Overcoming resistant hypertension
This condition is more common among older adults who battle high blood pressure.
- Reviewed by Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
Up to 70% of adults ages 65 and older have high blood pressure (hypertension). This is diagnosed when your systolic pressure (the top number on a blood pressure reading) of 130 millimeters of mercury (mm Hg) or higher or a diastolic pressure (the bottom number) of 80 mm Hg or higher.
Common drug treatments include calcium-channel blockers, ACE inhibitors, angiotensin-receptor blockers (ARBs), and diuretics, given either individually or in combination. Calcium-channel blockers help blood vessels relax, ACE inhibitors and ARBs block a key hormone pathway involved in raising blood pressure, and diuretics eliminate excess sodium and water in the body. Adopting healthy habits that help lower high blood pressure is also an important part of the treatment strategy — like losing weight, quitting smoking, reducing salt in your diet, and being more active.
Extra help
However, some people do not respond to such therapies. If your blood pressure remains above 130/80 mm Hg despite taking the best dosage you can tolerate of at least three different blood pressure medications (with one being a diuretic) and following healthy habits, you have what's called resistant hypertension.
"Resistant hypertension often takes longer to control, and requires more intensive evaluation," says Dr. Naomi D.L. Fisher, director of the Hypertension Service at Harvard-affiliated Brigham and Women's Hospital. "We pay close and careful attention to patients with resistant hypertension, as it can significantly increase a person's risk for a heart attack or stroke."
About 20% of people with hypertension battle resistant hypertension, according to the most recent statistics from the American Heart Association. Still, some people may be classified as having resistant hypertension when other factors are keeping their blood pressure elevated. "These should be checked first before making changes to existing medication," says Dr. Fisher.
For instance, people might not be taking their blood pressure medication as prescribed. They may skip doses because they forget, fear possible side effects, don't think the problem is serious, or can't afford the pills. "Speak with your doctor if you're having trouble taking your medication," says Dr. Fisher. "The doctor may offer solutions, like finding more affordable medication, combining pills, or changing your dosage to make it easier to take."
Other problems
Another issue is white-coat syndrome. Blood pressure readings are often taken at a doctor's office or medical clinic. These environments can increase anxiety levels and temporarily spike blood pressure. There are a few ways around this problem.
For instance, after your first reading at the office, ask the nurse or medical assistant who took your blood pressure to repeat the measurement after several minutes to see if it has changed. You also can help ease anxiety by doing several minutes of deep breathing exercises before your reading.
Still another option is to take readings at home with a blood pressure machine. If you have hypertension, guidelines recommend you measure your blood pressure in the morning and evening for one week, always before taking your pill, and then share the information with your doctor.
What's next
Your doctor will also explore other underlying issues that can contribute to resistant hypertension. For example:
Sleep apnea. This common condition is marked by repeated pauses in your breathing — lasting from a few seconds to a minute or so — while you sleep. Research has found that sleep apnea can quadruple the odds of having resistant hypertension among people at high risk for heart disease.
Alcohol. Excess drinking can elevate blood pressure. "Men should limit their intake to no more than two drinks daily," says Dr. Fisher.
NSAIDs. Nonsteroidal anti-inflammatory drugs (NSAIDs) — over-the-counter painkillers like ibuprofen (Advil, Motrin) and naproxen (Aleve) — can raise systolic blood pressure anywhere from 2 mm Hg to 5 mm Hg. "If you are taking more than occasional doses to control pain, you should discuss this with your doctor," says Dr. Fisher. Your doctor also may check for specific medical conditions that can affect blood pressure, such as kidney disease or a problem with one or both adrenal glands.
After all these boxes have been checked, there are other steps your doctor can take to treat resistant hypertension. These include re-examining your lifestyle habits, increasing your current medication dosage (if possible), or adding a fourth drug from another class like a mineralocorticoid-receptor antagonist, such as spironolactone (Aldactone) or eplerenone (Inspra) that inhibits harmful actions of the adrenal hormone aldosterone.
Image: © Milan Markovic/Getty Images
About the Author
Matthew Solan, Executive Editor, Harvard Men's Health Watch
About the Reviewer
Howard E. LeWine, MD, Chief Medical Editor, Harvard Health Publishing; Editorial Advisory Board Member, Harvard Health Publishing
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