Hypertension Control Difficulty

Arterial hypertension is difficult to control, it is also called resistant hypertension. It is one that cannot be controlled even with multiple antihypertensive medications, causing a high risk of cardiovascular disease.

Hypertension control
Hypertension control


The current consensus classifies hypertension as follows:
  • Normotensive: people with blood pressures lower than or equal to 120/80 mmHg
  • Pre-hypertensive: people with blood pressures between 121/81 - 139/89 mmHg
  • Hypertension grade I: blood pressures between 140/90 - 159/99 mmHg
  • Hypertension grade II: blood pressures greater than or equal to 160/100 mmHg

It's necessarry to note that a single measurement is not sufficient to establish the diagnosis of hypertension. The patient is hypertensive when their blood pressure levels present consistently above 139/89 mmHg. In our general text on hypertension (first link on the list above) it is explained in more detail how the diagnosis of hypertension is made.

Definition of resistant hypertension

Not all uncontrolled hypertension is synonymous to resistant hypertension. Need for 2 or 3 different medications to control blood pressure is commonplace in medical practice. Resistant hypertension is defined only when it cannot be checked with at least three different antihypertensive drugs (preferably one being diuretic), i.e. every patient who needs 4 or more different drugs to make their blood pressure below 140/90 mmHg is considered as having hypertension difficult to control. It is estimated that about 15% of hypertensive patients have criteria for resistant hypertension.

Note that it is necessary that the patient actually takes prescribed antihypertensives to characterize one as hypertension difficult to control. If the patient takes the drugs voluntarily wrong, going against what was prescribed, the pressure will remain high, not because it is tough, but because it is not being treated properly. Similarly, when treatment proposed by the physician is unsatisfactory or doses are insufficient or the choice of drug is erroneous, blood pressure can be uncontrolled which is actually a resistant hypertension. For example, a diuretic with no limitation to these patients is considered a treatment failure. In these cases simply setting the pressure for the treatment can be monitored under 4 different drugs.

Some cases, which are considered difficult to control, are actually patients with so-called white coat hypertension. These are patients, who are so anxious during medical visits that their blood pressures, although well controlled at home, can rise at the time of measurement by the doctor, giving the false impression of not being properly controlled.

Risk factors for hypertension difficult to control

Generally difficult to control hypertensions are those with high blood pressure, hypertension classified as grade II. A mild hypertension can usually be controlled with one or two different drugs. Some genetic, some environmental factors and the presence of certain diseases can impair blood pressure control, favoring the emergence of resistant hypertension. Among them we can mention:
Hypertension risk factors
Hypertension risk factors

Drugs that interfere in the treatment of hypertension

In addition to the above factors, the use of certain drugs can also interfere with the efficacy of antihypertensive drugs, so you have to increase their doses and / or more associated drugs in the treatment regimen. Among them we can mention:
  • Anti-inflammatory
  • Aspirin in doses above 500 mg per day
  • Oral contraceptives
  • Analgesics morphine derivatives
  • Amphetamines and derivatives
  • Corticosteroids
  • Cyclosporin
  • Nasal decongestants
  • Erythropoietin
  • Remedies based on Ephedra or Ma huang, widely used in treatments called natural weight loss. (Note: most of the remedies to lose weight, natural or not, contain substances that interfere with blood pressure)

Secondary causes of hypertension

The overwhelming majority of cases of hypertension is primary, or appears without an established cause. This means that the patient is hypertensive with no identifiable reason for the appearance of the disease. Hypertension with no apparent cause is called essential hypertension, which is responsible for over 90% of cases.

However, in a minority of patients hypertension can occur due to an underlying disease, it is so called secondary hypertension. If secondary hypertension is uncommon among population with hypertension, when separated only those with difficult to control hypertension, it becomes a relatively common cause. Among the causes of secondary hypertension in patients with difficult to control hypertension there are:
  • Chronic renal failure (CRF can cause hypertension but also may be a consequence of it)
  • Hyperaldosteronism (often caused by a benign tumor of the adrenal gland which produces excess aldosterone, a hormone that regulates uptake of salt in the kidneys)
  • Renal artery stenosis (reduction in the diameter of the artery to the kidney)
  • Obstructive sleep apnea

Treatment of difficult to control hypertension

To control blood pressure it is necessary to first make sure in some points, such as adherence to prescribed treatment and the absence of white coat hypertension. Eliminating drugs that may be interfering with the processing is also essential. If so, the patient should stop smoking, cut alcohol consumption, lose weight and start regular physical activity. The salt should be cut from the diet. Western population of the world eats too much salt and is not aware of the fact.

If all the above factors are corrected and blood pressure is still high, requiring at least 4 drugs for adequate control one must investigate secondary causes. Once identified a cause for hypertension, it should be treated.

If despite all the pressure remains high, some drugs may be associated with current antihypertensive regimen. Among them we can mention:
  • Spironolactone
  • Rilmenidine
  • Methyldopa
  • Hydralazine
  • Clonidine
  • Minoxidil

The latter drug is extremely potent, being able to control virtually all cases of resistant hypertension, but should be used with caution because it causes hypotension besides causing frequent side effects.

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