Resistant Hypertension

Resistant hypertension is high blood pressure that does not respond well to aggressive medical treatment. Hypertension is considered resistant when all of the following are true:

• Patient is taking three different blood pressure medications at the maximum dose.
• One of the blood pressure medications is a diuretic (removes fluid and salt from the body).
• Blood pressure remains above the goal (130/80 mmHg) despite medications.

Resistant hypertension substantially increases the risk of heart attack, stroke and kidney failure.

Resistant hypertension may have no symptoms at all for months or years, but then can cause heart attack, stroke, and kidney failure.

However, symptoms may be felt when blood pressure first rises and when levels are extremely high. These symptoms may include headaches, shortness of breath, chest pain and nosebleeds.

Dizziness is usually not a symptom of high blood pressure. In fact, dizziness can sometimes be a symptom of low blood pressure. Frequent or unexplained dizziness may be a warning sign of a serious condition and should be addressed by your physician.

Evaluating Resistant Hypertension

Paying attention to details of the full medical history and physical exam is essential for diagnosing resistant hypertension. Also obtaining special blood work and imaging studies are important to identify causes of resistant hypertension.

The generic approach of “one size fits all” in evaluating patients with resistant hypertension is not fruitful. It is important to work with a doctor who is familiar with diagnosing and treating resistant hypertension.

Full history and physical exam, which includes letting your doctor know about all medications and supplements, whether they are prescription, over-the-counter, herbal or recreational is important in properly managing resistant hypertension. It’s important to mention if you skip doses of daily medicines.

Many medications and supplements raise blood pressure. Examples include various pain medications, antidepressants, decongestants, aspirin at high doses and birth control pills. Stimulants — from caffeine and ADHD medications to cigarettes — as well as recreational drugs and excessive alcohol can also raise blood pressure. So can many “natural” or “herbal” supplements, as well as licorice-containing candies or drinks or some forms of flavored chewing gum and chewing tobacco.

Managing Resistant Hypertension

Proper blood pressure monitoring is an important part of diagnosing and managing resistant hypertension. Though it sounds simple, blood pressure can be measured incorrectly, and home blood pressure devices may not be properly calibrated. Your health care provider must take several factors into consideration, such as the size of your arm and your body’s position during measurement. Measurements of blood pressure in public places is not reliable or accurate. These freestanding devices often are located in noisy, busy areas of a store, so their readings don’t correlate best with measurements taken in a physician's office.

Patients with resistant hypertension are much more likely to have an identifiable secondary cause of hypertension. Identifying and treating these secondary conditions may eliminate hypertension or at least make it more treatable. Chronic kidney disease (CKD) is the most common form of secondary hypertension. We will discuss CKD in depth in the next few blogs.

These are the reasons why it is important to work with a doctor who knows how to diagnose and treat resistant hypertension and secondary causes of hypertension to have the best chance of managing these complex conditions that affect many patients.