Resistant Hypertension - Part 1
Resistant hypertension is one of the most challenging conditions encountered in primary care. When a patient's blood pressure remains above goal despite multiple antihypertensive medications, it's tempting to simply add another medication or refer to a specialist. In reality, the first step is often taking a systematic approach to confirm that the patient truly has resistant hypertension.
This episode walks through a practical framework for evaluating resistant hypertension, including medication adherence, home blood pressure monitoring, optimizing first-line therapy, and identifying common secondary causes. While this episode was originally recorded before the publication of the newest hypertension guidelines, the overall clinical approach remains highly relevant.
Since this episode aired, the updated hypertension guidelines have placed even greater emphasis on confirming hypertension with out-of-office blood pressure monitoring, screening appropriate patients for primary aldosteronism, and using evidence-based medication combinations before diagnosing true resistant hypertension.
If you're looking for a comprehensive overview of the newest guideline updates, be sure to check out our conversation with hypertension specialist Dr. Jordy Cohen, where we discuss the latest recommendations for primary care clinicians.
Updated July 2026: This page has been reviewed and updated to reflect current hypertension guideline recommendations. While this episode was recorded before the latest guideline updates, the overall approach to evaluating resistant hypertension remains clinically relevant. See the updated resources below for the newest recommendations.
Key Clinical Takeaways - updated 7/2026
Confirm true resistant hypertension before escalating therapy.
Confirm elevated blood pressure with validated home blood pressure monitoring whenever possible.
Assess medication adherence before adding additional antihypertensive medications.
Ensure patients are receiving guideline-recommended first-line medications at appropriate doses.
Evaluate for medications and lifestyle factors that contribute to elevated blood pressure.
Screen appropriate patients for primary aldosteronism, particularly those with resistant hypertension.
Consider common secondary causes such as obstructive sleep apnea and chronic kidney disease.
Refer patients with resistant hypertension when additional diagnostic evaluation or specialized management is needed.
Listen
Watch
Resistant Hypertension in Primary Care - What You’ll Learn
00:55 – What resistant hypertension is and why it matters in primary care
02:30 – The first step: assessing medication adherence and identifying barriers
05:00 – Confirming blood pressure with home monitoring and ruling out white coat hypertension
06:45 – Optimizing first-line antihypertensive medications before adding more therapy
08:45 – Lifestyle factors that contribute to uncontrolled blood pressure
09:05 – Evaluating for secondary causes of resistant hypertension
09:30 – Why obstructive sleep apnea is commonly overlooked
10:15 – Primary aldosteronism, chronic kidney disease, and renal artery stenosis
10:50 – Practical pearls for approaching resistant hypertension in everyday primary care
If you liked this post, also check out:
Looking for the newest hypertension recommendations?
Since this episode was originally published, new hypertension guidelines have been released. For an updated discussion of the latest recommendations—including the PREVENT calculator, single-pill combination therapy, primary aldosteronism screening, and home blood pressure monitoring—listen to:
→ New Hypertension Guidelines: Practical Updates with Dr. Jordy Cohen
Continue Learning
The Hypertension Management in Primary Care Course is part of the Real World NP Chronic Care Series, a comprehensive continuing education program designed specifically for nurse practitioners. Through case-based learning and practical clinical frameworks, you'll learn how to confidently diagnose, evaluate, and manage hypertension using current evidence and guideline-based recommendations.
The course has been peer-reviewed by hypertension specialists to help ensure the content reflects current best practices while remaining practical for everyday primary care.
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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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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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