Monthly Archives: March 2015

Resistant Hypertension

Definition: Blood pressure above goal despite three hypertension medications in three different classes or BP’s controlled with 4 or more medications. Refractory hypertension when uncontrolled despite maximal therapy.


Pseudo-Resistant Hypertension

  • white coat hypertension
  • inaccurate BP measurement
  • poor med compliance
  • suboptimal therapy
  • poor lifestyle and diet


If indicated, evaluate for:

  • primary aldosteronism
  • renal artery stenosis
  • chronic kidney disease
  • obstructive sleep apnea

Less commonly: pheochromocytoma, cushing’s disease, aortic coarctation


Pharmacological treatment

  • Standard 3 drug regimen
    • ACEI or ARB, long-acting CCB, long-acting thiazide
  • If eGFR <30, loop diuretic for long control
  • Add spironolactone if HTN is resistant despite 3 drug regimen.
    • Trial 12.5 mg QD and titrate up to but not above 50 mg/day
    • If patients cannot tolerate spironolactone, use eplerenone or amiloride
  • Add vasodilatory beta-blocker if still persistent.  Alternatives are guanfacine or clonidine.
  • If still persistent, then use hydralazine in women or minoxidil in men.

Transcatheter Aortic Valve Replacement

Symptomatic severe aortic stenosis has a poor prognosis.   The standard of care to this point has been surgical aortic valve replacement for symptomatic disease.  Patient’s with significant co-morbidities including but not limited to systolic heart failure, CAD, CVD, PAD, CKD, COPD, and age carry increased surgical risk.  As a result, TAVR was developed as an alternative approach to valve replacement in high risk patients.

Indications are as follows:

  1. Severe calcification of valve leaflets with reduced systolic motion AND mean gradient >40 mmHg (normal <5 mm HG) or jet velocity >4.0 m/s (normal <2.5 m/s)




  1. Aortic Valve area of <1.0 cm2 (normal 3-4 cm2) OR indexed effective orifice area <0.5cm2/m2

Symptomatic from aortic stenosis (NYHA Class II or greater) not related to co-morbid conditions

Agreement between 1 cardiac interventionalist and 2 cardiothoracic surgeons that surgical aortic valve replacement is either precluded or high risk based on the probability of death or serious irreversible morbidity exceeding the probability of meaningful improvement

Contraindications include but not limited to:

Evidence of acute MI within 1 month of intended treatment

Noncalcified or congenital uni/bicuspid aortic valve

Severe aortic regurgitation

Severe mitral regurgitation

Hypertrophic Cardiomyopathy

Severe LV dysfunction with LVEF of <20%

Severe pulmonary hypertension and RV dysfunction

Contraindication to all anticoagulation treatments

MRI confirmed stroke or TIA within 6 months

Renal Insufficiency with Cr >3mg/dL and/or ESRD on dialysis

Severe Dementia

Estimated life expectancy <12 months due to noncardiac comorbidities

Significant aortic disease (eg: AAA, thoracic aneurysm 5+ cm in diameter, significant tortuosity, narrowing of abdominal or thoracic aorta, etc.)

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