Difficult to Manage Hypertension

I saw a patient in the Ambulatory GIM clinic referred for hypertension. He had a history of difficult to manage hypertension and was currently taking 5 agents to lower blood pressure: ACE inhibitor, calcium channel blocker, beta-blocker, loop diuretic, and a nitroglycerin patch. Despite these, he was referred to the ED after a family doctor found an office blood pressure over 200/110. Thankfully he was asymptomatic and investigations showed no evidence of end organ damage. In the office his blood pressure was in the normal range. However, we were still concerned about refractory hypertension. My preceptor helped me work through a differential diagnosis for secondary causes hypertension. We ordered plasma metanephrines and a renin-aldosterone ratio to assess for pheochromocytoma and Conn's syndrome, respectively. We ordered an abdominal ultrasound to assess for renal artery stenosis. On physical exam we did not detect any signs of Cushing syndrome and so thought 24h urine cortisol wasn't necessary. We also thought about whether the patient would benefit from intensive blood pressure control. The patient did not have a history of diabetes or stroke and so might benefit from a blood pressure target under 120 systolic evidenced by the SPRINT trial. This was a great educational experience allowing me to think through refractory hypertension and it also allowed us to explore some emerging evidence on more aggressive blood pressure targets.

- MH