Resistant Hypertension

1
Resistant Hypertension

• Prof. Dr. Sarma VSN Rachakonda
• M.D (Internal Medicine)., M.Sc., (Canada), FCGP,
• FICP, FIMSA, FRCP (G), FCCP (USA), FACP (USA)
• Hon. National Professor of Medicine, IMA CGP,
  India
• Senior Consultant Physician Cardio-metabolic
  Specialist
• Adjunct Professor, Tamilnadu Dr. MGR Medical
  University, Chennai

www.drsarma.in
2
Understand These KEY Words

• Essential Hypertension
• Uncontrolled Hypertension
• Pseudo Resistant Hypertension
• Resistant Hypertension
• Refractory Hypertension
• Secondary Hypertension
• Reno Vascular Hypertension
• Malignant Hypertension

3
B.P Measurement Issues Revisited

• Sitting and standing recording of BP,
  Contralateral
• Two readings five minutes apart, rarely lower
  limb BP
• After resting, preferably same time of day
  morning
• Korotkoffs phase V disappearance for diastolic
• Standard cuff size -12 x 26 cm, Large cuff 13 x
  36 cm
• Calibration of the instrument from time to time
• Cuff should encircle 80 of the arm - very thin
  clothing
• Quite environment, relaxed doctor and patient
• No smoking, alcohol or caffeine by the patient
• Auscultatory gap, recollect Korotkoffs phases,
  Phase IV?

4
The Target Blood Pressure (JNC7)
Non DM
DM, CKD
5
Pseudo Resistant Hypertension

• White Coat hypertension (not without risk)
• TOD is minimal in White Coat hypertension
• Uncompressible arteries of old age(Oslers Pseudo
  HT)
• Measurement issues small cuff (lt 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
• Be cautious to a patient as label pseudo
  hypertension

6
24 hr. Ambulatory BP Monitoring (ABPM)
To distinguish white coat and pseudo
hypertension, home BP and ABPM
Masked hypertension
7
Non Compliance for Rx. of Hypertension

• Hypertension in most patients is asymptomatic
• TOD and complications are often occult
• Side effects of the drugs, Cost, Combinations
• Complexity of the regimens, timings
• Multiple medications for comorbidities
• Lack of understanding of gravity of the disease,
  TOD
• False belief that hypertension got cured
• Social, economic and personal factors

8
How to Evaluate for Non Compliance
9
What Is Resistant Hypertension?
In Compliant Patient On life style change
10
Clinical Markers for Resistant Hypertension

• Advancing age
• High Base line Blood Pressure
• Obesity and Over Weight
• Excessive Dietary Salt Intake, Alcoholism
• Chronic Kidney Disease (CKD)
• Diabetes Mellitus (Type II)
• Left Ventricular Hypertrophy (LVH)
• Black Race, Female Gender

11
Medications Interaction for BP control

• Non narcotic analgesics, NSAIDs, Aspirin
• Selective COX-2 inhibitors (Celecoxib)
• Sympathomimetic agents (decongestants)
• Diet pills, Cocaine, Ephedrine
• Stimulants (Methylphenidate, Amphetamine)
• Alcohol (binge drinking, gt30 ml/day)
• Oral Contraceptive Pills (OCP), Steroids,
  Anabolics
• Cyclosporine, Erythropoietin
• Liquorice, herbal compounds (ephedra)

12
Genetics and Resistant Hypertension
Mostly Polygenic
13
Whom We Should Watch for Sec HT?
14
Causes of Resistant Hypertension
15
Strong Associates of Resistant Hypertension
16
Problems of Resistant Hypertension
17
Secondary and Resistant Hypertension
30
5
18
Common Causes of Secondary Hypertension
19
Prevalence of Resistant Hypertension
ALLHAT, CONVINCE, LIFE, INSIGHT
20
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 Conns, Cushings, Pheochromocytoma 0.3-1.0
Oral Contraceptive Pills (OCP) 0.5
Miscellaneous 0.5
21
Mechanisms for Secondary Hypertension
22
Secondary Hypertension Renal Causes
Chronic Kidney Disease (CKD)
Renal Artery Stenosis (RAS)
23
Secondary Hypertension Renal Causes
Intimal Atherosclerotic Plaques
Mainly Tunica Media affected
24
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

25
Fibro Muscular Dysplasia (FMD)
26
FMD Treated with Angioplasty
27
Atherosclerotic RAS Treated with Angioplasty
28
Renal Parenchymal Disease and RHT

• CKD is a common cause and complication of RHT
• Serum creatinine of gt1.5 mg can cause RHT
• Increased sodium and fluid retention
• Expansion of intravascular volume fluid
  overload
• CKD is strong predictor of poor outcomes and RHT

29
Secondary Hypertension Adrenal Causes
Excess Glucocorticoid Activity
Excess Mineralocorticoid Activity
30
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

31
Cushings 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

32
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

33
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 5?THC in Urine
Deoxycorticosterone Low Low Low Pl Deoxycorticosterone
34
Other Causes of Secondary Hypertension
Prolonged uses of External Agents
Coarctation, PAN and Aortitis, PTHT
35
Physical Examination in Hypertension

• BP measurement (contralateral, all arms)
• Weight, waist circumference, BMI
• Peripheral pulses, ABI, bruits (Carotid)
• Thyroid examination Hypo and hyper features
• Cardiovascular system examination
• Abdomen masses, bruit, aortic pulsation
• Fundus examination for retinopathy

36
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

37
Secondary Hypertension Evaluations
38
Life Style Principles for Hypertension

• Salt Restriction
• Weight Loss
• Physical Activity
• Smoking Cessation
• Alcohol Abstinence
• Glycaemia and Lipid Control

39
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 ß-Blocker and a
  diuretic
• Transdermal Clonidine

40
Some Practical Points of Rx. of RHT
41
Anti hypertensive drugs - interactions
Antihypertensive Drug Interacting Drug
Hydrochlorothiazide Cholestyramine
Propranolol Rifampicin
Guanethadine Tricyclics
ACE Inhibitors Indomethacin
Diuretics Indomethacin
All Drugs Cocaine, Tricyclics
Most of the BP Drugs Phenylpropanolamine
42
Future Options For Resistant Hypertension

• Direct Renin Inhibitors (Aliskiren)
• Neutral Endopeptidase (NEP) Inhibitors
  (Omapatrilat)
• New Aldosterone Antagonists (Eplerenone)
• Aldosterone Synthase Inhibitors
• Clonidine Extended Release
• Endothelin Antagonists (Darusentan)
• Novel Combinations Algorithms

43
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
• Neurovascular decompensation may be temporary

44
(No Transcript)
45
Thank you all
www.drsarma.in