Resistant Hypertension - Part 1
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Show notes:
Resistant hypertension is a common chief complaint in primary care clinics. But for new nurse practitioners, there’s a lot to sort through.
Resistant Hypertension in Primary Care
In this video, I walk through the thought processes and approaches to managing resistant hypertension in primary care.
✅ How to talk about medication adherence with patients
✅ The role of ongoing blood pressure checks — both during clinic visits and at home
✅ Considerations for current medications and dosing
✅ How to investigate the secondary causes of hypertension
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WEBVTT
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP, an educational
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company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel
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In this week's episode, I'm going to be talking about resistant hypertension.
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And there's actually a lot to say about this.
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So I'm really going to start with the high level.
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And then there's a couple of other videos I'm thinking about making.
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If you're interested, leave me a comment below.
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But yeah, I wanted to talk about the general thought process behind resistant hypertension
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and approach to make sure that we're really taking a stepwise approach to managing
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resistant hypertension for patients.
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So what is resistant hypertension anyway?
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The definition is persistently elevated blood pressure out of the goal range.
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So that's changed a little bit over the years, kind of back and forth, going from
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140 over 90 to 130 over 80 and vice versa.
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So generally speaking, greater than 140 over 90 consistently despite being on three
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or more medications or anti-hypertensive medications or that's not at goal with
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three medications or is at goal with four medications.
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So I want to talk about this.
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This is very common in primary care and it frustrates a lot of newer nurse practitioners
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and even nurse practitioners just generally speaking.
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So a couple of things we want to think about when you're in the situation with this
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patient and you're thinking about how do I help them?
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Because the moral of the story is if their blood pressure is still out of range of
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the goal, then they're at risk for a lot of comorbidities, right?
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They're at risk for damage to their kidneys, their risk for heart attack, risk
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for stroke, things like that.
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So we do want to manage this.
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We want to talk about it with patients and we want to explain to them so that they
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understand kind of what's going on.
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So the general approach that I take with resistant hypertension, like what's
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going on here?
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Why is this blood pressure so high?
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And we're still on three medications.
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Also, I want to add that the medications are maxed at their most effective
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doses, that they're all the way up.
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It's like basically everything's turned up to the max and it's still not
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really working or it's barely working.
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So the things we want to think about, number one is adherence.
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So I think it's very easy, especially as newer clinicians, to make assumptions
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about, of course, everyone's taking their medications.
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I mean, really, we don't think that, but then I think subconsciously I find
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myself still doing that sometimes where I'm like, oh, wait, I need to check
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and make sure they're actually taking their medications, right?
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And I need to make sure that I have a safe enough space for them such that
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they feel comfortable disclosing that they're not taking their medications.
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I've talked about that a couple of times in a couple of different videos,
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but I always lead with how often do you take your medication?
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Never a couple of times a week, when I remember every day, like I give them all
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the options of what's a quote unquote acceptable answer so that they feel less
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uncomfortable disclosing that they're probably doing something that they think
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I'm not going to like.
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And that's not even always the case.
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Sometimes I'll say that to patients, multiple visits, and then they disclose
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on the fifth one that they are, you know, whatever behavior they don't want
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to tell me about, they tell me about, right?
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So anyway, starting with that.
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What is the adherence situation and approaching it in that very
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nonjudgmental way, very open ended way?
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How often are you taking your medications?
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Do you know the medications that you're taking?
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Do you have a list?
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Does anybody help you?
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Do you do it yourself?
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Do you have any barriers to picking up your medications?
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Like having a whole conversation about medication adherence is really
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foundational to this situation because we cannot help patients with our
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advice of medication management if we're not meeting each other at the same place.
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And this is the same thing with diabetes too.
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This happens a lot with patients who have diabetes.
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So in those types of visits, so, you know, getting that information,
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reconciling the actual medications that they're taking.
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Do they know what the medications are?
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Do they know what the doses are?
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When was their last refill?
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Again, because patients don't always know that when we prescribe a
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medication, we're supposed to continue to take it unless we've
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explicitly said that to them.
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Like, did they take 30 days worth and then they were done because they
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thought that they were done versus did they understand this as like
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a longer term thing?
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The next piece is about checking their blood pressure, both at the office
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and do they check it at home?
