Algorhythm for management of resistant hypertension from a llecture on youtube by Mark POHL,Cleveland clinic

2. An algorithm for the management of
Resistant Hypertension
Is the patient compliant
No Yes
Is the regimen adequate
No Yes
Are drugs interactions possible

3. An algorithm for the management of
Resistant Hypertension
Are drugs interactions possible
Yes No
Does the patient have pseudohypertension
Yes No
Does the patient have office
hypertension

4. An algorithm for the management of
Resistant Hypertension
Does the patient have office hypertension
Yes No
Has secondary hypertension been excluded
Yes No
Alter regimen empirically
BP Controlled BP not Controlled
Evaluate mechanisms and alter regimen appropriately

5. Secondary causes
Renal parenchymal disease
(Polycystic Kidney Disease)
Renovascular hypertension
Primary aldosteronism
Pheochromocytoma
Hypothyroidism

6. 1. Age of onset <20 ; >50
2. Level of BP >180/110
3. Target organ damage
 Fundi Grade II or worse
 Serum Creatinine >1.5mg/dl
 Cardiomegaly or LVF

7. 4. Presence of features suggesting secondary
causes
Unprovoked hypokalemia
 Abdominal bruit
 Variable BP with tachycardia, sweating and
tremor
 Family history of renal disease, proteinuria
5. Poor response to appropriate drug regimen

8. Clinical clues
 Onset of hypertension < 30 years or > 50 years
 Accelerated or malignant hypertension
 Unexplained deterioration of renal function or
during therapy with ACEI
 Acquired resistance to a previously
antihypertensive regimen
 Presence of systolic/diastolic abdominal bruit

9. Clinical clues
 Persistent hypokalemia during diuretic therapy
despite concomitant administration of K
sparing agents and or oral KCl
 Resistance to anti-hypertensive therapy
 Obtrusive sleep apnea (OSA)

10. Biochemical clues
 Spontaneous hypokalemia i.e. serum K <
3.5mEg/L and 24 hour urinary potassium
>30mEq
 Serum K < 3.0mEq/L on conventional diuretic
dosages
 Plasma aldosterone/plasma renin activity
(PRA) >30

11. Clinical clues
 Symptomatic paroxysms of hypertension with
headache, tachycardia, palpitation and sweating.
 History of labile BP
 Substandard weight or recent weight loss
 A pressor response to antihypertensive drugs or
during induction of anesthesia
 Refractory hypertension
 Occasional occurrence with neurocutaneous
syndrome
 Unusual liability of BP or orthostatic hypotension
 Abnormal glucose tolerance

12. Biochemical clues
 Elevated plasma metanephrines
 Elevated values of 24 hours urinary NMN + MN
i.e. >1.3mg/24hrs
 Elevated plasma catecholamine i.e.
>2,000pg/ml that is non-suppressible by
clonidine

13. clinical clues
 Proteinuria, hematuria, renal insufficiency
 Common secondary cause of hypertension not
usually reversible
 Sulfosalycilic acid for light chains
 Spot urine protein/ creatinine ratio 24 hours
quantitative protein
 Renal ultrasound, KUB

14. clinical clues
HYPERTHYROID
 Hyperdynamic circulation,
SBP
 Exophthalmos
 History of weight loss
HYPOTHYROID
 High prevelance diastolic
hypertension
 Fatigue, constipation
HYPERPARATHYROIDISM
 Most asymphamatic
 Hypercalemia
 Polyuria, polydypsia and
renal calculi
 May occur with MEN

15. Associated condition
 Smoking
 Increasing obesity
 Sleep Apnea
 Insulin resistance/
hyperinsulinemia
 Ethanol intake >30ml per day
 Anxiety induced
hyperventilation or panic
attack
 Chronic pain
 Intensive vasoconstriction
(arteritis)
 Organic brain syndrome
(memory deficit)

16.  Patient resistance
 Physician resistance
 Insufficient dosage
 Infrequent administration
 Inadequate physician
education
 Lack of Physician motivation
 Drug interactions
 Excessive salt intake
 Office hypertension
 Secondary causes of
hypertension
 True-drug hypertension

17. NEUROHORMONAL
ABERRATION
MANAGEMENT
Plasma renin activity (increase
RAAS)
Beta-Blocker ACE I – ARB direct
renin inhibitor
Aldosterone production Spironolactatone Eplerenone
Plasma catecholamines Clonidine Methyldopa Prazocin

18. HEMODYNAMIC ABERRATION MANAGEMENT
Plasma volume
 Diuretics
 Sodium Restriction
Peripheral resistance
 Vasodilators
 ACES, ARB
 Direct renin inhibitors
 Calcium antagonist