Cases Of Resistant Hypertension Research Articles

The truth hidden behind a case of resistant hypertension

The truth hidden behind a case of resistant hypertension

Place of imidazoline receptor agonists in the treatment of arterial hypertension

The review is devoted to one of the most controversial issues of modern antihypertensive therapy — the role of new generation sympatholytics — selective I1-imidazoline receptor agonists (AIRs). In modern European recommendations, AIR (moxonidine rilmenidine), along with other centrally acting drugs (reserpine, alpha-methyldopa, clonidine), are mainly intended for additional therapy in rare cases of resistant hypertension, when other treatment options have been ineffective. Nevertheless, AIR invariably finds its place in Russian recommendations for the treatment of arterial hypertension (AH). This class of drugs is recommended for patients with AH in combination with metabolic syndrome and obesity. It is noted that an important property of AIR is its positive effect on carbohydrate and lipid metabolism. This information is based on an analysis of Russian and foreign studies, which convincingly indicate that this class of drugs not only provides adequate and long-term blood pressure control, but also has the above-mentioned positive metabolic effects. At the same time, AIRs are much less likely to cause side effects characteristic of older generation centrally acting drugs. Thus, AIRs have become firmly established in clinical practice in Russia for the treatment of patients with AH in certain clinical situations.

Prevalence and determinants of resistant hypertension in the delta region of Egypt: A prospective observational study.

Hypertension (HTN) is a leading cause of morbidity and mortality affecting about 30%-40% of the adult population in developed countries. Fewer data were published about the prevalence, sociodemographics, and clinical characteristics of the resistant hypertensive population in Egypt. Hence, our aim is to focus the attention on these determinantsespecially in the delta region of Egypt. Data belonging to patients visiting our HTN clinic in the Cardiovascular Department, Tanta University Hospital, Gharbeyah Governorate, Egypt, were collected over 12 months, between January 1, 2022, and 31 December 31, 2022, and then carefully analyzed. We found that the prevalence of resistant hypertension (RHTN) in the delta region of Egypt was 18%. We noted more RHTN cases in older age, that is, mean ± Std. was 51.5 ± 13.24 and 62.1 ± 7.56 for non-RHTN and RHTN, respectively. Also, the prevalence was higher in women representing about 54.4% of cases. Sixty-two percentof the patients with RH were obese (mean ± Std. of body mass indexwas 30.7 ± 5.36 in HTNand 47.7 ± 30.3 in RHTNgroups with p value <0.001). We found a significant relationship between chronic kidney disease, diabetes, and RHTN. Control of HTN among the Egyptian population in the delta region was unsatisfactory and higher than rates published globally. RH was more obvious in women, elderly, obese population, and diabetic and chronic kidney disease patients. Excessive use of nonsteroidal anti-inflammatory drugs, smoking, and high salt intake were clearly observed.

WHEN HYPERTENSION IS RESISTANT WE THINK IT OVER!