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So if we look at a textbook, there's like gold standard is like 24 hour
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ambulatory hypertension monitoring.
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I've literally never ordered that.
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I don't, maybe it's just like a resource thing.
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That's not accessible at my clinic.
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The way that I get around, if you have that, that sounds amazing,
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but the moral of the story is we're trying to figure out is your
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blood pressure fine at home and it's not great here, right?
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Because do they have that like white coat hypertension phenomenon?
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And so the way that I get around that is through having patients check
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their blood pressure at home with a cuff, with an arm cut cuff,
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not a wrist cuff, and then I also have them bring it to their visit
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so I can collaborate, you know, corroborate the numbers of like
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what I see in clinic and what their blood pressure cuff is
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monitoring just to make sure that they're concordant.
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And then of course I have a conversation with them because they
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are full humans that get to decide what they want to do with their lives.
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So I asked them, you know, I explained this context of the situation,
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why I care about hypertension if we haven't already had that
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conversation and then have a conversation about, okay, like,
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here's what I recommend.
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We check your blood pressure at home and see if it's high at home
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and if it's high here or if it's just high here.
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And this is why, right.
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And getting that, getting that understanding and buy-in from the patient.
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And so that's the that's the next step, like adherence, one and barriers to medication.
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Do they understand them?
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Do they need help with them?
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Do they check their blood pressure at home?
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Can they check it?
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You know, I'm very easy with patients because, you know,
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I understand that they're full humans and they have lives outside of the clinic.
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And so whatever they can agree to for checking the blood pressure is awesome.
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Can you check your blood pressure a couple of days a week, morning, afternoon?
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Write it down. Can you check it every day?
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Can you check it every day in the morning and write it down? Right.
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Something is better than nothing. Right. Baby steps.
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The next thing that I want to think about with patients
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when it comes to resistant hypertension is what medications I kind of ties back to before.
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But what medications, from my perspective, are we actually taking?
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And so, again, there's been a little bit of changes over the last couple of years.
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There's JNC aid and there were some updates.
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So I really want to dig into that a little bit more.
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But generally speaking, there's a couple of first line options.
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And I say that because a lot of people
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historically have been on medications for a long time before the guidelines were changed.
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So they might be on a beta blocker, for example, with no good reason
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aside from hypertension, right, because we might use that in someone
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with a myocardial infarction.
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Like, there are good reasons to use beta blockers,
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but we want to know the reason why they are not first line for hypertension.
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Right. So keeping that in mind. Right.
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Like, what are the medications that they're taking and like,
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what are the first line options?
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So diuretics, calcium channel blockers,
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and either an ACE inhibitor or an ARB.
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So those are the kind of like first line options.
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Are they taking those or what are they taking instead?
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And then what are the doses of each of those medications?
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And are they titrated to their maximum effectiveness?
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And one little pearl of practice, one thing that I've been wanting
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to dig into a little bit more and provide as a resource
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is the different types of hypertension medications.
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And I love this stuff because I'm a nerd, but like, for example,
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the ACE inhibitor called lysinopril
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has a maximum dose of 40 milligrams per the FDA.
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However, 20 milligrams is shown to be the maximum efficacious dose.
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And so you can actually technically max out at 20
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because it loses more effectiveness and increases side effects
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after that point. Right.
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So anyway, that's just like fun stuff.
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I like it.
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But thinking about what are the agents they're on,
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are they at the maximum amounts that are appropriate?
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So the next thing to think about is lifestyle.
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So just like as a general baseline for hypertension management,
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like, what are we doing?
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Like, what's the story?
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How are we sleeping?
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How much water are we drinking?
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What's our diet like?
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What's the exercise like?
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What's their BMI like? Right.
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Because all of those things are factors in their hypertension.
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However, the next step is evaluating secondary hypertension.
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What are the like, what is causing it to be this high? Right.
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And so there's like essential, quote unquote,
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essential primary hypertension and there's secondary.
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And if you treat the secondary cause,
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then it helps with the primary thing. Right.
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So I actually want to splice this video
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into talking more about the secondary causes,
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just because I feel like it warrants more,
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a little bit more, a little more juice there.
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So anyway, the first thing to think about is sleep apnea.
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And I feel like I want to get on a soapbox about this.
