This document presents the case of a 58-year-old African American female with resistant hypertension, edema, and a reduced ejection fraction of 35% whose blood pressure remains high despite treatment with minoxidil, furosemide, lisinopril, and metoprolol. Additional testing showed cardiomegaly on chest X-ray, elevated serum creatinine and low potassium, and elevated aldosterone with low renin, suggesting primary aldosteronism. Questions are raised about additional workup, diuretic therapy, use of spironolactone, and rate control.

1. Domenic Sica, M.D.
Eminent Scholar
President – American Society of Hypertension
Professor of Medicine and Pharmacology
Chairman, Section of Clinical Pharmacology and
Hypertension
Virginia Commonwealth University Health System
Richmond, Virginia
Case Presentation

2. Resistant hypertension
• 58 year old African-
American female with
difficult to treat hypertension
and dyspnea on exertion
• Physical examination
remarkable for 2+ peripheral
edema and a heart rate of
90 with home blood
pressure readings typically
in the 170/90 mm Hg range
• Minoxidil 5-mg twice daily
• Furosemide 40-mg twice
daily
• Lisinopril 20-mg twice daily
• Metoprolol 100-mg twice
daily

3. Resistant hypertension
• Chest X-Ray shows
cardiomegaly
• Echocardiogram shows an
ejection fraction of 35 %
• Renal function has a serum
creatinine of 1.5-mg/dL and
a potassium of 3.4 mmol/L
• Plasma aldosterone is 16-
ng/dL and plasma renin
activity is 0.30-ng/mL/hr
• Minoxidil 5-mg twice daily
• Furosemide 40-mg twice
daily
• Lisinopril 20-mg twice daily
• Metoprolol 100-mg twice
daily

4. Resistant hypertension
• What additional work-up
should be done – cardiac or
otherwise ?
• How should diuretic therapy
be addressed ?
• Where should
spironolactone be
positioned in his treatment ?
• What should be done for
rate control with this degree
of tachycardia?
• Minoxidil 5-mg twice daily
• Furosemide 40-mg twice
daily
• Lisinopril 20-mg twice daily
• Metoprolol 100-mg twice
daily