Objective: Hypertension is defined as resistant when the treatment strategy fails to lower office SBP and DBP values to &lt;140 mmHg and/or &lt;90 mmHg, respectively, and the inadequate control of blood pressure is confirmed by ABPM or HBPM in patients whose adherent to therapy. We report a case of resistant hypertension of a 64-year-old woman who referred to our Center in August 2021 for uncontrolled BP (160/94 mmHg) despite anti-hypertensive treatment with ramipril/hydrochlorothiazide 5/25 mg, atenolol 50 mg, ramipril 5 mg and lacidipine 4 mg daily and mild hypokalaemia (3.3 mmol/L). Design and method: Clinical history revealed dyslipidemia in treatment with simvastatin 20 mg/daily, osteoporosis in treatment with calcium and vitamin D supplements, parathyroid nodules in follow-up,family history of CAD. Laboratory tests confirmed hypokalaemia (3.1 mmol/L). Blood glucose, creatinine,lipids thyroid function were normal; no proteinuria was observed. The echocardiogram showed left ventricular hypertrophy with EF 60% and grade-1 diastolic dysfunction. Results: After wash-out of anti-hypertensive drugs, the screening tests revealed high aldosterone plasma levels (1166 pg/mL) and low renin level (1.6 microu/mL) with an ARR of 729. Other adrenal hormone levels were within normal limits. The saline infusion test confirmed the hyper-aldosteronism and an abdominal CT scan revealed a left adrenal neoformation of 17 x 15 mm in seize (Figure 1A). The patient underwent adrenal venous sampling which did not show lateralization and patients refuse to repeat the procedure. Anti-hypertensive therapy with spironolactone, eplerenone, canrenone and amiloride was stopped due to diarrhoea and rectal tenesmus (colonscopy excluded microscopic colitis). A 131I-norcholesterol adrenal scintigraphy with dexamethasone suppression documented early uptake only in the left adrenal gland (Figure 1B). After surgical evaluation, the patient underwent a video-laparoscopic left adrenalectomy and the histological examination revealed an adrenal cortical adenoma. The post-operative course was complicated by a syncopal episode due to hypotension (80/50 mmHg) with head injury for which antihypertensive therapy was revised and at the discharged she takes valsartan 80 mg, verapamil 40 mg twice. Conclusions: Primary aldosteronism intolerant to potassium-sparing diuretics and aldosterone antagonists is a rare condition and the establishment of a multidisciplinary team can improve its management.

PRIMARY ALDOSTERONISM: INITIAL EXPERIENCE FROM A NEWLY ESTABLISHED ESH HYPERTENSION CENTER OF EXCELLENCE - WORK IN PROGRESS

Objective: Primary aldosteronism is a common, yet underdiagnosed, cause of hypertension and resistant hypertension. It is estimated to be responsible for 6% of all cases of hypertension and 23% of all cases of resistant hypertension and is associated with disproportionately high rates of cardiovascular events and renal damage relative to the degree of hypertension. We sought to determine the prevalence of primary aldosteronism in patients referred to our center with the diagnosis of hypertension or resistant hypertension Design and method: From 08/03/2021 to 04/01/2022, 46 Patients (18 Females, 39.1%) were evaluated for primary aldosteronism. Thirty two patients (69.6%) were diagnosed with hypertension, of which 22 patients were newly diagnosed and were not on antihypertensive therapy. Fourteen patients (30.4%) were diagnosed with resistant hypertension and were on an average of 4 antihypertensive medications (range, 3 to 7). All were screened with Serum aldosterone (Ald) (pg/ml) and Plasma Renin activity (PRA) (mU/L) levels and ratio. To confirm the diagnosis, a seated saline suppression test (SSST) was performed when the Ald/PRA ratio was above 300. Adrenal computed tomography (CT) and adrenal vein sampling (AVS) were recommended or performed whenever the SSST was positive. Results: Of the 32 Patients with hypertension, 7 had an abnormal Ald/PRA ratio, 2 of which had a SSST which was positive in 1. Of the 14 patients with resistant hypertension, 7 (50%) had an abnormal Ald/PRA ratio, 4 of which underwent a SSST which was positive in all 4. Adrenal CT and AVS were done in 3 patients with resistant hypertension and positive SSST. AVS confirmed unilaterality in 2, both with adrenal adenomas. Adrenalectomy was recommended for the 2 patients and was performed in one with significant improvement in blood pressure control. Conclusions: Although this is a small number of evaluated patients, the data suggests that primary aldosteronism is not rare in hypertensive patients and is a common cause of resistant hypertension. All efforts should be made to improve physicians and patients’ awareness about its prevalence.

Thiazides and mineralocorticoid receptor antagonists in chronic kidney disease

The latest treatment guidelines for patients with arterial hypertension continues to indicate as the first line therapy a minimal association between renin-angiotensin system (RAS) blockers and a thiazide-type or a thiazide-like diuretic. In addition, according to 2018 ESC/ESH (European Society of Cardiology/European Society of Hypertension) guidelines for the management of arterial hypertension, a mineralocorticoid receptor antagonist may be added in resistant hypertension cases (uncontrolled hypertension under at least 3 classes of antihypertensive drugs including a RAS blocker, thiazide diuretic and a calcium channel blocker) for general population. For chronic kidney disease (CKD) patients, achieving the optimal blood pressure (BP) level can be difficult because high complication rates can be encountered in any antihypertensive class mentioned, especially for RAS blockers and mineralocorticoid receptor inhibitors. This brief review aims to highlight the importance of diuretics use in CKD patients and the boundaries of their usage.

