STILL HYPERTENSIVE ON 5 DRUGS: WHAT NOW?
DAVE RAINHAM, MD, of Kitchener, ON, describes the following case: "A 52-year-old woman with asthma and moderate obesity has high blood pressure that won't budge. She's on prazosin 4 mg daily, fosinopril (Monopril) 40 mg daily, hydrochlorothiazide/triamterine (Dyazide) 25 mg/50 mg b.i.d., and diltiazem 300 mg daily. She insists she's compliant but her blood pressure is persistently 210/110. A basic blood screen (creatinine, electrolytes, blood indices) was normal. Do you have any suggestions, short of tertiary referral?"
This patient clearly has drug-resistant hypertension, which is defined as persistent hypertension despite four good doses of medications. She should be referred to an expert on hypertension to investigate secondary causes. Because of her obesity, Cushing's is a possibility -- a 24-hour urine collection for free cortisol wouldn't be unreasonable. I'd also consider this woman for a renal angiogram to rule out renal artery stenosis. Finally, I'd want to perform a 24-hour urine collection for free catecholamines and vanillylmandelic acid (VMA) to look for a pheochromocytoma. GC