Lance Sloan, MD

Panelists discuss how patients with resistant hypertension should be referred to specialists after 3 to 6 months of unsuccessful treatment, emphasizing that while primary care providers can manage most hypertension cases, specialists with particular interest and experience are needed for complex cases.

Collaborating in a Multidisciplinary Team to Control Resistant Hypertension

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The management of resistant hypertension requires a collaborative approach between primary care providers and specialists, though primary care physicians should be empowered to manage the majority of hypertensive patients. Referral to specialists should be considered when blood pressure goals are not achieved after 3 to 6 months of appropriate therapy, when secondary causes are suspected, or when patients have complex comorbidities requiring specialized expertise.

The choice of specialist varies by community resources and expertise, with referrals potentially going to cardiologists, nephrologists, or endocrinologists depending on local availability and the specialist’s particular interest in hypertension management. The key is identifying health care providers in each community who have developed expertise and maintain a systematic approach to resistant hypertension evaluation and treatment, rather than focusing solely on specialty designation.

Effective management requires a step-wise approach including ruling out pseudoresistance, identifying and treating secondary causes, eliminating interfering substances, implementing lifestyle modifications, and optimizing background antihypertensive therapy. This systematic methodology can be successfully implemented by well-trained primary care providers with appropriate specialist support when needed, ensuring that the millions of patients with resistant hypertension receive optimal care despite specialist availability limitations.

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Panelists discuss how resistant hypertension is defined as blood pressure remaining above 130/80 mm Hg despite 3 medications, including a diuretic, affecting 10% to 15% of hypertensive patients, and how to differentiate true resistance from pseudoresistance caused by adherence issues, improper measurement, white coat effect, and interfering medications.

Defining Resistant Hypertension

Resistant hypertension affects approximately 10% to 15% of all hypertensive patients, representing roughly 10 million Americans with blood pressure remaining above 130/80 mm Hg despite 3 properly prescribed antihypertensive medications from different drug classes, including a diuretic. This condition represents a significant clinical challenge that specialists encounter frequently in practice, requiring systematic evaluation to distinguish true resistance from apparent resistance.

The critical distinction between true resistant hypertension and pseudoresistance cannot be overstated, as up to 50% of apparently resistant cases may actually represent pseudoresistance. The primary causes of pseudoresistance include medication nonadherence, improper blood pressure measurement techniques, and white coat hypertension. Health care providers must systematically address these factors through proper cuff sizing, patient positioning, adequate rest periods, and comprehensive out-of-office blood pressure monitoring using ambulatory monitoring or validated home devices.

Secondary causes of hypertension, particularly primary hyperaldosteronism, require active screening in resistant hypertension patients regardless of potassium levels. Current recommendations emphasize obtaining aldosterone-to-renin ratios in all patients with treatment-resistant hypertension, as 10% to 15% will have elevated aldosterone with suppressed renin. Additional secondary causes include mild autonomous cortisol secretion, pheochromocytoma, and medication interference from NSAIDs. Identifying these treatable causes can significantly improve blood pressure control and reduce cardiovascular risk.

Lance Sloan, MD

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