HIPERTENSI SEKUNDER: GEN-GEN YANG MERANGSANG PEREMBESAN ALDOSTERON YANG BERLEBIHAN

Hypertension is highly prevalent in Malaysia and even the rest of the world. Primary aldosteronism (PA) is one of the most common treatable cause of secondary hypertension. PA occurs due to excessive secretion of aldosterone in the adrenal glands. Up to one in five resistant hypertension cases are due to PA. Therefore, there are a high number of individuals who have the potential to be cured of their hypertension. However, this is difficult to achieve due to limitations in the procedure of diagnosing the PA disease. The challenge now is to know the best usage of available diagnostic methods to detect those who would most likely be cured of hypertension which may be associated with the genotype of the disease. In the past decade, five genes have been found to cause excess aldosterone production in aldosteroneproducing adenomas (APAs), namely KCNJ5, ATP1A1, ATP2B3, CACNA1D and CTNNB1. These somatic mutations have been found to activate the intracellular signaling pathway that regulates aldosterone production. Studies on bilateral adrenal hyperplasia (BAH) samples also have identified the genetic causes for the many hereditary hyperaldosteronism, namely familial hyperaldosteronism types I, II, III, and IV/V. Herein we review the genetic factors of PA as a result of either aldosterone-stimulating somatic mutations or germline variants, and the associated clinical phenotype. Keywords: Primary aldosteronism; hypertension; hyperaldosteronism; mutation

A genome-wide association study identifies a novel candidate locus at the DLGAP1 gene with susceptibility to resistant hypertension in the Japanese population

Numerous genetic variants associated with hypertension and blood pressure are known, but there is a paucity of evidence from genetic studies of resistant hypertension, especially in Asian populations. To identify novel genetic loci associated with resistant hypertension in the Japanese population, we conducted a genome-wide association study with 2705 resistant hypertension cases and 21,296 mild hypertension controls, all from BioBank Japan. We identified one novel susceptibility candidate locus, rs1442386 on chromosome 18p11.3 (DLGAP1), achieving genome-wide significance (odds ratio (95% CI) = 0.85 (0.81–0.90), P = 3.75 × 10−8) and 18 loci showing suggestive association, including rs62525059 of 8q24.3 (CYP11B2) and rs3774427 of 3p21.1 (CACNA1D). We further detected biological processes associated with resistant hypertension, including chemical synaptic transmission, regulation of transmembrane transport, neuron development and neurological system processes, highlighting the importance of the nervous system. This study provides insights into the etiology of resistant hypertension in the Japanese population.

Particularities of multivessel disease in a diabetic patient

Atherosclerosis is a complex chronic inflammation in the large and medium arteries that is most often associated with hyperlipidemia and/or several other risk factors. Diabetes mellitus has also been shown to dramatically influence the extent and clinical complications of atherosclerosis, moreover, patients with diabetes are known to have a predisposition to develop multivessel disease. We report a case of resistant hypertension associated with multivessel disease in a diabetic patient. The presence of progressive kidney failure, initially interpreted in the context of diabetic nephropathy and found to be due to severe renal artery stenosis, and the presence of atherosclerotic disease in the previously discovered cerebral and coronary arteries and in the recently found carotid and renal artery territories, without affecting the peripheral arteries and rather unexpected in a diabetic smoker, represent particularities of this clinical case.

Eplerenone as a treatment for resistant hypertension in pregnancy.

