Resistant hypertension needs special attention

Published: September, 2005

At least half of the 80 million Americans with high blood pressure don't have it under control. Sometimes poor control stems from lack of trying. A growing number of people, though, have what's called resistant hypertension — blood pressure that stays stubbornly above the target (see "Blood pressure goals") in spite of lifestyle changes and medications.

Persistently high blood pressure is a problem. It is a key contributor to stroke, heart failure, and other cardiovascular conditions.

Strictly speaking, you have resistant hypertension if your blood pressure is still high even though you are taking three or more pressure-lowering medications, or if you need to take four or more medications to reach your blood pressure target.

Having resistant hypertension doesn't mean your blood pressure will always float above the healthy range. Instead, it means you need extra help finding its pressure points.

Starting strategies

Taming resistant hypertension starts with the same steps used to control garden-variety high blood pressure. The first is understanding your pattern. You can do this by wearing a pager-sized automatic blood pressure recorder for 24 hours or by buying a home blood pressure monitor and checking your pressure several times a day.

Second, make sure you are covering the bases. This means:

  • taking the right medications, in the right doses, at the right times
  • not taking medications that can boost blood pressure (see below)
  • making lifestyle choices that ease, rather than elevate, blood pressure.

Drugs and supplements that boost blood pressure

  • Painkillers and anti-inflammatory agents such as aspirin, ibuprofen, naproxen, and celecoxib (Celebrex)
  • Diet pills
  • Cocaine, amphetamines, other stimulants
  • Excess alcohol
  • Oral contraceptives or estrogen
  • Cyclosporine
  • Erythropoietin
  • Natural licorice
  • Ephedra or ma huang; yohimbine

Here are some specifics:

Stick to your meds. Try to follow the regimen your doctor prescribed.

Fine-tune medications. Almost everyone with resistant hypertension should be taking a thiazide diuretic (water pill) such as chlorthalidone or hydrochlorothiazide. Medications that can be added to the diuretic include beta blockers, calcium-channel blockers, ACE inhibitors, angiotensin-receptor blockers, alpha blockers, potassium-sparing diuretics, aldosterone antagonists, and renin blockers. Some people respond better to certain types than to others. Tinkering with timing may also help — some people can get by with once-a-day medications, while others need to take shorter-acting pills two or three times a day.

Shake the salt habit. If you have resistant hypertension, hide your salt shaker, stay away from foods packed with sodium, and beware of the sodium in many processed foods.

Make a DASH for it. Adopting the clinically proven DASH diet, especially the low-sodium version, can drop blood pressure by 10 points or more.

Go easy on alcohol. Excess alcohol can elevate blood pressure. Keep it moderate — no more than one drink a day for women, two for men.

Watch your weight and pick up the pace. Exercising more and losing excess weight are great ways to lower blood pressure.

Reduce stress. Just as mental and emotional stress can raise blood pressure, meditation, deep breathing, and other stress-busting activities can lower it.

Blood pressure goals

Under 120/80: the ideal
Under 140/90: the goal if you are being treated for high blood pressure
Under 130/80: the goal if you have high blood pressure and diabetes or chronic kidney disease

Hidden causes

High blood pressure usually stems from arteriosclerosis, the hardening and stiffening of the arteries. But it can also be a sign of trouble elsewhere in the body. If you have resistant hypertension, it's worth being checked for what doctors call a secondary cause.

A commonly overlooked source of high blood pressure is the breath-holding type of snoring known as obstructive sleep apnea. Treating it can improve blood pressure.
Some people with resistant hypertension have overactive adrenal glands.

The accumulation of artery-clogging plaque in blood vessels that nourish the kidneys, a condition called renal artery stenosis, is another hidden contributor to resistant hypertension. Opening the blocked arteries with balloon angioplasty often improves blood pressure.

Renewing your focus

When your blood pressure is high, lifestyle changes and medications can usually ratchet it down into the healthy range. If they don't, it's worth broaching the topic of resistant hypertension with your doctor.

January 2009 update

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