Refractory hypertension

February 18, 2020

I had a patient today who was referred to the hypertension clinic for management of her refractory hypertension on 5 medications. This 50-something year old female patient was diagnosed with hypertension over 25 years ago after developing pre-eclampsia. She was on an ACE inhibitor, beta-blocker, calcium channel blocker, thiazide-like diuretic, and triamterene (potassium-sparing diuretic). Her past medical history also includes diet-controlled diabetes and dyslipidemia which were all at target. Interestingly, when I saw her, she was tapered down to 2 medications (ACE inhibitor and beta-blocker) as her blood pressure has been within target of 130/80 (given her diabetes). Upon further inquiry, she reports that the only change she's had since her referral is weight loss of about 10 kg. It is uncertain if she has had any work-up for secondary causes of her hypertension.

Looking into the literature, it seems that weight loss can have significant impact on blood pressure.

• "The Framingham Study found that hypertension is about twice as prevalent in the obese as the nonobese of both sexes." (Harsha, 2008)
• The Trial of Hypertension Prevention (TOHP), one of the largest of these studies, included a weight loss intervention arm.30 In this instance, a 2-kg loss in weight over a 6-month period resulted in a decline of 3.7 mm Hg in systolic and 2.7 mm Hg in diastolic blood pressure (Hypertension Prevention Trial Research Group, 1990)

This case highlights to me the importance of counselling patients on lifestyle modifications. For diet,  would recommend looking into the DASH (Dietary Approaches to Stop Hypertension).

-JT-

Reference(s):

Harsha, D. W., & Bray, G. A. (2008). Response to Weight Loss and Blood Pressure Control: The Pro Side. Hypertension, 51(6), 1420-1425.

Hypertension Prevention Trial Research Group. (1990). The Hypertension Prevention Trial: three-year effects of dietary changes on blood pressure. Archives of Internal Medicine, 150(1), 153-162.

https://www.heartandstroke.ca/get-healthy/healthy-eating/dash-diet