Materiały źródłowe

• #1 Evaluation and Management of Secondary Hypertension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9728017/

  Hypertension is typically described as essential, or primary, when there are no clearly discernible reasons for elevated blood pressure (BP) 130/80mmHg. Secondary hypertension, or hypertension that can be attributed to another underlying cause, is less common than primary hypertension but also underrecognized. […] Identifying the underlying cause of secondary hypertension may lead to successful intervention with the potential to improve quality of life and reduce cardiovascular morbidity and mortality. Common secondary causes of hypertension include primary aldosteronism (PA), renovascular disease, chronic kidney disease (CKD), obstructive sleep apnea (OSA), and drug-induced or alcohol-induced hypertension. […] In this review, we focus on identification and treatment of common causes of secondary hypertension and highlight the importance of obtaining a detailed history from the patient to facilitate appropriate diagnosis and treatment.

• #1 Secondary hypertension: Causes and treatments f

  https://www.riversideonline.com/en/patients-and-visitors/healthy-you-blog/blog/s/secondary-hypertension

  For secondary hypertension, treatment depends on addressing the cause. Typically, medication is prescribed to treat the condition that caused the hypertension. […] Some people may also need to take high blood pressure medication until the underlying condition is treated successfully. For many, their high blood pressure can be cured once the medical condition is properly treated.

• #1 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  Management of secondary hypertension comprises adequate control of blood pressure with a healthy lifestyle and appropriate antihypertensive drugs and addressing the secondary causes mentioned above. […] It is recommended to refer these patients to clinicians with expertise, in order to treat the underlying cause of hypertension. […] Identification of hypertension-inducing/provoking drugs is an essential part of management in patients with secondary hypertension. […] The most common renal parenchymal diseases leading to secondary hypertension include diabetic nephropathy, chronic glomerulonephritis, glomerulosclerosis, and autosomal dominant polycystic kidney disease (ADPKD) and all these disorders result in chronic kidney disease (CKD). […] Hypertension is found in more than 2/3 of the patients with CKD and it accelerates its progression to end-stage renal diseases.

• #1 Evaluation and Management of Secondary Hypertension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9728017/

  Primary aldosteronism (PA) or Conn Syndrome is the commonest form of secondary hypertension and is amenable to treatment if diagnosed appropriately. […] Early recognition of PA is crucial because treatment reliably lowers blood pressure, reduces the number of antihypertensive medications needed, and improves cardiac and renal function. […] Screening for PA in primary care is easy, inexpensive, and non-invasive. Furthermore, screening for PA can potentially identify patients with treatable forms of hypertension and modify cardiovascular risk. Current guidelines recommend screening for PA in patients with severe hypertension and/or hypertension with hypokalemia (spontaneous or diuretic-induced), particularly in those with resistant hypertension. […] Depending on the PA subtype, unilateral laparoscopic adrenalectomy or mineralocorticoid receptor antagonist therapy can successfully treat and reverse hypertension, hypokalemia, and excess cardiovascular risk imposed by autonomous aldosterone secretion. […] Patients with bilateral adrenal disease should be treated medically with a mineralocorticoid receptor antagonist both for blood pressure control and to protect against target organ damage from effects of aldosterone that are independent of blood pressure control. Spironolactone remains the preferred initial agent, and should be started at low doses 12.5-25mg daily and increased in 25mg increments every 4-8 days to a maximum of 100 mg daily.

• #1 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  The vast majority of hypertensive patients are never sought for a cause of their high blood pressure, i.e. for a ‘secondary’ form of arterial hypertension. […] The early detection of a secondary form is crucial, because if diagnosed in a timely manner, these forms can be cured at long-term, and even when cure cannot be achieved, their diagnosis provides a better control of high blood pressure, and allows prevention of hypertension-mediated organ damage, and related cardiovascular complications. […] Given the unprecedented progress made in the last decades in the understanding, screening, work-up, and management of SH, the purpose of this mini-review is to furnish concise updated information on the diagnosis and treatment of the most common forms of SH. […] Unilateral laparoscopic adrenalectomy is the best treatment that can be offered to PA patients with proven unilateral disease.

• #1 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  MRAs, such as spironolactone, canrenone potassium, potassium canrenoate, eplerenone, alone or in combination with other antihypertensive drugs, are recommended for those patients with BAH or not suitable for surgery. […] The first-choice treatment for FMD-RVH is renal artery angioplasty without stenting. […] The gold-standard therapy for PPGLs is surgery for solitary or multiple tumors clustered in one area. […] Controlling cortisol hypersecretion by surgery or by cortisol lowering drugs or glucocorticoid receptor antagonists, can effectively lower BP in most hypertensive CS patients and normalize it in ~ 50% of cases. […] The proper work-up of OSA patients varies according to individual features. […] PAP treatment improves signs and symptoms of OSA, and lowers BP values, more strongly in OSA patients with resistant hypertension.

