Ajaykumar D. Rao, MD, MMSc, FACP, discusses the complexity of patients with resistant hypertension and secondary hypertension, and when patients benefit from a referral to clinical hypertension experts. With Temple’s Comprehensive Hypertension Program, patients’ cases are reviewed in tandem by a multidisciplinary team of experts, rather than individual specialists on a case-by-case basis.
talk a little bit about resistant hypertension. Uh My name is J. D. Row. I'm one of the associate professor of medicine at uh Lewis Katz School of Medicine at Temple University. I'm a clinician in the section of endocrinology, diabetes and metabolism. And my clinical practice is part of Temple Faculty physicians. Uh Temple University Hospital in Temple Health. Thanks for joining. So our objectives today will be to talk about resistant hypertension and how frequently does it actually occur? What are some actual causes of resistant hypertension? When to consider referral to specialty resources and what can be achieved with these referrals to other providers in patients with difficult to control blood pressure. So what is resistant hypertension and how frequently does it occur? So resistant hypertension is really blood pressure that's above goal. Uh And when there's use of three antihypertensive agents of different classes taken at maximally tolerated doses by an individual patient. One of these classes should include a diuretic and that's very important. Um As many patients can be responsive to diuretic agents controlled resistant hypertension is a term defined as blood pressure at goal while taking four or more antihypertensive medications. So what is not resistant hypertension? White coat hypertension is not resistant hypertension and we'll talk about some tools that are available now to help distinguish white coat hypertension from resistant hypertension. Non adherence is also not resistant hypertension. Many providers prescribe appropriate treatments but I have not identified factors that are leading to problems with adherence and that's very important to do and there can be other factors that are very difficult to assess in a clinical setting. Perhaps there are other medications that are increasing blood pressure that one doesn't know about. So, it's really important to take a good uh, inventory and assessment of what medications patients are on prescribed and non prescribed. And of course it's always important to consider lifestyle modification, whether it be weight loss, appropriate, um handling of salt balance in certain patients, other dietary factors. It's really important to keep that in mind for problems with difficulty in controlling blood pressure. And of course, like I mentioned before, addressing the factors that are leading to patient level non adherence. So what's the importance of early identification of patients with difficult to control blood pressure? So there's a high risk for downstream cardiovascular events in these patients. And clearly literature shows that many of these patients can have early cardiovascular disease and it's really important to assess these patients earlier rather than later. I think an interesting point here is that many of these patients will probably have a secondary cause of hypertension. And we'll talk about this a little bit later. Um, identifying these secondary causes could lead to reverse ability of their difficult to manage blood pressure. Some of these patients may require early and aggressive treatment. So it's really important to identify these patients earlier than later. Um and and a lot of these patients may require specialized diagnostic tools and interventions to assess what's going on. So what are some causes of resistant hypertension. So, what is secondary hypertension? So most patients that we usually take care of, we comment that they have primary or essential hypertension. This is the bulk of the patients that we treat in an algorithm and based blood pressure lowering treatment strategy. There is now increasing awareness that close to 10% of these patients may harbor an identifiable identifiable cause of their high blood pressure condition, also known as secondary hypertension. And so secondary hypertension is really linked to resistant hypertension because we really should be considering secondary hypertension in all patients who have resistant hypertension. With no other explainable reasons. Here are some causes of secondary hypertension. So there can be causes that are centered around the kidney. So reno vascular disease such as renal artery stenosis or fiber vascular dysplasia. I'm a treating endocrinologist. So I'm interested in endocrine causes uh could be excess valdosta ronin. The circulation, something known as primary valdosta rhone is um excess cortisol, something known as cushing's disease, or cushing syndrome. Uncontrolled thyroid thyroid disease, which can either be underactive thyroid or overactive thyroid. Um and also the rare entity of theo chromosome toma where patients can have excesses of their adrenaline and nor adrenaline surging into their body and causing high blood pressure problems? There can be vascular issues such as correct ation of the aorta? Um and other conditions can also cause hypertension, such as obstructive sleep apnea. And patients, women who are pregnant can have issues with their blood pressure control. Clearly as you can see, this sort of multiple reasons for having secondary hypertension lends itself to the need for a multidisciplinary approach. Um And this is very crucial in the management of patients where you're suspecting a secondary form of hypertension. So when should one consider referral? Who should you refer to and what can be achieved with early referral? So when should you consider referral? So resistant hypertensive patients with resistant hypertension whether they are controlled or uncontrolled really need to be referred to an expert in hypertension. And the reason this is important is that we could be missing a secondary form of hypertension. Traditionally the way this has happened is either a referral to an individual specialty where one thinks where the problem lies. So perhaps referring to a cardiologist, referring to a nephrologist or referring to an endocrinologist based on what the provider might be thinking is going on. But hopefully from what I've presented, you can clearly understand that a multidisciplinary approach is really needed in most of these patients. As the clinically available data really makes it difficult to to choose one specialist or the other upfront with other without understanding what's going on with the patient Benefits of early referral include utilization of 24 hour blood pressure monitoring. 24 hour blood pressure monitoring has really become standard of care for many patients living with high blood pressure. This involves continuous monitoring which is really an amazing technology for most of our patients. And it does now appear from large scale studies that um your 24 hour blood pressure tracing is probably more related to end organ outcomes than an isolated blood pressure measurement in the clinic or even in your own home. Another crucial part of 24 hour blood pressure monitoring is that it really helps distinguishing white coat hypertension which is of course high blood pressure reading in the office with normal blood pressure readings back in your usual home. Um And also can distinguish mass hypertension which is really something that we forget about. Which is somebody who has a normal blood pressure in the office but is also but instead is actually having a high blood pressure at home. And the 24 hour blood pressure monitor. Can really assess this very elegantly. The actual most important part of 24 hour blood pressure monitoring is really to assess if somebody has sustained hypertension. And this is really somebody where you need to be considering uh you know assessing what really is going on with the patient considering secondary forms of hypertension. Another benefit of early referral is appropriate laboratory testing. Um So one could be assessed for various hormonal factors which we talked about earlier that could be causing secondary forms of hypertension. Also there could be a nice assessment of early end organ damage whether it be by a 12 lead E. K. G. Or an echocardiography. And these might be things that you may not traditionally order in a patient with high blood pressure in the initial visit. And this helps understand whether the patient is suffering from an organ damage from their high blood pressure. And most importantly this can definitely ensure a secondary cause of hypertension is not missed an individual patient. The summary I think identification of a resistant hypertensive patient is crucial. And hopefully I've been able to show you how early referral could be beneficial for an individual patient. There are very very variety of diagnostic agents that can be helpful in these in this early referral setting such as 24 hour ambulatory blood pressure monitoring. And this has really become a very meaningful and useful technology for many of our patients living with high blood pressure. I strongly encourage you to consider referral to a hypertension program near you. Uh Temple has a comprehensive hypertension program uh And we're happy to see these patients um and and help them get to better outcomes with you. Thanks