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.
- 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
- 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.