• #1 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  So it is imperative to achieve good hypertension control in this population. […] Currently, there is no cure for chronic kidney disease and the main focus of the management is to treat the reversible causes responsible for the progression to advanced kidney disease. […] Adequate blood pressure control is an essential component of management in CKD and contemporary guidelines recommend renin-angiotensin (RA) antagonists as the preferred drug therapy for the treatment of hypertension in CKD. […] The RA-blocking drugs not only control hypertension but also prevent the progression of CKD, especially in patients with proteinuria. […] Management of renovascular hypertension (renal artery stenosis) is divided into medical therapy and revascularization. […] Medical therapy involves the use of anti-hypertensive drugs to control blood pressure and in the case of atherosclerotic disease, the use of antiplatelets, statins, diet, and lifestyle changes.

• #1 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  ACE inhibitors and ARBs are the anti-hypertensive drugs of choice in patients with unilateral renal artery stenosis, however, these drugs are contraindicated in bilateral renal artery stenosis due to the risk of rapid renal dysfunction. […] Other pharmacologic treatment options are calcium channel blockers and thiazide diuretics. […] Unilateral primary aldosteronism (e.g., unilateral adrenal hyperplasia or aldosterone-producing adenoma) gets treated with unilateral laparoscopic adrenalectomy. […] If the patient is not a surgical candidate or a patient has the bilateral adrenal disease, then medical management with a mineralocorticoid receptor antagonist is recommended and spironolactone is the drug of choice for primary aldosteronism. […] For Cushing Syndrome or Cushing Disease, an open surgical or laparoscopic resection of the lesion/tumor is the treatment of choice.

• #1 Chapter 13. Secondary hypertension | Hypertension Research

  https://www.nature.com/articles/hr201416

  In patients with fibromuscular dysplasia, potent hypotensive effects are achieved, and the long-term prognosis is relatively favorable. […] For vascular reconstruction, PTRA is initially considered because of its low-level invasiveness. […] The long-term prognosis of fibromuscular dysplasia after PTRA is also relatively favorable, but restenosis may occur. […] The results of previous clinical studies have not demonstrated any marked difference between antihypertensive drug therapy alone and a combination of antihypertensive drug therapy and PTRA. […] In patients with unilateral renal artery stenosis-related hypertension, the use of RA system inhibitors should be considered. […] In patients with bilateral renal artery stenosis, RA system inhibitors may induce the rapid exacerbation of renal function and are contraindicated as a general rule.

• #1 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  ACE inhibitors and ARBs are the anti-hypertensive drugs of choice in patients with unilateral renal artery stenosis, however, these drugs are contraindicated in bilateral renal artery stenosis due to the risk of rapid renal dysfunction. […] Other pharmacologic treatment options are calcium channel blockers and thiazide diuretics. […] Percutaneous revascularization is recommended along with medical therapy in selective patients, especially those with fibromuscular dysplasia. […] The combination of drug therapy and percutaneous revascularization has been reported to reduce blood pressure significantly and this strategy has long-term renoprotective effects in patients with fibromuscular dysplasia. […] Unilateral primary aldosteronism (e.g., unilateral adrenal hyperplasia or aldosterone-producing adenoma) gets treated with unilateral laparoscopic adrenalectomy.

• #1 Hypertension Treatment & Management: Approach Considerations, Nonpharmacologic Therapy, Pharmacologic Therapy

  https://emedicine.medscape.com/article/241381-treatment

  Effective management and treatment of hypertension requires clinicians and patients to work together to balance pharmacologic and nonpharmacologic interventions and to prevent target organ damage. […] Antihypertensive therapy has been demonstrated to significantly reduce the risk of death from stroke and coronary artery disease. […] Therefore, earlier detection of hypertensive nephrosclerosis (using means to detect microalbuminuria) and aggressive therapeutic interventions (particularly with angiotensin-converting enzyme inhibitor drugs [ACEIs]) may prevent progression to end-stage renal disease. […] Adults with hypertension and chronic kidney disease (CKD) should be treated to a BP goal of less than 130/80 mm Hg. […] Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in Black adults with hypertension.

• #1 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  The definite treatment of pheochromocytoma is surgical resection of the hormone-producing lesion, however preoperative alpha and beta-adrenergic blocking drugs are an essential part of pheochromocytoma management. […] Continuous positive airway pressure (CPAP) therapy is the mainstay of treatment for OSA. […] To note, however, lifestyle modifications like weight loss, along with the usage of CPAP have a synergistic effect on lowering blood pressure and are better than either intervention alone. […] In patients refractory to the above treatment, few upper airway surgeries can be performed to help with symptoms and reduction in blood pressure, like uvulopalatopharyngoplasty (UPPP) in adults and tonsillectomy and adenoidectomy in children. […] Interventions for hypertension in pregnancy are lifestyle modifications and anti-hypertensives. […] The anti-hypertensives commonly used in pregnancy are labetalol, nifedipine, and methyldopa.

