Resistant hypertension when goal is not achieved-
Ans. is 'c' i.e., 3 drugs + diuretics o Resistant hypertension is defined in the 2008 American Heart Association guideline as blood pressure that remains above goal in spite ofconcurrent use of'"three antihvpertensive agents^ of different classes, one of which should be a diuretic.o Patients whose blood pressure is controlled with "four or more" medications are considered to have resistant hypertension.Pharmacologic therapyo The pharmacologic treatment of resistant hypertension, by definition, involves combinations of "three or more " drugs, including a "diuretic".o Three drugs with different mechanism of action should be sequentialy combine:o The triple combination consists ofAn ACE inhibitor or ARBA long-acting dihydropyridine calcium channel blocker (usually amlodipine), andA long-acting thiazide diuretic (preferably chlorthalidone) well tolerated.o This triple combination is often effective and generally well tolerated. Among patients with uncontrolled hypertension who are already being treated with such a three drug regimen at maximum recommended and tolerated doses, spironolactone is added.o Most patients with resistant hypertension are being treated with a three-drug regimen different from ihe preferred regimen of an angiotensin inhibitor, long-acting dihydropyridine calcium channel blocker, and diuretic chlorthalidone; in addition, most who are prescribed four or more antihypertensive drags are not receiving an aldosterone antagonist.Diureticso Persistent volume expansion (typically not sufficient to produce edema) contributes to resistant hypertension, even among patients who have been on conventional doses of thiazide diuretics,o Effective diuretic use is almost always necessary to achieve blood pressure control in patients with resistant hypertension.o Diuretics should be titrated until the blood pressure goal or the maximum recommended dose (as described below) has been reached or the patient has signs suggestive of overdiuresis such as fatigue, orthostatic hypotension, or decreased tissue perfusion as evidenced by an otherwise unexplained elevation in ihe serumcreatinine concentration. If overdiuresis is suspected, diuretic therapy needs to be reduced.o In those with little renal impairment, chlorthalidone is preferred to hydrochlorothiazide for the treatment of resistant hypertension.Aldosterone antagonistso The available aldosterone antagonists, spironolactone and eplerenone, are mineralocorticoid receptor antagonists, while potassium-sparing diuretics (eg, amiloride and triamterene) block collecting tubule sodium channels that are normally opened by aldosterone. Spironolactone, eplerenone, and amiloride provide significant antihypertensive benefit when added to existing multiple drug regimens in patients with resistant hypertension.o This should be done in patients with resistant hypertension:o If the patient is on hydrochlorothiazide, switch to chlorthalidone.o If the current regimen includes a drug not from the three recommended drug classes, add the missing preferred drug and assess the response.o If the patient is still hypertensive despite being treated with the three preferred drugs, add an aldosterone antagonist.o If the patient is still hypertensive, additional medications are added sequentially.o Possible agents that may be used includeVasodilating beta blockers (labetalol, carvedilol, or nebivolol)Centrally acting agents (clonidine or guanfacine), andDirect vasodilators (hydralazine or minoxidil).
4 drugs + diuretics
2 drugs + diuretics
3 drugs + diuretics
5 drugs + diuretics
Hypertension