosis

Slide44 l.jpg

Associations of Clinical Characteristics with Renal Artery Stenosis

Krijnen, P. et. al. Ann Intern Med 1998;129:705-711

Diagnosis of renal artery stenosis l.jpg

Diagnosis of Renal Artery Stenosis

  • Clinical Features

    • Severe hypertension, resistance, flash pulmonary edema, cad/cvd/pvod, abdominal bruits, hypokalemia, high renin level, marked clinical response to angiotensin blockade, ARF

  • Imaging Options

    • Duplex ultrasound, MRA, CT angiography

Slide46 l.jpg

Diagnostic Tests for Renal Artery Stenosis in Patients Suspected of Having Renovascular Hypertension: A Meta-Analysis G. Boudewijn C. Vasbinder, MD; Patricia J. Nelemans, MD, PhD; Alfons G.H. Kessels, MD, MSc; Abraham A. Kroon, MD, PhD; Peter W. de Leeuw, MD, PhD; and Jos M.A. van Engelshoven, MD, PhD 18 September 2001 | Volume 135 Issue 6 | Pages 401-411

  • Our meta-analysis indicates that CTA and gadolinium-enhanced MRA are superior to the other studied diagnostic tests for the detection of renalarterystenosis. Careful selection based on clinical evaluation, which can increase the pretest probability to 20% to 40%, is a prerequisite for cost-effective use of these tests in the work-up strategy for patients with possible renovascular hypertension Because only a limited number of published studies on CTA and gadolinium-enhanced MRA could be included in our meta-analysis, further research is recommended.

What is the definition of ras l.jpg

What is the definition of RAS?

Stenosis is considered >=50% luminal narrowing

Clinically relevant (also called “critical”) stenosis is not well defined (50-70% by some pharmacologic studies vs. 80% by renal vein renin

Response to intervention does not correlate well with pre or post treatment degree of stenosis

What is the natural history of ras l.jpg

What is the natural history of RAS?

  • RAS is part of a systemic disease that effects the entire vascular tree and both kidneys

  • Patients are at greater risk for CV events than of ESRD

  • Angiographic progression occurs in 49% and occlusion occurs 14%

  • Renal atrophy over two years was 11.7% vs. 20.8% for stenoses <60% and >=60% respectively

Goals of management of ras l.jpg

Goals of Management of RAS

  • Prevention of clinical events such as stroke, MI, chf, or renal failure

  • Surrogate markers or goals are:

    • Improvement or normalization of BP

    • Restoration of renal artery patency

Slide50 l.jpg

November 2003 • Volume 42 • Number 5

Controversies in nephrologyStable patients with atherosclerotic renal artery stenosis should be treated first with medical management

Medical therapy vs revascularization l.jpg

Medical Therapy vs. Revascularization

  • Medical therapies such as antihypertensives, antiplatelet agents and lipid lowering agents will not restore patency, may or may not improve BP, but have proven efficacy in the reduction of CV events and death

  • Renal artery revascularization can restore patency, has at best a modest effect on BP , and has no clearly documented effect in the prevention of renal failure or CV events

The role for inhibition of the raas l.jpg

The Role for Inhibition of the RAAS

  • 108 patients at high risk for severe RAS were treated with ACEI with diuretics

    • 44 with bilateral stenosis

    • 29 with a solitary functioning kidney

    • 20 with unilateral stenosis

  • 57 developed >=20% rise in creatinine between 4 days and 4 weeks (about half early)

    • All recovered to baseline after stopping the ACEI

      • KI 1998; 53:986-993

Predictors of poor response to revascularization l.jpg

Predictors of Poor Response to Revascularization

  • Elevated Resistive Indices that are indicative of glomerulosclerosis and interstitial fibrosis

  • Advancing Age

  • Small kidney size

Complications of renal artery revascularization l.jpg

Complications of renal artery revascularization

  • Serious complications excluding hematomas occurred in 11% of renal artery stent procedures

  • 9.5% incidence of clinical atheroembolic events

  • ~5% incidence of ARF

  • 5 fatalities in a meta-analysis of 644 patients

Role for revascularization l.jpg

Role for Revascularization

  • Resistant hypertension

  • Patients intolerant of ACEI or ARB with severe hypertension (more than 20% increase in serum creatinine)

  • Patients with rapidly declining renal function (1/3 may benefit)

  • Recurrent or intractable pulmonary edema

Summary l.jpg


  • Establish Dx, risks and benefits

  • Eliminate interference and optimize lifestyle, adherence and regimen

  • Consider secondary causes

  • See frequently and modify regimen

References l.jpg

The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

European Society of Hypertension Newsletter 2003; 4, No. 15

Minireview: Primary Aldosteronism-Changing Concepts in Diagnosis and Treatment. Endo 144(6):2208-2213

Obesity, Sleep Apnea, and Hypertension. Hypertension Dec 2003:1067-1074

Clinical Usefulness of Ambulatory Blood Pressure Monitoring. J Am Soc Neph 15: S30-S33, 2004

Mayo Clinic Proceedings March 2000. 278-284


  • Login