• #1 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  If the patient is not a surgical candidate or a patient has the bilateral adrenal disease, then medical management with a mineralocorticoid receptor antagonist is recommended and spironolactone is the drug of choice for primary aldosteronism. […] For Cushing Syndrome or Cushing Disease, an open surgical or laparoscopic resection of the lesion/tumor is the treatment of choice. […] The definite treatment of pheochromocytoma is surgical resection of the hormone-producing lesion, however preoperative alpha and beta-adrenergic blocking drugs are an essential part of pheochromocytoma management. […] It is recommended to start alpha-adrenergic blocking drugs first and then add beta blockers for the treatment of tachyarrhythmias. […] Initiation of beta-adrenergic blocking drugs is not recommended alone/before the alpha-adrenergic blockade, as it results in hypertensive crisis due to the unopposed alpha-adrenergic effect.

• #1 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  Pheochromocytoma crisis is treated with intravenous phentolamine followed by initiation of oral alpha-adrenergic blocking drugs. […] The specific treatment of patients with hypothyroidism includes thyroid replacement therapy, while hyperthyroidism is treated with antithyroid drugs. […] The other treatment options are determined by the primary mechanism of thyroid disorders. […] The definite treatment of patients with hypertension due to acromegaly is transsphenoidal resection of the hormone-producing tumor. […] Coarctation of the aorta is the major cause of vascular hypertension in the younger population. […] The choice of antihypertensive drugs for this population depends on the other co-existing conditions, however, the definite treatment is the percutaneous or surgical correction of the coarctation.

• #1 Evaluation and Management of Secondary Hypertension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9728017/

  Renovascular disease (RVD), often referred to as renal artery stenosis, is an important and potentially correctable cause of secondary hypertension that occurs in about 5% of individuals with a diagnosis of hypertension, with higher prevalence among the elderly. […] Medical therapy is the first-line treatment in all cases of RVD. The ESC and AHA recommend angiotensin-converting enzyme inhibitor (ACEI), angiotensin-receptor blocker (ARB), or calcium channel blocker therapy, with a specific recommendation from the ESC to closely monitor estimated glomerular filtration rate (eGFR) and potassium upon initiation of an ACEI/ARB. […] Obstructive sleep apnea (OSA) is a breathing disorder where the upper airway recurrently collapses during sleep and induces intermittent hypoxemia. […] Treatment of OSA carries several benefits, including improvement in blood pressure. The mainstays of treatment, however, are continuous positive airway pressure (CPAP) and medically supervised weight loss. The use of CPAP for treatment of OSA is associated with improvement in blood pressure, with varying results depending on the severity of hypertension.

• #1 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  An alternative to CPAP is oral appliances, used in mild to moderate OSA, which are non-inferior to CPAP in the reduction of blood pressure and may even help with better compliance in patients. […] In patients refractory to the above treatment, few upper airway surgeries can be performed to help with symptoms and reduction in blood pressure, like uvulopalatopharyngoplasty (UPPP) in adults and tonsillectomy and adenoidectomy in children. […] Interventions for hypertension in pregnancy are lifestyle modifications and anti-hypertensives. […] The anti-hypertensives commonly used in pregnancy are labetalol, nifedipine, and methyldopa. […] If an acute decrease in blood pressure is required, intravenous labetalol or intravenous hydralazine are options.

• #1 Secondary Hypertension: Discovering the Underlying Cause | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/1001/p453.html

  Patients who are obese and who have signs or symptoms of obstructive sleep apnea and hypertension should be assessed with polysomnography. […] Patients with RAS should be treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers unless there are contraindications to their use. […] The best initial test for primary hyperaldosteronism is measurement of the ratio of the plasma aldosterone concentration to plasma renin activity after potassium repletion. […] Treatment of OSA may improve blood pressure control, sleep quality, daytime sleepiness, and mortality.

• #1 Drug-induced causes of secondary hypertension

  https://atm.amegroups.org/article/view/15358/html

  Resistant hypertension is a blood pressure that remains above the treatment goal despite use of optimal doses of three antihypertensive drugs of different classes including a diuretic (1). […] Patients with resistant hypertension should be screened for causes of secondary hypertension (2). […] This article will discuss some of the drug-induced causes of secondary hypertension. […] Excessive alcohol use raises blood pressure and can cause resistance to antihypertensive drug therapy (4,9). […] Nonsteroidal anti-inflammatory drugs should be avoided if possible in persons with hypertension and other analgesics used depending on the indication. […] Antidepressants such as monoamine oxidase inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants may cause an elevated blood pressure (4). […] A sympathomimetic hypertensive crisis may be induced by abruptly stopping clonidine or other sympatholytic drugs or by using cocaine, amphetamines, phencyclidine, or monoamine oxidase inhibitors (20).

