A 56-year-old male has a 10-year history of hypertension which has been poorly controlled for the last 3 years despite adherence with lifestyle modification and optimization of medications. He is increasingly frustrated with his poor BP control. He is currently taking olmesartan 40 mg daily, amlodipine 10 mg daily, HCTZ 25 mg daily, carvedilol 25 mg twice daily, and eplerenone 50 mg daily. He has never been a smoker. Work up for secondary hypertension has included normal plasma renin and aldosterone levels, normal plasma metanephrine levels, and a negative renal doppler study. He claims to be strictly adherent with his medication regimen.
The correct answer is: E. Refer to a hypertension center for consideration of renal denervation.
Refractory hypertension is defined as uncontrolled blood pressure despite use of 5 or more antihypertensive agents of different classes, including a long-acting thiazide-like diuretic and a mineralocorticoid receptor antagonist, at maximal or maximally tolerated doses. The patient is on an appropriate and optimized antihypertensive regimen. Triple combination therapy may improve compliance with his medications, but he claims to be adherent with his regimen. He is a non-smoker and is unlikely to have renal artery stenosis so a more definitive test such as CTA of renal arteries is not required. Refractory hypertension is a separate entity from resistant hypertension and is generally attributable to increased sympathetic activity, so this patient is potentially an excellent candidate for renal denervation.
This patient case quiz is part of the larger Overcoming Challenges in Hypertension Management grant. Educational grant support is provided by Medtronic. To visit the Overcoming Challenges in Hypertension Management grant page and access additional educational activities on this topic, click here.
References
- Matanes F, Khan MB, Siddiqui M, Dudenbostel T, Calhoun D, Oparil S. An Update on Refractory Hypertension. Curr Hypertens Rep. 2022;24(7):225-234. doi: 10.1007/s11906-022-01185-6. Epub 2022 Apr 6.
- Dudenbostel T, Siddiqui M, Oparil S, Calhoun DA. Refractory Hypertension: A Novel Phenotype of Antihypertensive Treatment Failure. Hypertension. 2016;67(6):1085-92. doi: 10.1161/HYPERTENSIONAHA.116.06587. Epub 2016 Apr 18.
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