Article Figures & Data
Figures
- Figure 1.
Ruling out the white-coat effect in patients with suspected resistant hypertension. The systematic use of out-of-office blood pressure (BP) measurements should be employed to rule out the white-coat effect. If readily available, it is reasonable to proceed directly to ambulatory BP monitoring. Otherwise, home BP monitoring can be used as an initial strategy. If the home BP monitoring confirms that BP is indeed above goal, no further testing is needed. If home BP monitoring suggests the white-coat effect, it is recommended to proceed to ambulatory BP monitoring to confirm (SORT C). *Target BP may be lower in patients with diabetes or chronic kidney disease. **Refer to Table 1. ABPM, ambulatory blood pressure monitoring. (Adapted from Refs. 11 and 52.)
Tables
Have the patient perform measurements for a minimum of 5 consecutive days On each day, 3 morning and 3 evening measurements should be performed approximately 1 minute apart without removing the cuff Have patient record dates and times of all measurements When calculating the average, discard the first 2 days' measurements and the first measurement of each triplicate set of measurements Average the remaining measurements Information from Ref. 13.
More common Aldosteronism Obstructive sleep apnea Renal artery stenosis Renal parenchymal disease (can be cause or consequence) Less common Carcinoid syndrome Coarctation of aorta Cushing's Disease Hyperparathyroidism Pheochromocytoma Polycythemia Adapted from Refs. 1, 18, and 52.
Acetaminophen Alcohol Certain antidepressants (eg, bupropion, tricyclic antidepressants, selective serotonin reuptake inhibitors, venlafaxine, monoamine oxidase inhibitors) Corticosteroids Cyclosporine Dietary and herbal supplements (eg, ginseng, ephedra, ma huang, bitter orange) Erythropoietin Licorice (including some types of chewing tobacco) Nonsteroidal anti-inflammatory drugs (including cyclooxygenase-2 inhibitors) Oral contraceptives Sympathomimetics (eg, cocaine, amphetamines, diet pills, decongestants) Tacrolimus Adapted from Refs. 1, 18, and 52.
Assess adherence to therapy • Ask about adherence to the treatment plan • Ensure adherence to medications is as simple as possible (eg, once daily dosing regimens, generics, fixed-dose combination pills) Rule out measurement error and white coat effect • Repeat office measurement of BP making sure cuff size is correct (too small a cuff will overestimate BP) and proper technique is followed • Consider out-of-office monitoring (Figure 1) Consider associated comorbidities • Address chronic kidney disease if present • Emphasize weight loss if patient is overweight • In older patients with coronary artery disease, a low diastolic BP may limit degree to which systolic BP can be reduced Reconsider secondary causes • Test for primary aldosteronism • Consider testing for obstructive sleep apnea • Consider rarer causes such as Cushing's syndrome, coarctation of the aorta, pheochromocytoma, and hyperparathyroidism Address volume overload and interfering substances • Emphasize reducing dietary sodium; consider consulting nutrition specialist to assist • Discontinue or reduce medications, supplements, and other agents (eg, alcohol) that interfere with BP control (Table 3) Intensify therapy • Options for intensifying pharmacologic therapy (assumes patient already on low-dose thiazide diuretic, an ACEI or ARB, a long-acting calcium channel blocker, and possibly a beta-blocker): - Increase dose of diuretic (or change HCTZ to chlorthalidone) or change to a loop diuretic for those with GFR <30 mL/min
- If no contraindications, add spironolactone as first-choice (starting at 12.5 mg daily); eplerenone (starting at 25 mg daily), or amiloride (starting at 2.5 mg daily) are alternatives
- Use a vasodilating β-blocker (eg, carvedilol)
- Add a calcium channel blocker from the alternate class (eg, add a nondihydropyridine if already on a dihydropyridine)
- Add clonidine or guanfacine
Consult hypertension specialist For directory of hypertension specialists, see http://www.ash-us.org/HTN-Specialist/HTN-Specialists-Directory.aspx ACEI, angiotensin converting enzyme inhibitor; ARB, angiotensin II receptor blocker; BP, blood pressure; GFR, glomerular filtration rate; HCTZ, hydrochlorothiazide.