• #1 Secondary hypertension – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/secondary-hypertension/diagnosis-treatment/drc-20350684

  Treatment for secondary hypertension involves treating the medical condition that’s causing it with medications or surgery. Once the condition is treated, blood pressure might decrease or return to normal. […] Treatment might require continuing to take blood pressure medication, as well. The underlying medical condition might affect this choice of medication. […] Possible drug choices include: […] Thiazide diuretics. Diuretics, sometimes called water pills, are medications that help kidneys eliminate sodium and water. Thiazide diuretics are often the first but not the only choice in high blood pressure medications. […] Beta blockers. These medications reduce the workload on the heart and open the blood vessels. This causes the heart to beat slower and with less force. […] Angiotensin-converting enzyme (ACE) inhibitors. These medications help relax blood vessels by blocking the formation of a natural chemical that narrows blood vessels.

• #1 Secondary hypertension – Diagnosis & treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/secondary-hypertension/diagnosis-treatment/drc-20350684

  Angiotensin II receptor blockers. These medications help relax blood vessels by blocking the action of a natural chemical that narrows blood vessels. […] Calcium channel blockers. These medications help relax the muscles of the blood vessels or slow the heart rate. […] Direct renin inhibitors. These medications relax and widen the arteries by preventing the action of a protein (enzyme) called renin. […] Treatment for secondary hypertension can sometimes be complicated. It might take more than one medication combined with lifestyle changes to control high blood pressure. Your health care provider will want to see you more often possibly as often as once a month until your blood pressure is controlled. Your provider may also recommend that you keep track of your blood pressure at home.

• #1 Resistant hypertension: A stepwise approach | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/90/2/115

  If blood pressure is still not controlled on maximally tolerated therapy with these 3 agents, a mineralocorticoid receptor antagonist (spironolactone or eplerenone) should be the fourth-line agent. […] Patients should be referred to a hypertension specialist if blood pressure remains uncontrolled despite the above therapies. […] Experimental devices and other therapies are currently being explored in patients with resistant hypertension.

• #1 Treatment of resistant hypertension – UpToDate

  https://www.uptodate.com/contents/treatment-of-resistant-hypertension

  Treatment of resistant hypertension is defined as a blood pressure that remains above goal despite concurrent use of three antihypertensive agents of different classes taken at maximally tolerated doses and at appropriate dosing frequency, one of which should be a diuretic (the diuretic should be selected based upon kidney function). […] Patients with resistant hypertension are at high risk for adverse cardiovascular events and are more likely to have a secondary cause of high blood pressure, which may be at least in part reversible. By definition they require more aggressive medication treatment, as well as the potential use of specialized interventions, to control their high blood pressure. […] The treatment and prognosis of resistant hypertension that is not due to secondary causes will be reviewed here.

• #1 Resistant hypertension: A stepwise approach | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/90/2/115

  Resistant hypertension can be challenging to manage, but a stepwise approach to diagnosis, evaluation, and treatment can lead to better blood pressure control. […] Along with lifestyle modification, a stepwise approach to management using antihypertensive medications with differing mechanisms of action is critical to achieving blood pressure control. Patients may require more anti-hypertensive medications. […] Patients with resistant hypertension should be evaluated for secondary hypertension, since recognition and directed therapy may improve blood pressure control. […] A multifactorial approach to treat resistant hypertension includes a combination of lifestyle modification, pharmacotherapy, and addressing underlying contributing diseases. […] The initial pharmacologic approach to resistant hypertension consists of 3 medications, each mechanistically different, at maximally tolerated doses, as follows: An ACE inhibitor or ARB, a long-acting dihydropyridine calcium channel blocker, and a diuretic.

• #1 Resistant Hypertension: An Overview | ECR Journal

  https://www.ecrjournal.com/articles/global-burden-resistant-hypertension-and-potential-treatment-options?language_content_entity=en

  When spironolactone and other MRAs are not tolerated or contraindicated, alternatives include amiloride, which was found to be as effective as spironolactone in reducing BP when used at high dosages (10-20 mg/day), beta-blockers like bisoprolol 5-10 mg/day, alpha-1 antagonists such as doxazosin extended release 4-8 mg/day, and centrally acting agents such as the alpha-2 adrenergic receptor agonist clonidine 0.1-0.3 mg twice daily. […] Renal denervation involves disrupting renal sympathetic nerves to reduce their stimulatory effect on BP. By using catheter-based techniques, nerves in the renal arteries are ablated, leading to decreased sympathetic activity, lower BP, decreased renin activity and increased renal blood flow. […] Therefore, renal denervation emerges as an additional viable treatment alternative for adult patients grappling with uncontrolled RH, as indicated by the latest European guidelines stating the potential utility of this strategy in the context of RH with a class II recommendation, provided that the eGFR is 40 ml/min/1.73 m2.

