This review by a hypertension expert was referred to me by Dr. Hopkins, and it is an easy read and nice walkthrough of the steps we can takein clinic to evaluate patients on 3 or more drugs who do not have well controlled hypertension. This comes up pretty frequently in clinic, so it will be high-value reading.
A couple of quick points:
-Remember that "Virtually all of the data obtained on the benefits of treating high BP are based on treating the value of the BP obtained in the sitting position after a minimum of 5 minutes of rest in a quiet environment with an empty bladder, feet on the floor, and back supported." And the cuff should cover at least 80 percent of the patient's arm; a cuff that is too small will also give a falsely elevated reading.
-Using the figure from the article, one can select drugs that are "complimentary rather than overlapping."
-Townsend R R CJASN 2011;6:2301-2306
-Mineralocorticoid antagonists like spironolactone can be a nice fourth line additions to multidrug regimens that already contain a thiazide/beta blocker/ACEi/CCB type of regimen
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