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I get really amped about it because I feel like it just gets missed.
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It just seems like it's it's not considered as much as it should be.
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And it really wearing a CPAP mask for quality of life
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is not ideal for most patients.
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However, the quality of life that improves
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because they are treated for sleep apnea is remarkable.
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And it also helps their hypertension.
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It helps their heart health.
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It helps with so many other things.
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So it's just really important to do an evaluation.
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Or are they at risk for sleep apnea?
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There's a couple other secondary causes.
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But again, I really want to get into those a little bit more in another video.
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But just like very high level, there's primary, primary aldosteronism.
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And I think I want to make a video specifically about that,
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because I just feel like I want to learn more about that, too,
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and make sure that I'm doing it right.
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So I'll learn about that and report back. How about that?
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It's actually recommended to screening for everybody
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who has resistant hypertension to look into primary aldosteronism.
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And then there's also renal artery stenosis and then CKD.
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Those are the most common secondary causes,
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but definitely starting with sleep apnea.
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And then there's a couple of other things that we want to think about
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in terms of like the lesser common secondary causes.
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But like I said, I'm going to save that for another video.
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But anyway, that's the general approach.
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And I think one other kind of like pearl to throw in there
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is I think I think the pearl like the takeaways,
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a couple of takeaways I want you to take from this video
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is just like all of that extra assessment that I think that,
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especially as newer clinicians or even clinicians who are experienced,
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honestly, it's it's clinic is busy, life is overwhelming.
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And it's very easy to be like,
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you know what, this person's blood pressure is high.
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They're on three medications.
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I feel like I need to add a fourth.
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I'm going to refer them, which is totally fine and appropriate.
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Anybody who has resistant hypertension can be referred
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for further diagnostic support and treatment by a cardiologist, for example.
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However, there are so many things that we can do as primary care providers.
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So if you can start with all the assessment questions,
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doing that medication reconciliation and understanding of yourself of like, OK,
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are they on the optimal agents at the maximum doses that they should be?
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Right. Do they measure their blood pressure at home?
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Is their cuff calibrated with our cuff?
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Can they check it at a CVS?
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Well, not not a sponsor, just any drug store
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their blood pressure.
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And then making sure we're not forgetting about the secondary causes,
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specifically sleep apnea, number one secondary hypertension
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cause, and then looking into primary aldosterone ism,
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which I will report back about a little bit more.
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And then those two other ones, kidney disease and then renal artery stenosis.
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But again, renal artery stenosis, like I don't want to go off
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too much on a tangent on that one.
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But I think that when you're this is like, again,
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like another pearl of like working with newer clinicians is that
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sometimes it's really tempting to be like, OK,
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I'm looking up resistant hypertension.
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One, two, three, four, five.
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I'm just going to order this test, this test, this test, this test.
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It's really easy to order to, you know, check the button
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for duplex ultrasonography for renal artery stenosis.
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The most important thing to know, though, is like,
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what are we going to do about that? Right.
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And so that's that's like the tricky part of using algorithms
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that we need to know that stuff
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before we order the test in the first place and feel comfortable
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interpreting that result and then choosing an intervention.
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Because if it doesn't change our management of care, then, you know.
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We don't do it right.
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It doesn't serve it doesn't serve the patient.
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So so anyway, that is a very high level approach to resistant hypertension.
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I will certainly report back if you're interested in learning
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more about hypertension medications.
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I'm like really excited to get into that.
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So let me know if you're interested.
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And if you haven't grabbed the ultimate resource guide for the new
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NP, head over to real world NP dot com slash guide.
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with notes from me, patients, stories and bonuses.
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I really just don't share anywhere else.
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Thank you so much for watching.
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Hang in there and I'll see you soon.
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That's our episode for today.
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Thank you so much for listening.
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Make sure you subscribe, leave a review and tell all your NP friends.
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So together, we can help as many nurse practitioners as possible,
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give the best care to their patients.
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If you haven't gotten your copy of the ultimate resource guide
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for the new NP, head over to real world and dot com slash guide.
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You'll get these episodes sent straight to your inbox every week
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with notes from me, patient stories and extra bonuses.
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I really just don't share anywhere else.
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Thank you so much again for listening.
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Take care and talk soon.
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