• #1 Secondary Hypertension Causes, Symptoms, Treatment, More

  https://www.healthline.com/health/high-blood-pressure-hypertension/secondary-hypertension

  Certain changes to behavior and choices may help reduce high blood pressure. These changes are usually done along with other treatments. These include eating less salt, exercising regularly, drinking only in moderation, and maintaining a healthy weight. […] Secondary hypertension may be resistant to standard treatments, such as medication. If the underlying issue is found and addressed, the treatments are usually very successful.

• #1 Resistant Hypertension: Causes, Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/15601-resistant-hypertension

  Resistant hypertension treatment may consist of lifestyle changes and medicines. […] Changes you can make include: Limiting salt (eating fewer than 2,400 milligrams per day) and alcohol. […] Treatment for resistant hypertension may be as simple as making sure you’re following instructions for taking medicine. In about 40% of resistant hypertension cases, medications aren’t working because people aren’t taking them correctly. […] If you’ve been taking your medication correctly and still have resistant hypertension, your provider may add another medication. Some people need to take four or five kinds of blood pressure medicines. […] The most common classes of blood pressure medicines are: Diuretics, Calcium channel blockers, ACE inhibitors/angiotensin receptor blockers (ARBs). […] Depending on your potassium level, your provider may need to double your diuretic dose or add a fourth type of medication an aldosterone antagonist like spironolactone to regulate your blood pressure.

• #1

  https://step2.medbullets.com/cardiovascular/120007/hypertension

  Treatment […] consider treating patients with ACE inhibitors even sooner if they have an underlying condition that can lead to hyperfiltration damage (diabetes, scleroderma renal crisis) […] lifestyle modifications […] first line of treatment […] including weight loss (most effective) […] exercise […] abstaining from alcohol […] smoking cessation […] salt restriction […] decrease in fat intake […] and cholesterol control to reduce risk of CAD […] diuretic (HCTZ) and -blockers (first line medications) […] lifestyle modification fail after 6 months to 1 year […] medications include diuretic (first-line HCTZ) and -blockers (no comorbid disease) […] calcium channel blockers and ACEIs (second-line medications) […] lifestyle modification and first line medication fail

• #1 Secondary Hypertension: Causes & Symptoms

  https://my.clevelandclinic.org/health/diseases/21128-secondary-hypertension

  Treatment depends on the cause. Since many different conditions can cause secondary hypertension, there are many possible treatments. Your healthcare provider will tailor a plan to your needs. Theyll explain what you can expect each step of the way. […] As part of your plan, you may: Take medications to lower your blood pressure, Take medications to treat other medical conditions, Change what you eat or drink, Limit alcohol, Quit smoking, Get regular physical activity, Use a device (like a CPAP machine), Have a procedure or surgery. […] Secondary hypertension has a positive outlook with treatment. Early detection and treatment can lower the risk of damage to your blood vessels and heart from ongoing high blood pressure. […] Learning the why behind your high blood pressure might feel like a relief. But you might also have many new questions as you figure out what the underlying condition means for you. Nows the time to learn as much as you can about your diagnosis. Ask your provider how you can manage the condition to help lower your blood pressure. Youll work together to develop a treatment plan thats right for you.

• #1 Secondary hypertension Guide: Causes, Symptoms and Treatment Options

  https://www.drugs.com/health-guide/secondary-hypertension.html

  The treatment of secondary hypertension depends on its cause. When secondary hypertension results from a tumor or a blood vessel abnormality, surgery may be recommended. However, the decision to do surgery is often guided by the age and general health of the patient. For some patients, anti-hypertensive medications may be a safer option than surgery. […] The following list of medications are related to or used in the treatment of this condition. […] In many patients with secondary hypertension, high blood pressure can be cured when their underlying medical illness is treated successfully.

• #1 Secondary Arterial Hypertension: When, Who, and How to Screen?

  https://www.acc.org/latest-in-cardiology/journal-scans/2014/01/10/15/45/secondary-arterial-hypertension-when-who-and-how-to-screen

  Secondary hypertension (defined as hypertension due to an identifiable cause) affects only 5-10% of hypertensive patients. […] The authors wrote, practicing physicians cannot simply forget about renal artery stenosis despite the fact that randomized trials show little if any benefit of revascularization. The authors suggest that urgent revascularization could be lifesaving in those with flash pulmonary edema secondary to bilateral renal artery stenosis. […] Even after identification and treatment of a secondary cause of hypertension, BP may not return to normal. This is likely secondary to concomitant essential hypertension and/or vascular remodeling that has occurred over time.

