resistant hypertension is common problem in our clinical practice, focusing of recent update and management.

1. DR SUBHASH DUKIYA
CARDIOLOGY, JIPMER
Refractory hypertension
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2.  Resistant hypertension (RHTN) is defined as high blood pressure
(BP) that requires 4 or more medications for treatment. As defined,
RHTN includes patients whose BP is controlled or uncontrolled
after use of 4 or more medications.
 patients with RHTN who never achieve BP control in spite of
maximum medical therapy (i.e., refractory hypertension)
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3. What Is Resistant Hypertension?
In Compliant Patient
On life style change
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5. Prevalence of Resistant Hypertension
*ALLHAT, CONVINCE, LIFE, INSIGHT
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7. Causes of Resistant Hypertension 7

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9. Strong Associates of Resistant Hypertension 9

10. Pseudo Resistant Hypertension
 “White Coat” hypertension (not without risk)
 Uncompressible arteries of old age(Osler’s Pseudo HT)
 Measurement issues – small cuff (< 80% of arm)
 BP Recorded without 5-10 minutes of rest
 Non-compliance with drug treatment
 40% patients discontinue Rx in the first year
 No life style modification practiced
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11. 24 hr. Ambulatory BP Monitoring (ABPM)
To distinguish white coat and pseudo hypertension, home BP and ABPM
Masked hypertension
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13. Genetics and Resistant Hypertension
Mostly Polygenic
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14. Secondary and Resistant Hypertension 14

15. Whom We Should Watch for Sec HT? 15

16. Evaluation of Resistant Hypertension
 Good blood pressure recording technique – cuff size
 Strict compliance with treatment recommendations
 Evaluation for secondary causes of resistant hypertension
 Ambulatory BP monitoring (ABPM) – to exclude “White Coat”
 Assessment for TOD – CKD, Retinopathy, LVH – is essential
 History of drug intake that can cause resistant hypertension
 Day time sleepiness, loud snoring, apnoeic spells - OSAS
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17. Common Causes of Secondary Hypertension 17

18. Relative Prevalence of Secondary Hypertension
Primary or Essential Hypertension 93-95%
Secondary Causes 5-7%
Renal Hypertension 3-5%
Parenchymal 2-3%
Reno vascular 1-2%
Endocrine: Conn’s, Cushing’s, Pheochromocytoma 0.3-1.0%
Oral Contraceptive Pills (OCP) 0.5%
Miscellaneous 0.5%
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19. Mechanisms for Secondary Hypertension 19

20. Secondary Hypertension: Renal Causes
Renal Artery Stenosis (RAS) Chronic Kidney Disease (CKD)
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21. Secondary Hypertension: Renal Causes
Mainly Tunica Media affected Intimal Atherosclerotic Plaques
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22. Renal Artery Stenosis (RAS) and RHT
 Atherosclerotic (intimal) Reno vascular disease is 90%
 Fibro muscular (media) hyperplasia is 10%
 Duplex USG, MR angiography, Renal CT, Renal Scintigraphy
 MR Angiography is highly sensitive for detecting RAS
 15% of patients of CAG show asymptomatic RAS
 Renal revascularization, stenting are the Rx of choice
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23. Secondary Hypertension: Adrenal Causes
Excess Mineralocorticoid Activity Excess Glucocorticoid Activity
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24. Primary Aldosteronism and RHT
 20% of cases of RHT have Primary Aldosteronism
 Suppression of Renin Activity, Low K+
and Mg++,
Met Alkalosis
 Higher 24 hour urinary aldosterone excretion
 In the background of higher dietary sodium intake
 General increase in R-A-S activity due to obesity
 AT II independent Aldosterone excess
 Stimulated by adipocyte derived secretagogues
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25. Cushing’s Syndrome and RHT
 70% to 80% of patients with Cushing's have RHT
 Excessive stimulation of nonselective mineralocorticoid R
 IRS, DM and OSAS which coexist may contribute
 TOD is more severe in Cushing's syndrome
 Routine antihypertensive drugs are not effective
 MR Antagonist - Eplerenone or Spironolactone are effective
 Surgical excision of ACTH or Cortisol producing tumour
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26. Pheochromocytoma and RHT
 Small but important cause of Secondary RHT
 Prevalence is 0.1% to 0.6% of hypertensives
 Increased BP variability – A CV risk factor by itself
 Episodic Hypertension, Palpitation, Headache and Sweating
 Dysglycemia and abnormal GTT are usually associated
 Has a diagnostic Specificity of 90%
 Plasma free metanephrine and normetanephrine
 Has 99% sensitivity and 89% specificity
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27. D.Dx. of Corticoid Induced Hypertension
Type of HT Serum K Pl Renin Aldosterone Increase in others
Primary Hyper
Aldosteronism
Low Low High
Glucocorticoid
Remediable (GRA)
Normal Low High 18 OH-C, THC in Urine
Mineralocorticoid
Excess (apparent)
Low Low Low THC+ 5αTHC in Urine
Deoxycorticosterone Low Low Low Pl Deoxycorticosterone
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28. Other Causes of Secondary Hypertension
Coarctation, PAN and Aortitis, PTHT Prolonged uses of External Agents
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29. Secondary Hypertension: Evaluations 29

30. Drug Treatment of Resistant Hypertension
 If a correctable cause is found, treat that
 Aggressive drug therapy – Optimizing the current Rx.
 Effective Diuresis – Furosemide BID/Torsemide OD
 MRA antagonists, Spironolactone, Triamterene, Amiloride
 Hydralazine or Minoxidil + β-Blocker and a diuretic
 Transdermal Clonidine
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31. Some Practical Points of Rx. of RHT 31

32. Future Options For Resistant Hypertension
 Direct Renin Inhibitors (Aliskiren)
 Neutral Endopeptidase (NEP) Inhibitors (Omapatrilat)
 Aldosterone Synthase Inhibitors
 Clonidine Extended Release
 Endothelin Antagonists (Darusentan)
 Novel Combinations Algorithms
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33. Non Pharmacological Approaches
 The following procedures are invasive and irreversible
 Implantable pulse generators – perivascular carotid
sinus leads to be surgically implanted
 Renal Denervation – particularly in those with renal origin
of the disease – Promising results
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35. Take home message
High prevalence gjmresistant HTN
Drug adherence
R/O sec. cause
Life style changes
Optimize drugs 35

36. Thank you
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