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Resistant Hypertension

Malcolm Thaler, MD and Rob Orman, MD
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Rob and Malcolm Thaler discuss evaluation and management of patients with resistant and secondary hypertension.


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Irvin S. -

Regarding hyperaldosteronism and hypokalemia: we are classically taught that these 2 go hand in hand. However, most patients with hyperaldosteronism are normokalemic. We should therefore not be dissuaded from checking for hyperaldosteronism in the normokalemic patient.

Fredrik H. -

I have a question regarding resistant hypertension. If my patient is on 3 medications including ace or arb and I want to screen with plasma aldosterone to plasma renin concentration to rule out hyperaldosteronism. Do I need to stop the active medications then because they change the renin or aldosterone levels? And if yes how long should they be without medication before the screening?

Heidi J., MD -

Hi Frederik -

Here is Dr. Thaler's reply:

A great question! ACEIs and ARBs can sometimes raise the plasma renin concentration (PRC) and affect the plasma renin activity (PRA) as well, thus throwing off the plasma aldosterone activity (PAC)/PRA ratio. If the PRA is still pretty much undetectable despite ACEI/ARB therapy, as you would expect in hyperaldosteronism, then that is reliable and you have your answer. If it is not, however, then you can't be sure, and you have to stop the ACEI/ARB and remeasure. However, it may not be worth it. Why not just add the aldosterone antagonist (e.g. spironolactone) and see what kind of clinical response you get? If the patient responds with a lowered BP, why bother pursuing the underlying pathophysiology? You have the outcome you want - a normotensive patient! The risk of your missing an adrenal malignancy is tiny, but if you are concerned you can always order an adrenal CT. Hope this answers your question.

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