• #1 Secondary hypertension in adults | SMJ

  http://www.smj.org.sg/article/secondary-hypertension-adults

  It is important to diagnose these patients, as they often have increased cardiovascular morbidity and mortality than age-, sex- and BP-matched patients with essential hypertension, and treatment can lead to reversal of end-organ damage. […] Surgery is usually recommended for patients with a unilateral adrenal adenoma, while patients who have bilateral adrenal hyperplasia or who are not suitable for or keen on surgery are treated with mineralocorticoid receptor antagonists (spironolactone or eplerenone). […] Treatment involves correction of modifiable cardiovascular risk factors and control of hypertension. […] Continuous positive airway pressure (CPAP) is the standard treatment for OSA patients; its primary benefits are the improvement of daytime sleepiness and quality of life. […] Diagnosis and treatment of causes of secondary hypertension can lead to good clinical outcomes.

• #1 Evaluation and Management of Secondary Hypertension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9728017/

  Prescription medications, over-the-counter medications and supplements, illicit drugs, and alcohol are common causes of secondary hypertension. […] Ideally, in patients with hypertension and particularly those with resistant hypertension, drugs that increase blood pressure should be discontinued in lieu of alternative agents that do not affect blood pressure. […] Secondary hypertension is common among patients with hypertension and is often underrecognized. […] Patients with hypertension should be evaluated for risk factors for secondary hypertension and screened accordingly. In particular, patients with resistant hypertension should, at minimum, undergo testing for primary aldosteronism and screening for drugs that may induce hypertension, with further evaluation for renovascular hypertension and obstructive sleep apnea depending on their age, symptoms, and comorbidities.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  Management of secondary hypertension comprises adequate control of blood pressure with a healthy lifestyle and appropriate antihypertensive drugs and addressing the secondary causes mentioned above. […] It is recommended to refer these patients to clinicians with expertise, in order to treat the underlying cause of hypertension. […] Identification of hypertension-inducing/provoking drugs is an essential part of management in patients with secondary hypertension. […] The most common renal parenchymal diseases leading to secondary hypertension include diabetic nephropathy, chronic glomerulonephritis, glomerulosclerosis, and autosomal dominant polycystic kidney disease (ADPKD) and all these disorders result in chronic kidney disease (CKD). […] Hypertension is found in more than 2/3 of the patients with CKD and it accelerates its progression to end-stage renal diseases.

• #2 Secondary Hypertension Causes, Symptoms, Treatment, More

  https://www.healthline.com/health/high-blood-pressure-hypertension/secondary-hypertension

  When hypertension occurs as a result of another condition, its known as secondary hypertension. Treatment involves treating the underlying cause. […] This type of hypertension may be treated, even cured, if the underlying cause is identified and treated. But if it isnt, it can lead to complications, including aneurysm and organ damage. […] If the cause is identified, treatment is usually successful. The specific treatment for secondary hypertension will depend on what the cause is. Some of these possible treatments include: […] Several types of medication may be helpful in treating high blood pressure. Diuretics, for example, help the kidneys eliminate water and sodium. This reduces the amount of fluid cycling through blood vessels. That can lower blood pressure. […] If a tumor is found, surgery may be needed to remove it.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  If the patient is not a surgical candidate or a patient has the bilateral adrenal disease, then medical management with a mineralocorticoid receptor antagonist is recommended and spironolactone is the drug of choice for primary aldosteronism. […] For Cushing Syndrome or Cushing Disease, an open surgical or laparoscopic resection of the lesion/tumor is the treatment of choice. […] The definite treatment of pheochromocytoma is surgical resection of the hormone-producing lesion, however preoperative alpha and beta-adrenergic blocking drugs are an essential part of pheochromocytoma management. […] It is recommended to start alpha-adrenergic blocking drugs first and then add beta blockers for the treatment of tachyarrhythmias. […] Initiation of beta-adrenergic blocking drugs is not recommended alone/before the alpha-adrenergic blockade, as it results in hypertensive crisis due to the unopposed alpha-adrenergic effect.

• #2 Practice Recommendations for Diagnosis and Treatment of the Most Common Forms of Secondary Hypertension | High Blood Pressure & Cardiovascular Prevention

