Resistant and Refractory Hypertension
Resistant and Refractory Hypertension
Ananth Karumanchi, MD interviews David Calhoun, MD about refractory and resistant hypertension, a topic he presented on for Hypertension 2015 in Washington, DC.
Content
1.968 -> - Well my name is Ananth
Karumanchi, and I'm a
4.417 -> nephrologist at the Beth Israel
Deaconess Medical Center,
6.762 -> and a Professor of Medicine
at Harvard Medical School.
8.852 -> - And I'm David Calhoun,
Professor of Medicine at
12.103 -> the University of Alabama in Birmingham,
14.355 -> and Medical Director of the hypertension
16.689 -> program there in Birmingham.
18.605 -> - So, David, what is
refractory hypertension,
21.983 -> and why should doctors be
aware of this condition?
25.315 -> - Well, we're proposing
a refractory hypertension
29.495 -> as sort of a new phenotype
of anti-hypertensive failure,
33.569 -> so, historically resistant hypertension or
36.542 -> difficult to treat hypertension
has been defined as
39.758 -> blood pressure's uncontrolled
on three or more medicines,
42.544 -> and we've recognized an even
more severe group of patients
46.805 -> who really, we can never
control their blood pressure
49.301 -> in spite of maximum
therapy, so that may be
51.797 -> five, six, or even seven medications.
54.421 -> So, that's the group
that we're referring to
57.022 -> as refractory hypertension or a phenotype
60.099 -> of anti-hypertensive failure.
62.026 -> It's uncommon, even in our clinic,
64.069 -> probably only five percent
of patients referred to us,
66.74 -> but they are a very
striking group in terms of
70.037 -> how sever their hypertension is and
72.417 -> the rate of complications
in that group of patients.
75.54 -> - Is this condition increasing?
77.244 -> - Well, the major risk factors for having
81.252 -> resistant hypertension,
or I should say the
84.294 -> strongest risk factors, are probably
86.038 -> CKD, having CKD and
being African-American.
88.845 -> But, in terms of resistant hypertension,
92.084 -> probably two of the most
common risk factors are
95.521 -> obesity and older age, and
because as a population,
100.107 -> really worldwide, we're
getting older and heavier.
104.693 -> And so I think that's the
reason that the prevalence
108.57 -> of resistant hypertension
is likely increasing.
111.032 -> - And finally, David, how do you manage
114.073 -> these patients in your practice?
116.453 -> - Our standard approach, if you will,
119.513 -> I mean obviously you have to
individualize per patient,
123.756 -> but our standard approach is to,
126.508 -> our first two medications
we like to use are
129.375 -> firstly a RAS-blocker, so either
an ACE inhibitor or an ARB.
133.543 -> We add to that a calcium channel blocker,
136.806 -> which is in our clinic
most often Amlodipine
139.395 -> because it's an effective,
once-a-day medication.
142.483 -> As a third drug, we will
add, we use, Thiazide
145.862 -> or a Thiazide-like diuretic,
we are mostly in our clinic
148.741 -> using Chlorthalidone because
it does have a long half-life
152.491 -> and clearly is more
effective, more efficacious,
156.415 -> than Hydrochlorothiazide
even at the same dose amount.
160.246 -> Our standard fourth
drug is Spironolactone.
163.706 -> We may start as low as
twelve and a half milligrams,
166.423 -> going typically to twenty five milligrams,
169.256 -> occasionally fifty
milligrams in obese patients
171.972 -> or patients we know that
have aldosterone levels.
174.724 -> After that, it gets difficult.
176.883 -> We probably use most often as a fifth drug
179.809 -> a combined alpha-beta blocker,
181.899 -> so Labetalol in our
clinic, and then lastly,
185.777 -> we would add a centrally
acting agent, such as,
189.945 -> ideally, when it's
long-lasting, so we tend to use
194.031 -> Guanfacine, and then
finally, as a last resort,
197.201 -> just vasodilators, so
minoxidil or hydralazine.
203.505 -> - Let me ask you one last question.
205.084 -> Do you screen for other,
secondary factors like sleep apnea
208.834 -> or adrenal adenomas in these populations?
212.05 -> - We do, especially the
latter, in our patients
215.719 -> referred to us for resistant hypertension,
218.145 -> and if we confirm that they
do have resistant hypertension
222.476 -> on a routine basis, we have
them do a 24-hour urine
225.982 -> during their normal day, so
normal diet, normal activity.
230.405 -> And so we look at their sodium excretion,
233.32 -> we look at their protein
excretion, so we also get
236.779 -> aldosterone levels in that urine
as well as cortisol levels,
240.251 -> so looking for both
hyperaldosteronism and Cushing's.
245.208 -> I won't say sleep apnea
is known to be very high
249.909 -> in patients with resistant hypertension.
252.012 -> I wouldn't say we send them
automatically for a sleep study,
254.682 -> but we are very, we are
certainly very aggressive about
258.641 -> screening for sleep apnea
based on symptoms like
262.263 -> loud snoring, witnessed
apnea, daytime sleepiness,
265.944 -> and they have a very low
threshold for sending
268.73 -> them for a sleep study
if the patients report
271.238 -> any of those signs or symptoms.
273.571 -> - Well, thank you very much.
Source: https://www.youtube.com/watch?v=3OSF5jZUscA