12/19/2023 0 Comments Another word for satisfactoryThis should achieve a comparable blood pressure lowering effect. Alternatively, if patients are intolerant to an ACEI because of cough it is acceptable to replace the ACEI with an angiotensin receptor blocker (ARB). For instance, in patients over 55 years of age with evidence of heart failure a thiazide diuretic might be a more suitable first-line option than a CCB. Comorbidities must be considered when selecting an antihypertensive agent. Whatever regimen is chosen it is important that it be tailored to the individual patient. Triple therapy must be optimised before selecting further add-on therapy because optimal dosing and drug selection can see blood pressure normalise in many patients. If monotherapy is insufficient the regimen could be modified depending on therapeutic effect by altering dose or adding an additional class of drug. Guidelines endorse commencement of antihypertensive treatment with only one drug because adequate monotherapy controls hypertension in 30% of cases. These options can then be trialled in combination and titrated as necessary before adding a thiazide as the third medication. The guidelines of the National Institute for Health and Clinical Excellence (NICE) recommend initial treatment with an angiotensin-converting enzyme inhibitor (ACE inhibitor) in patients younger than 55 years of age, or a dihydropyridine calcium channel blocker (CCB) in patients older than 55 or black patients of any age. The preferred initial drug choices are the same as for essential hypertension. In general, the best strategy is to formulate a combination therapy that targets different physiological mechanisms and accounts for patient comorbidities. There is little randomised trial data to guide choice of drug regimen for patients with resistant hypertension and recommendations are largely empirical. Additional tests should be chosen depending on the clinical circumstances of the patient as revealed by history and examination. Pressure readings from ambulatory monitoring correlate more closely with morbidity and mortality than measurements obtained in clinic.įurther screening investigations for secondary causes are not compulsory. Because of the confounding nature of the white-coat effect, 24-hour ambulatory blood pressure monitoring should also be undertaken. It is also advisable to order serum sodium, potassium and glucose because the test is simple and often helpful. Any derangement in these baseline investigations warrants a renal ultrasound scan. This is due to the high prevalence of chronic kidney disease in this population. Oftentimes however, the clinical assessment will be unremarkable.īeyond history and examination, all patients with resistant hypertension should be investigated at minimum with a serum creatinine test, estimated glomerular filtration rate and urine dipstick. For example the patient may have symptoms of obstructive sleep apnoea, or alternatively episodic palpitations with headaches and diaphoresis might suggest pheochromocytoma, while an abdominal bruit could indicate renal artery stenosis. Įvaluation for secondary causes should include comprehensive history and physical examination searching for any clues pointing towards to an underlying diagnosis. Other implicated factors include failure to adhere to lifestyle advice, poor measurement technique, white-coat hypertension and the use of medications that interfere with blood pressure. The commonest reasons for apparent treatment resistance are medication non-compliance and insufficient drug therapy. Pseudo-resistant hypertension refers to poorly controlled disease which appears resistant but is actually attributable to other factors. The true prevalence of resistant hypertension is difficult to quantify because many patients actually suffer ‘pseudo-resistant’ hypertension. If at six months treatment is proving unsuccessful the possibility of resistant hypertension may be contemplated. Approximately six months of treatment with three conventional antihypertensive agents should be allowed for at least some blood pressure correction. Resistant hypertension presents in patients who have persistently elevated blood pressure which responds minimally to therapy. Possible end-organ consequences of untreated hypertension include heart failure, stroke, ischemic heart disease and renal failure. Uncontrolled blood pressure is a considerable cardiovascular risk factor that makes target-organ damage more likely. Although hypertension is usually asymptomatic detection and treatment remains important.
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