  https://link.springer.com/article/10.1007/s40292-020-00415-9

  MRAs, such as spironolactone, canrenone potassium, potassium canrenoate, eplerenone, alone or in combination with other antihypertensive drugs, are recommended for those patients with BAH or not suitable for surgery. […] The first-choice treatment for FMD-RVH is renal artery angioplasty without stenting. […] The gold-standard therapy for PPGLs is surgery for solitary or multiple tumors clustered in one area. […] Controlling cortisol hypersecretion by surgery or by cortisol lowering drugs or glucocorticoid receptor antagonists, can effectively lower BP in most hypertensive CS patients and normalize it in ~ 50% of cases. […] The proper work-up of OSA patients varies according to individual features. […] PAP treatment improves signs and symptoms of OSA, and lowers BP values, more strongly in OSA patients with resistant hypertension.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  So it is imperative to achieve good hypertension control in this population. […] Currently, there is no cure for chronic kidney disease and the main focus of the management is to treat the reversible causes responsible for the progression to advanced kidney disease. […] Adequate blood pressure control is an essential component of management in CKD and contemporary guidelines recommend renin-angiotensin (RA) antagonists as the preferred drug therapy for the treatment of hypertension in CKD. […] The RA-blocking drugs not only control hypertension but also prevent the progression of CKD, especially in patients with proteinuria. […] Management of renovascular hypertension (renal artery stenosis) is divided into medical therapy and revascularization. […] Medical therapy involves the use of anti-hypertensive drugs to control blood pressure and in the case of atherosclerotic disease, the use of antiplatelets, statins, diet, and lifestyle changes.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  ACE inhibitors and ARBs are the anti-hypertensive drugs of choice in patients with unilateral renal artery stenosis, however, these drugs are contraindicated in bilateral renal artery stenosis due to the risk of rapid renal dysfunction. […] Other pharmacologic treatment options are calcium channel blockers and thiazide diuretics. […] Percutaneous revascularization is recommended along with medical therapy in selective patients, especially those with fibromuscular dysplasia. […] The combination of drug therapy and percutaneous revascularization has been reported to reduce blood pressure significantly and this strategy has long-term renoprotective effects in patients with fibromuscular dysplasia. […] Unilateral primary aldosteronism (e.g., unilateral adrenal hyperplasia or aldosterone-producing adenoma) gets treated with unilateral laparoscopic adrenalectomy.

• #2 Chapter 13. Secondary hypertension | Hypertension Research

  https://www.nature.com/articles/hr201416

  Therapeutic strategies should be determined in accordance with those for CKD complications. […] The treatment of renovascular hypertension is started with antihypertensive drugs in many cases. […] Combination therapy with RA system inhibitors, Ca channel blockers, diuretics and -blockers should be administered until a target blood pressure is achieved. […] The use of RA system inhibitors should be considered because they are useful for reducing blood pressure, maintaining renal function and improving the prognosis in patients with unilateral RVHT. […] In patients with bilateral RVHT, RA system inhibitors may rapidly induce renal dysfunction, and are contraindicated as a general rule. […] A combination of percutaneous transluminal renal angioplasty (PTRA) and antihypertensive drug therapy is useful for reducing blood pressure, but evidence regarding renoprotective effects is not sufficient.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  Correction of coarctation at an early age provides better long-term outcomes, but one-third of the patients remain hypertensive even after surgical correction of the coarctation of the aorta. […] Vasculitides of the large vessels (e.g Takayasu Arteritis) may also lead to hypertension due to a significant rise in systemic vascular resistance. […] Corticosteroids or other immunosuppressant agents along with antihypertensive drugs are recommended for the treatment of secondary hypertension due to vasculitides. […] Continuous positive airway pressure (CPAP) therapy is the mainstay of treatment for OSA. […] To note, however, lifestyle modifications like weight loss, along with the usage of CPAP have a synergistic effect on lowering blood pressure and are better than either intervention alone.

• #2 The start of a new review series: recent advances in the management of secondary hypertension | Hypertension Research

  https://www.nature.com/articles/s41440-020-0456-7

  W dodatku, zastosowanie terapii ciągłego dodatniego ciśnienia w drogach oddechowych jest skuteczne w poprawie kontroli ciśnienia krwi. […] Również omawiane są chirurgiczne, interwencyjne, instrumentalne i medyczne leczenie nadciśnienia naczyniowego, pierwotnego aldosteronizmu, guza chromochłonnego, przewlekłej choroby nerek oraz obturacyjnego bezdechu sennego.

• #2 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  An alternative to CPAP is oral appliances, used in mild to moderate OSA, which are non-inferior to CPAP in the reduction of blood pressure and may even help with better compliance in patients. […] In patients refractory to the above treatment, few upper airway surgeries can be performed to help with symptoms and reduction in blood pressure, like uvulopalatopharyngoplasty (UPPP) in adults and tonsillectomy and adenoidectomy in children. […] Interventions for hypertension in pregnancy are lifestyle modifications and anti-hypertensives. […] The anti-hypertensives commonly used in pregnancy are labetalol, nifedipine, and methyldopa. […] If an acute decrease in blood pressure is required, intravenous labetalol or intravenous hydralazine are options.

