Applied Evidence

When your patient’s blood pressure won’t come down

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Is your patient’s persistent hypertension really resistant to treatment, or are other factors at work? Consider these 2 cases and let this algorithm help you decide.




Encourage home BP monitoring. Home readings are often lower than those taken in the office and closer to the average BP recorded by 24-hour ambulatory monitors. C

Tell patients that reducing sodium intake not only reduces mortality, but it has positive cardiovascular effects separate from BP reduction, such as improved endothelium-dependent vasodilation. A

Search for secondary causes of resistant hypertension, such as renal artery stenosis, pheochromocytoma, obstructive sleep apnea, and hyperaldosteronism. A

Consider pseudohypertension in elderly patients who exhibit postural hypotension and fail to respond to increased doses of medication. C

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

CASE 1 Mr. Brown is a 60-year-old African American man who works as a mid-level executive at a local bank. About a year and a half ago, he was diagnosed with hypertension, joining a number of other family members who also have the condition. Reviewing his chart, you note that at many of his visits—but not all of them—his systolic blood pressure runs close to 150 mm Hg, with diastolic pressure <90 mm Hg. Today his blood pressure is 148/88 mm Hg, numbers that exceed the parameters of the currently accepted definition of hypertension: blood pressure ≥140 mm Hg systolic or ≥90 mm Hg diastolic, taken on 2 separate occasions with the patient sitting down.1

Mr. Brown is one of the more than 65 million American adults suffering from high blood pressure—the No. 1 diagnosis reported in outpatient medical offices.2,3 Despite such prevalence, blood pressure control in the United States is suboptimal, with only one-third of hypertensive patients under adequate control.1 In 2007, the total estimated cost of treating high blood pressure in the United States exceeded $66 billion.4

When you tell Mr. Brown that his blood pressure doesn’t meet the therapeutic goal of <140/90 mm Hg, he gives you his reasons: He was late, he rushed, the traffic was bad, and the nurse rushed him into the exam room before he even had time to catch his breath. He insists his blood pressure is “normal” at home, and blames the elevated numbers on anxiety. He also tells you he was up working most of the night before, drinking coffee to stay awake to finish an urgent project.

Mr. Brown’s current medication regimen includes daily doses of lisinopril-hydrochlorothiazide (HCTZ) 20/25 mg daily and simvastatin 20 mg. He tells you he has no chest pain, shortness of breath, cough, edema, claudication, paroxysmal nocturnal dyspnea, or orthopnea. When you ask if he takes his lisinopril-HCTZ every day, he says Yes, but you have your suspicions.

Consider pseudo-resistance

Suboptimal blood pressure control can be classified as either pseudo-resistant or resistant hypertension. According to the definition used in the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC7), resistance is the “failure to achieve goal BP in patients who are adhering to full doses of an appropriate 3-drug regimen that includes a diuretic.”1

Hypertension is described as “pseudo-resistant” when persistent elevations in blood pressure are the result of a failure to comply with the medication regimen, “white-coat” syndrome, poor blood pressure technique, or a combination of these.5,6 Physician failure to prescribe adequate doses of medication, so-called clinical inertia, may also be a factor.5,7 Causes and remedies for pseudo-resistance are summarized in the algorithm.

In Mr. Brown’s case, he’s told you that he’s taking his lisinopril-HCTZ every day, but when you check your records, you see that the intervals between his refill requests range between 34 and 36 days. So you ask him, again, whether he is taking his lisinopril-HCTZ daily, and this time he says he takes the medication “at least 5 or 6 days a week.”

Encourage compliance. To motivate Mr. Brown, you tell him his blood pressure does not meet the goal of <140/90 mm Hg and that pressure higher than goal is a significant risk factor for cardiovascular disease. You emphasize the importance of taking his medication every day—a mantra you’ve repeated to countless patients over the years. In fact, it’s estimated that up to 40% of patients will discontinue their medication at some point during treatment.8 Patients’ reasons vary and may include medication side effects, the cost of treatment, or a patient’s personal philosophy. Cultural differences may also play a role in noncompliance.9

You talk with Mr. Brown a bit more and confirm that his poor compliance is due to simple forgetfulness and not another underlying reason that would need to be addressed. You hand him a pill calendar to help him keep track of his medication. You review the dosage and feel confident that you’ve prescribed a regimen simple enough for Mr. Brown to stick to and adequate to bring his pressure down.

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