Mineralocorticoid receptor antagonists are highly effective in the management of resistant hypertension and primary hyperaldosteronism. Recent studies demonstrate that mineralocorticoid receptor antagonists significantly reduce blood pressure, severity of obstructive sleep apnoea and arterial stiffness in patients with resistant hypertension and moderate-severe obstructive sleep apnoea. Eplerenone is a selective mineralocorticoid receptor antagonist that does not act as an androgen receptor blocker, thus reducing the risk of fetal anti-androgenic effects. Rat and rabbit studies demonstrated that when exposed to 30 times the equivalent therapeutic human dose, 100 mg/day, there were no teratogenic or demasculinisation effects. To date, the use of eplerenone has been reported in six human pregnancies in women with Gitelman syndrome, primary hyperaldosteronism and cardiac failure, in which no teratogenic effects were seen. Described here is a case of resistant hypertension associated with obstructive sleep apnoea in pregnancy, treated with eplerenone. The potential role of using eplerenone in pregnancy as treatment for resistant hypertension is discussed. Trial registration: Not applicable.

Low-Level Cumulative Lead and Resistant Hypertension: A Prospective Study of Men Participating in the Veterans Affairs Normative Aging Study.

BackgroundBone lead offers a better method over blood lead measurement to discern long‐term lead exposure and accumulation. We examined the risk of resistant hypertension based on bone lead levels in a prospective cohort study of NAS (Normative Aging Study).Methods and ResultsParticipants had clinic data on hypertension (systolic blood pressure, diastolic blood pressure, and antihypertension medication), lead (blood, bone‐patella, bone‐tibia), and demographic and confounding variables. Cases of resistant hypertension were identified by meeting criteria for: (1) inadequate systolic blood pressure (>140 mm Hg) or diastolic blood pressure (>90 mm Hg) while taking 3 medications or (2) requiring >4 medications for blood pressure control. A modified Poisson regression was used for model analysis. Of the 475 participants, 97 cases of resistant hypertension (20.4%) were identified. Among the cases of resistant hypertension, the median tibia and patella lead levels were 20 μg/g and 25 μg/g, respectively, while median tibia and patella lead levels were 20 μg/g and 27.5 μg/g, respectively, in participants without resistant hypertension. Tibia lead demonstrated a significant association with resistant hypertension (relative risk, 1.19; 95% confidence interval, 1.01–1.41 [P=0.04]) per interquartile range increase in tibia lead (13–28.5 μg/g). Patella lead was not associated with resistant hypertension (relative risk, 1.10; 95% confidence interval, 0.92–1.31 [P=0.31]) per interquartile range increase in patella lead (18–40 μg/g). Blood lead levels were not significantly associated with resistant hypertension (relative risk, 1.11; 95% confidence interval, 0.88–1.40 [P=0.38]).ConclusionsTibia lead represents a novel risk factor for resistant hypertension. Our study demonstrates an increased association between tibia lead and resistant hypertension status, with an increased risk of 19% per 1 interquartile range increase in tibia lead.

A simple UHPLC-PDA method with a fast dilute-and-shot sample preparation for the quantification of canrenone and its prodrug spironolactone in human urine samples

IntroductionNowadays, the treatment of hypertension represents an important issue, particularly in developed countries. While in most cases the standard therapeutic approaches, consisting in the administration of 1 to 3 drugs, are adequate to reach adequate blood pressure levels, in some cases more drugs are needed: this condition is called “resistant hypertension”. In this context, the administration of a diuretic, such as spironolactone or canrenoate salts, represents a standard practice. Since a reliable discrimination of real cases of resistant hypertension from cases of poor therapeutic adherence is currently difficult to obtain, the adoption of therapeutic drug monitoring has been suggested as a useful tool for this purpose. In this work, the authors developed and validated a simple, cheap and fast dilute-and-shot method with UHPLC-PDA analysis for the quantification of spironolactone and its metabolite canrenone in human urine samples. MethodsStandards and quality controls were prepared in urine. Only 100 μL of sample were added with 80 μL of internal standard (6,7-dimethyl-2,3-di(2-pyridyl)quinoxaline) working solution and 820 μL of phosphate buffer 10 mM pH 3.2 (phase A):acetonitrile (phase B) 90:10 v:v solution. Chromatographic separation was performed on an Acquity® UPLC HSS T3 1.8 μm 2.1 × 150 mm column, with a binary gradient for 11 min at 40 °C. ResultsAccuracy, intra-day and inter-day precision, selectivity and sensitivity fitted FDA guidelines for all analytes (LLOQ and LOD were 156.25 ng/mL and 78.12 ng/mL, respectively, for both analytes) and recovery resulted high and reproducible. Method performances were tested on urine samples from hypertensive patients with good results. DiscussionThis simple analytical method could represent a useful tool for the management of antihypertensive therapy.

