Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for evaluation of resistant hypertension, defined as office BP persistently >140/90 mmHg despite concurrent use of three antihypertensive agents of different classes, including a diuretic, at maximally tolerated doses. Patient reports high medication adherence. No evidence of white-coat effect confirmed by ABPM/HBPM. Secondary causes (OSA, primary aldosteronism, renal artery stenosis) currently under investigation.
Clinical Examination Findings
General: Patient appears in no acute distress. CV: Regular rate and rhythm, S1/S2 audible, no murmurs, rubs, or gallops. PMI non-displaced. Carotid upstrokes brisk, no bruits. Extremities: No peripheral edema, pulses 2+ bilaterally. Fundoscopic: No grade III/IV hypertensive retinopathy (no papilledema, hemorrhages, or exudates). Neurological: Non-focal.
Treatment Protocol
Plan: 1. Confirm medication adherence and optimize current regimen (ensure diuretic is chlorthalidone or indapamide). 2. Screen for secondary hypertension (plasma aldosterone/renin ratio, TSH, renal ultrasound, sleep study). 3. Initiate fourth-line therapy with mineralocorticoid receptor antagonist (spironolactone) if eGFR >30 and K+ <5.0. 4. Lifestyle modification: Strict sodium restriction (<2g/day) and DASH diet. 5. Follow-up in 4 weeks for BP titration.