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How to Manage a Patient Whose Blood Pressure is Uncontrolled Despite Triple Drug Therapy?. Dr. Satyavan Sharma, MD, DM, FACC, FAMS, FESC, FSCAI Consultant Cardiologist, Bombay Hospital & Medical Research Center Mumbai, INDIA.
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Dr. Satyavan Sharma, MD, DM, FACC, FAMS, FESC, FSCAI
Bombay Hospital & Medical Research Center
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Phone: 91-22-22054532, 91-9820122010
1. Title, 2. Index, 3. Key words, 4. Definition, 5. What is target BP (JNC-7), 6. Prevalence of uncontrolled HT, 7. Causes for uncontrolled HT, 8. Causes : Check list 1, 9. 24 hrs ambulatory BP monitoring, 10. Causes Check List 2, 11. What to do?,12. Searching for secondary HT : Check List 3, 13. HT : Physical Examination, 14. Fundus Examination showing, 15. Investigations in a patient with uncontrolled HT, 16. Evaluation (imaging techniques ) for secondary hypertension, 17. Investigations for renal artery stenosis, 18. Causes of RAS, 19. CT angiography in patient with secondary HT, 20. Aortoarteritis causing hypertension refractory to drugs, 21. Coarctation of aorta diagnosed on angiography, 22. Pheochromocytoma diagnosed on MIBG scan, 23. Clues to renal parenchymal HT, 24. What drugs to avoid ?, 25. How to treat uncontrolled HT?, 26. Fibro muscular dysplasia treated by renal angioplasty, 27. Stenting for atherosclerotic RAS, 28. Genuine drug refractoriness, 29. Summary, 30. References.
Classification of HT (JNC – 7)+
Prevalence difficult to estimate
General population: Low
Specialized HT clinics: High
*Clinical trials +: 30-50%
*(ALLHAT, CONVINCE, LIFE, INSIGHT: BP not reduced to
target levels of >140/90 in 30-50%)
+ Reference 3
24 h Ambulatory BP Monitoring to Exclude White Coat Hypertension
+ Reference 4, 5, 6
K+, diabetes status
+Reference 2, 6
Renogram / scintigraphy
CT angio, MRA, DSA
Renal vein renin ratioInvestigations for Renal Artery Stenosis (RAS)+
Abbreviations: PRA=plasma renin activity, CT= computed tomography, MRA= magnetic resonance imaging, DSA= digital subtraction angiography
+ Reference 4, 6
Bilateral Atherosclerotic RAS with Functioning Lt. Kidney
MRA (left), digital subtraction (middle), showing aortic narrowing and CT angio (right), showing renal artery stenosis in different patients
Consult hypertension specialist
Treat correctable cause, if any (renal angioplasty,
Stenting+, surgery for phaeochromocytoma)
Aggressive drug therapy:
- Optimize existing drugs
- Add frusemide, aldosterone antagonist
- Hydralazine or minoxidil with betablocker
and a diuretic
- Clonidine (oral or transdermal)
- Combine ACE-I and ARB
- Renin inhibitors (aliskiren)
Intensify lifestyle modifications