Trends for prevalence and incidence of resistant hypertension: population based cohort study in the UK 1995-2015

Objective To estimate the incidence and prevalence of resistant hypertension among a UK population treated for hypertension from 1995 to 2015.Design Cohort study.Setting Electronic health records from the UK Clinical...

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OBJECTIVES/SPECIFIC AIMS: Our objective is to create a Resistant Hypertension (RHTN) computable phenotype from electronic health record (EHR)-based data, and to determine the characteristics associated with RHTN within a large, diverse, EHR-based database. METHODS/STUDY POPULATION: The OneFlorida Clinical Research Consortium includes 10 unique health care systems providing care for approximately half of the state (48%, ~10 million). OneFlorida houses a Data Trust which contains longitudinal EHR data and claims data from these providers in a common format, the PCORnet common data model v3.0. For the current project, data from 5 health care systems were considered. All of the adult hypertension (HTN) patients with a HTN diagnosis from an outpatient encounter were extracted from the OneFlorida Data Trust. Additional data such as demographics, prescribing, and vitals information were also extracted. The RHTN computable phenotype was created by constructing a drug exposure variable that took into consideration the number of antihypertensive medications an individual was prescribed at any point in time over the course of the OneFlorida dataset. RHTN was defined as any blood pressure requiring four or more antihypertensive drugs, or uncontrolled blood pressure (≥140/90) on 3 antihypertensive drugs. RHTN cases had to meet the definition criteria twice during the data period, at least 30 days apart. All data extraction, computation phenotype coding, and statistical analyses were conducted using SQL or SAS. RESULTS/ANTICIPATED RESULTS: Our preliminary results show that there were n=342,026 adults with a HTN diagnosis from an outpatient visit in the data set. After the RHTN computable phenotype was constructed, n=11,670 RHTN cases were identified from the n=130,901 HTN individuals with all of the required variables in the data set (8.9% RHTN prevalence). In all, 55% of RHTN cases were Black or African American, compared with the total HTN population (25% Black/African American). RHTN cases also had more prescriptions for loop diuretics, centrally acting agents, α-blockers, and vasodilators compared with the total HTN population. Not surprisingly, the RHTN cases had 26% of the antihypertensive prescriptions in the data set, and the RHTN cases had fewer blood pressure readings that were in control (only 49.4% of readings &lt;140/90). DISCUSSION/SIGNIFICANCE OF IMPACT: Overall, our preliminary data shows that it is possible to create the very complicated computable phenotype of RHTN within the OneFlorida Data Trust. We found that the RHTN prevalence in OneFlorida is 8.9% which is consistent with previous studies from NHANES. Although promising, these results require further validation of the computable phenotype and replication in other similar data sets in order to ascertain their true meaning. Once validated, the experience gained from this computable phenotype can be applied to many other phenotypes.

Early morphologic alterations in renal artery wall and renal nerves in response to catheter-based renal denervation procedure in sheep: difference between single-point and multiple-point ablation catheters.

