Description
The commonest difficult patient in general practice
Every general clinic has them: on three antihypertensives, properly dosed, still above target, seen every few months, gradually accumulating organ damage while everyone concludes the pressure is simply difficult.
Most of the time it is not resistant. It is something else that was never checked.
Start with what is cheap to exclude
Measurement technique, white-coat effect, dosing adequacy and — above all — adherence, which studies repeatedly show explains a large share of apparent resistance and is almost never investigated first. Establishing genuine resistance before ordering a secondary workup saves the patient investigations and the service considerable expense.
Secondary causes worth finding
Primary aldosteronism gets the prominence the evidence supports rather than the footnote it usually receives — commoner and more treatable than most clinicians assume, and routinely missed. Renal artery disease. Obstructive sleep apnoea. Phaeochromocytoma. Drug-induced hypertension, including the over-the-counter agents patients never mention because they do not consider them medication.
Treating beyond three drugs
Sequencing, spironolactone as a fourth agent, and where renal denervation currently stands. Where a drug is unavailable on a local formulary, the guide states what the substitution costs.
Suits
General physicians, family doctors, nephrologists, diabetologists and cardiologists running blood pressure clinics.
PDF, lifetime access, at CardiologyBooks.com.
Before the label is applied
Most patients carrying the label do not have resistant hypertension. The guide begins where the diagnosis is usually lost: unconfirmed out-of-office readings, an inadequate three-drug combination, undisclosed non-adherence, and the cuff that is the wrong size. Each is given a practical method of exclusion that a clinic can actually run.
When it is real
Once resistant hypertension is confirmed, the text moves through secondary causes in order of yield — primary aldosteronism first, because it is far commoner than its referral rate suggests — then to the fourth agent, the role of spironolactone, and the point at which renal denervation and specialist referral become reasonable. Drug interactions, NSAID and decongestant use, obstructive sleep apnoea and alcohol are covered as the reversible contributors they usually are.
