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Treating resistant hypertension

Drugs may not be enough to lower stubborn high blood pressure.

Approximately half of the 67 million Americans with high blood pressure are unable to bring their blood pressure down to desired levels with medications. When taking the maximum-tolerated doses of at least three medications—one of which is a diuretic—fails to work, these people are said to have resistant hypertension. It’s a huge concern.

“The risk of heart attack, stroke, or kidney failure doubles for every increase of 20/10 milligrams of mercury [mm Hg], starting at 115/75 mm Hg. If your blood pressure is 135/85 mm Hg, you have twice the risk of a cardiovascular event compared with someone whose blood pressure is 115/75,” says Dr. Randall M. Zusman, director of the division of hypertension at Harvard-affiliated Massachusetts General Hospital.

Treating resistant hypertension

Blood pressure categories established by the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure

Why drugs may fail

Many people require three or more medications to control their blood pressure. With more than 200 blood pressure medications available, including 60 diuretics and 15 beta blockers, that’s a lot of potential combinations. It takes dedication to find the combination that works for an individual.

Hypertension Danger Zones

Hypertension Danger Zones

“It’s challenging to generate an effective treatment regimen that is free of side effects, but it can be done. You have to use medicines from different classes that work in different ways and have additive or synergistic mechanisms of action,” says Dr. Zusman.

The dose of a blood pressure-lowering medication must be titrated (raised gradually over time). Some physicians start a medication at a low dose and delay raising the dose for months, for fear of causing side effects. This simply delays finding an effective therapy.

“When a medication doesn’t produce the desired effect, the dose needs to be raised at regular intervals—perhaps monthly—until you get a response, or until maximum tolerance is reached. At this point, you add a second drug and repeat the process until blood pressure control has been achieved,” Dr. Zusman explains. “It sometimes takes four, five, six, or even seven drugs to be successful.”

Non-medical treatments

Lifestyle changes also may be needed, whether or not medications are successful in controlling blood pressure. That’s because anti-hypertensive medications are not magic bullets: their effects can be blunted by a diet that is too high in salt.

Effective weight loss—often an important strategy for successful blood pressure control—also can be thwarted by a diet that is too high in calories. The good news is that exercise can help with both weight loss and blood pressure. “Even if you don’t lose weight, activities like walking, swimming, and biking will lower your blood pressure,” says Dr. Zusman.

Novel treatment coming

A new type of treatment for resistant hypertension called renal denervation is undergoing clinical trials. The technique involves zapping key nerves around the kidney artery with radio waves emitted by a catheter that is temporarily placed in the artery. Just how this procedure actually lowers blood pressure is not yet known, but it has produced significant effects in people with medication-resistant hypertension. In some people, renal denervation also resulted in substantial improvements in diabetes, as well as blood pressure.

A large clinical trial of renal denervation has just begun in the United States. Although results will not be available for a few years, the procedure is generating a great deal of excitement and optimism. “This is an opportunity to develop a treatment that has the potential to provide a clinically significant—hopefully permanent—reduction in blood pressure,” says Dr. Deepak Bhatt, chief of cardiology at Harvard-affiliated VA Boston Medical Center and one of the principal investigators of the trial.

Chocolate therapy

One ounce a day of dark chocolate with a cocoa content of 70% or higher can produce a drop in blood pressure.

Posted by: Dr.Health

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