Renal sympathetic hyperactivity is critically involved in hypertension pathophysiology; renal denervation (RDN) presents a novel strategy for treatment of resistant hypertension cases. This study assessed effects of two RDN systems to detect acute intravascular, vascular and peri-vascular changes in the renal artery, and renal nerve alterations, in the sheep. The procedures using a single-point or multi-point ablation catheters, Symplicity Flex(TM), Medtronic versus EnligHTN(TM), St. Jude Medical were compared; the intact contralateral kidneys served as controls. Histopathological and immunohistochemical assessments were performed 48 h after RDN procedures; the kidney and suprarenal gland morphology was also evaluated. Special staining methods were applied for histologic analysis, to adequately score the injury of renal artery and adjacent renal nerves. These were more pronounced in the animals treated with the multi-point compared with the single-point catheter. However, neither RDN procedure led to complete renal nerve ablation. Forty-eight hours after the procedure no significant changes in plasma and renal tissue catecholamines were detected. The morphologic changes elicited by application of both RDN systems appeared to be dependent on individual anatomical variability of renal nerves in the sheep. Similar variability in humans may limit the therapeutic effectiveness of RDN procedures used in patients with resistant hypertension.

UHPLC–MS/MS method with sample dilution to test therapeutic adherence through quantification of ten antihypertensive drugs in urine samples

Nowadays, hypertension represents an important health problem, particularly in developed countries. In some cases the standard therapeutic approaches are not able to reestablish the normal blood pressure values: this condition is called “resistant hypertension”. However, a fraction of cases of resistant hypertension are actually due to poor adherence to the prescribed therapy. Therapeutic Drug Monitoring could represent a direct and useful tool to correctly identify non-compliant patients. Nevertheless, high throughput methods for the simultaneous monitoring of a wide panel of drugs in the same analysis are lacking and, furthermore, there is not a generally acknowledged “standard” matrix for this test (plasma or urine).In this work, we validated a UHPLC–MS/MS assay to quantify ten among the most used antihypertensive agents in urine samples, covering all the current classes: amlodipine, atenolol, clonidine, chlortalidone, doxazosin, hydrochlorothiazide, nifedipine, olmesartan, ramipril and telmisartan.Both standards and quality controls were prepared in urine matrix. Only 100μL of each sample were added with 40μL of internal standard and 860μL of water:acetonitrile 90:10, acidified with 0.05% formic acid. Chromatographic separation was performed on an Acquity® UPLC HSS T3 1.8μm 2.1×150mm column, with a gradient of water and acetonitrile, both added with 0.05% formic acid.Accuracy, intra-day and inter-day precision fitted FDA guidelines for all analytes, while matrix effects resulted reproducible among different urine lots. Method performances were tested on urine samples from hypertensive patients with good results. This simple analytical method could represent a useful tool for the management of antihypertensive therapy.

Genome-wide study of resistant hypertension identified from electronic health records.

Resistant hypertension is defined as high blood pressure that remains above treatment goals in spite of the concurrent use of three antihypertensive agents from different classes. Despite the important health consequences of resistant hypertension, few studies of resistant hypertension have been conducted. To perform a genome-wide association study for resistant hypertension, we defined and identified cases of resistant hypertension and hypertensives with treated, controlled hypertension among >47,500 adults residing in the US linked to electronic health records (EHRs) and genotyped as part of the electronic MEdical Records & GEnomics (eMERGE) Network. Electronic selection logic using billing codes, laboratory values, text queries, and medication records was used to identify resistant hypertension cases and controls at each site, and a total of 3,006 cases of resistant hypertension and 876 controlled hypertensives were identified among eMERGE Phase I and II sites. After imputation and quality control, a total of 2,530,150 SNPs were tested for an association among 2,830 multi-ethnic cases of resistant hypertension and 876 controlled hypertensives. No test of association was genome-wide significant in the full dataset or in the dataset limited to European American cases (n = 1,719) and controls (n = 708). The most significant finding was CLNK rs13144136 at p = 1.00x10-6 (odds ratio = 0.68; 95% CI = 0.58–0.80) in the full dataset with similar results in the European American only dataset. We also examined whether SNPs known to influence blood pressure or hypertension also influenced resistant hypertension. None was significant after correction for multiple testing. These data highlight both the difficulties and the potential utility of EHR-linked genomic data to study clinically-relevant traits such as resistant hypertension.

