So, your hypertension is being treated with several blood pressure medications, BUT your blood pressure is STILL not controlled. Why?
You might have apparent resistant hypertension.
What is this all about?
Apparent resistant hypertension should be ruled out in order to treat resistant hypertension aggressively as soon as possible for the best possible result.
Here, I will define hypertension, resistant hypertension, refractory hypertension, and apparent resistant hypertension.
Then, I will give two brief scenarios that might sound confusing. But, I will try to emphasize that it is VERY important for you to reveal three things to your health care provider:
1) Your true blood pressure measurement because high blood pressure may be due to inaccurate blood pressure measurements FROM poor technique
2) The EXACT medication you are taking, especially if it is different than what was prescribed. Medication nonadherence is a major problem with obtaining the RIGHT blood pressure treatment.
3) White coat hypertension
All three factors are VERY IMPORTANT to take into consideration before YOUR BLOOD PRESSURE can be adequately treated.
Apparent Resistant Hypertension
Several key things need to be done to diagnose resistant hypertension. Otherwise, you might have hypertension (essential) or resistant apparent resistant hypertension.
The key things according to the most current resistant hypertension guidelines are:
1) Office blood pressure measurement according to the NEW 2017 hypertension guidelines
2) Exclusion of white coat syndrome
3) Exclusion of medication nonadherence
Hypertension is a major cause of damage to many organs. Resistant hypertension, if uncontrolled, puts you at a higher risk than hypertension. See the video below to see why you should not leave hypertension or resistant hypertension untreated.
Hypertension
Hypertension is defined as blood pressure greater than 140/90 mm Hg based on at least two measurements on at least two occasions.
According to the current hypertension guidelines, AT LEAST two blood pressure medications will be needed to get to goal.
There are foods and supplements that can help improve hypertension and resistant hypertension. See the video below by Dr. Axe. He shares EPIC INFORMATION about diet, exercise, and supplements to consider.
Resistant Hypertension
Resistant hypertension is hypertension that is difficult to treat or resistant to treatment despite at least three different kinds (classes) of antihypertensive medication. The fact that your hypertension requires three blood pressure medications makes it difficult to treat or resistant to treatment.
On average about 14.8 % of people treated with anti hypertensive medication have resistant hypertension.
Resistant hypertension can be defined as controlled (<140/90 mm Hg) or uncontrolled (>140/90 mm Hg). However, when resistant hypertension is uncontrolled, it is called refractory hypertension. If you have refractory hypertension, it can be the worst type of hypertension because no medication regimen controls it.
Refractory Hypertension
Refractory hypertension is uncontrolled resistant hypertension despite treatment with an optimal medication regimen and tolerable doses of hypertension medication.
Apparent Resistant Hypertension
A surgeon general once said that “medications do not work in patients who do not take them. Blood pressure measurements are one of the most important tasks conducted in the medical office. Sometimes elevations are due to just being in the medical office. This is called white coat syndrome.
Scenario 1
Let us say you are African American and you are on four medications. For example, you are prescribed Lisinapril/HCTZ 20 mg/25 mg, Atenolol 100 mg and Diltiazem ER 360 mg daily. You have no comorbities and are tolerating the medications without side effects.
Yet, your blood pressure is constantly between 150/90 and 160/80 mm Hg at your office visits for at least the last 12 months.
This medication regimen appears to meet the requirements of resistant hypertension. It has four different classes of antihypertensive medication including a diuretic and maximum tolerable doses.
All things being equal, you have either resistant hypertension, treatment failure (refractory hypertension), or apparent resistant hypertension. More information and further testing would be needed for the correct diagnosis.
Nevertheless, you found a hypertension specialist who did a complete workup for resistant hypertension. Over the last 6 weeks, she has made several changes to your medication after the testing comes back normal.
Now you are on Chlorthalidone 12.5 mg and Amlodipine 5 mg daily. Your blood pressure measurements are constantly between 115/ 80 and 119/68 mm Hg at your office visit after three months.
Do you have hypertension, resistant hypertension, treatment failure (refractory hypertension), or apparent resistant hypertension? It appears that you have hypertension with apparent resistant hypertension.
Sometimes just a change in your treatment regimen can make the difference in having controlled blood pressure and uncontrolled blood pressure. It could also possibly make the difference between resistant, refractory, and apparent resistant hypertension.
Scenario 2
Now, pretend you are African American and you are on four blood pressure medications. For example, you are prescribed Lisinapril/HCTZ 20 mg/25 mg, Atenolol 100 mg and Diltiazem ER 360 mg daily.
Here, your blood pressure is constantly between 115/ 80 and 119/68 mm Hg at your office visits for at least the last 12 months.
Do you have hypertension, resistant hypertension, treatment failure (refractory hypertension), or apparent resistant hypertension?
Again, this medication regimen appears to meet the requirements of resistant hypertension. It has four different classes of antihypertensive medication including a diuretic and maximum tolerable doses. But now your blood pressure is controlled on four medications.
You have resistant hypertension. You do not appear to have treatment failure (refractory hypertension) since your blood pressure is controlled on four medications. Do you have apparent resistance hypertension? More information and further testing would be needed for the correct diagnosis.
You DON’T LIKE TAKING MEDICATION, but you are on four blood pressure medications a day. You want to get off the medications, but this regimen is controlling your blood pressure. What to do?
The WORST THING you can do is to stop taking your blood pressure medication. The best thing you can do is to keep taking your medication and see a hypertension specialist.
You found a hypertension specialist to get a second opinion. She did a complete workup on you to determine if you have resistant hypertension. Over the last 6 weeks, she has made several changes to your medication after all testing came back normal.
Now you are on Chlorthalidone 12.5 mg and Amlodipine 5 mg daily. Your blood pressure measurements are constantly less than 120/80 mm Hg at your office visit after three months.
You have hypertension and apparent resistant hypertension. You do not have treatment failure (refractory hypertension) since your blood pressure is controlled on two medications.
Summary
The two scenarios above are similar to the cases that I see repeatedly in the medical clinic. Of course, I have simplified the scenarios’ medication regimen and blood pressure measurements for ease of comprehension.
Nevertheless, I hope you understand that apparent resistant hypertension is real, and should be detected to get the best results. You will get the correct treatment sooner, minimize the amount of medication prescribed, and get to your target goal with the least delay.
Share Your Experience
What does your medication regimen look like? What is your blood pressure on that regimen? Let me know in the comment section below.
Resources
Judd, E. & Calhoun, D. (2014). Apparent and true resistant hypertension: definition, prevalence and outcomes. Journal of Human Hypertension 28(8), 463-468.