PS 14-67 A CURIOUS CASE OF RESISTANT HYPERTENSION

Objective: Renovascular hypertension is an important underdiagnosed secondary cause of resistant hypertension in young. Renal vascular atherosclerosis (90%) and renal fibromuscular dysplasia (FMD) (10%) are two main etiologies. FMD rarely cause clinically significant renal artery stenosis (RAS) and is typically truncal or distal. It's often curable with revascularization, percutaneous renal angioplasty being the treatment of choice. Design and Method: We hereby present a case of renovascular hypertension in young male which turned out to be unifocal FMD not amenable to percutaneous angioplasty. Results: We present a case of resistant hypertension in 34 years old male who was diagnosed with renovascular hypertension due to right RAS. Patient remained hypertensive (maximum BP 210/110 mmHg) despite being on nine antihypertensive medications including diuretics (Table). Computed tomographic angiogram revealed occlusion of right main renal artery (MRA) with reformation through lumbar collaterals. Digital substraction angiography revealed atretic right MRA at its origin while Diethylene Triamine Penta Acetic acid (DTPA) renogram showed a small poorly functional right kidney. As percutaneous interventional revascularization was not possible, autotransplantation of right kidney with in situ revacularization with reversed great saphenous vein graft was planned. Intraoperatively, small calibre right MRA was found which was not amenable to aortorenal bypass. Eventually, patient underwent right nephrectomy. Histopathological examination revealed ischemic nephropathy with fibromuscular dysplasia (Medial fibroplasia) (Figure). Patient recovered completely and doesn’t require antihypertensive drug treatment. Conclusions: FMD is rare cause of ostial unifocal RAS in males but must be ruled out in young hypertensives, even in absence of family history or the classic “string-of-beads” appearance in angiography. This case reiterates the need of multiple imaging modalities for early diagnosis and the usefulness of interventional procedures for prompt treatment of renovascular hypertension. In cases of FMD not amenable to percutaneous angioplasty, nephrectomy may be considered as curative option.

Refractory Hypertension: A Novel Phenotype of Antihypertensive Treatment Failure.

The term resistant hypertension has been used since the early 1960s to identify patients with difficult-to-treat hypertension, meaning mostly, resistance to pharmacological therapy.1 In the 5 decades since the term was seemingly first applied, resistant hypertension has been consistently defined as failure to control high blood pressure despite of use of ≥3 antihypertensive agents of different classes, including a diuretic.2–5 The 2008 American Heart Association Scientific Statement on resistant hypertension included in its definition patients whose blood pressure had been uncontrolled with 3 medications, but controlled with ≥4 medications.4 Although the number of medications required to satisfy the definition is arbitrary, the purpose of creating a category of resistant hypertension is to identify patients who, because of the difficulty in controlling their blood pressure, may benefit from special diagnostic and therapeutic considerations, including referral to a hypertension specialist. Having an agreed on definition that can be reliably applied to different cohorts has also facilitated research for this subgroup of patients, including identification of risk factors and underlying mechanisms, assessing outcomes and developing targeted treatments. The term refractory hypertension has often been used interchangeably with resistant hypertension to also refer to patients with difficult-to-treat hypertension.1–3,5 However, based on the number of respective PubMed citations resistant hypertension has been used much more often than refractory hypertension to indicate patients with hypertension resistant to pharmacological treatment. Recently, the term refractory hypertension has been applied to a small group of patients who are truly refractory to treatment, that is, patients who fail to achieve target blood pressure on maximal antihypertensive therapy.6 Determining whether such patients simply represent extreme cases of resistant hypertension or a novel phenotype in terms of risk and cause has been the focus of initial attempts to define and characterize …

RESISTANT HYPERTENSION IN A PATIENT WITH METABOLIC SYNDROME

Clinical case of resistant hypertension in a patient with metabolic syndrome is presented. Features of hypertension in metabolic syndrome and features of metabolic syndrome in women of pre- and postmenopausal age are also considered. Understanding the features of metabolic syndrome in women, as well as features of hypertension and metabolic syndrome will improve the results of treatment in patients with resistant hypertension.