• #2 Drug-induced causes of secondary hypertension

  https://atm.amegroups.org/article/view/15358/html

  Resistant hypertension is a blood pressure that remains above the treatment goal despite use of optimal doses of three antihypertensive drugs of different classes including a diuretic (1). […] Patients with resistant hypertension should be screened for causes of secondary hypertension (2). […] This article will discuss some of the drug-induced causes of secondary hypertension. […] Excessive alcohol use raises blood pressure and can cause resistance to antihypertensive drug therapy (4,9). […] Nonsteroidal anti-inflammatory drugs should be avoided if possible in persons with hypertension and other analgesics used depending on the indication. […] Antidepressants such as monoamine oxidase inhibitors, serotonin-norepinephrine reuptake inhibitors, and tricyclic antidepressants may cause an elevated blood pressure (4). […] A sympathomimetic hypertensive crisis may be induced by abruptly stopping clonidine or other sympatholytic drugs or by using cocaine, amphetamines, phencyclidine, or monoamine oxidase inhibitors (20).

• #2 Drug-Induced Hypertension

  https://www.uspharmacist.com/article/drug-induced-hypertension

  Drug-induced blood pressure elevations represent an important and modifiable cause of secondary hypertension; therefore, it is imperative that pharmacists recognize this causal relationship. […] Pharmacists should counsel patients that pseudoephedrine may modestly increase blood pressure and heart rate. […] The risk-benefit ratio should be evaluated carefully before using any sympathomimetic agent in persons with hypertension. […] Patients with hypertension should be more closely monitored for blood pressure elevations when using NSAIDs. […] The principal mechanism of corticosteroid-induced hypertension is the overstimulation of the mineralocorticoid receptor, resulting in sodium retention in the kidney. […] Corticosteroid-induced hypertension may respond to diuretic therapy. […] Pharmacists should maintain an awareness of the major drug classes that may increase blood pressure and/or interfere with effective blood pressure control. […] Pharmacists should screen for medications that raise blood pressure and should provide feedback to patients and medical providers to decrease this potential cause of secondary hypertension.

• #2 Secondary hypertension | UM Health-Sparrow

  https://www.uofmhealthsparrow.org/departments-conditions/conditions/secondary-hypertension

  Proper treatment of secondary hypertension can often control both the high blood pressure and the condition that causes it. Effective treatment reduces the risk of serious complications including heart disease, kidney failure and stroke. […] Treatment for secondary hypertension involves treating the medical condition that’s causing it with medications or surgery. Once the condition is treated, blood pressure might decrease or return to normal. […] Treatment might require continuing to take blood pressure medication, as well. The underlying medical condition might affect this choice of medication. […] Treatment for secondary hypertension can sometimes be complicated. It might take more than one medication combined with lifestyle changes to control high blood pressure. Your health care provider will want to see you more often possibly as often as once a month until your blood pressure is controlled. Your provider may also recommend that you keep track of your blood pressure at home.

• #2 Hypertension – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/hypertension/hypertension

  Treatment involves lifestyle changes and medications, including diuretics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, and calcium channel blockers. […] Primary hypertension has no cure, but some causes of secondary hypertension can be corrected. In all cases, control of blood pressure can significantly limit adverse consequences. […] Goal blood pressure for most patients, including patients with a kidney disorder or diabetes, is BP 130/80 mm Hg. […] Lifestyle modifications are recommended for all patients with elevated BP or any stage hypertension. The best proven nonpharmacologic interventions for prevention and treatment of hypertension include the following: Increased physical activity, ideally with a structured exercise program; Weight loss, if appropriate; Healthy diet rich in fruits, vegetables, whole grains, and low-fat dairy products, with reduced saturated and total fat content; Reduced dietary sodium, optimally to 1500 mg/day (3.75 g sodium), but at least a 1000 mg/day reduction; Enhanced dietary potassium intake, unless contraindicated due to chronic kidney disease or use of medications that reduce potassium excretion; Moderation in alcohol intake in those who drink alcohol to 2 drinks daily for men and 1 drink daily for women; Smoking cessation.

• #2 Definition of hypertension and pressure goals during treatment (ESC-ESH Guidelines 2018)

  https://www.escardio.org/Journals/E-Journal-of-Cardiology-Practice/Volume-17/definition-of-hypertension-and-pressure-goals-during-treatment-esc-esh-guidelin

  The recommended treatment for resistant hypertension is the addition of low-dose spironolactone to existing treatment, or the addition of further diuretic therapy if intolerant to spironolactone, with either eplerenone, amiloride, higher-dose thiazide/thiazide-like diuretic or a loop diuretic, or the addition of bisoprolol or doxazosin. […] Secondary hypertension is hypertension due to an identifiable cause, which may be treatable with an intervention specific to the cause. […] Nevertheless, intervention is still important because it will often result in much better BP control with less medication.

• #2 Secondary Hypertension: Discovering the Underlying Cause | AAFP

  https://www.aafp.org/pubs/afp/issues/2017/1001/p453.html

  Patients who are obese and who have signs or symptoms of obstructive sleep apnea and hypertension should be assessed with polysomnography. […] Patients with RAS should be treated with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers unless there are contraindications to their use. […] The best initial test for primary hyperaldosteronism is measurement of the ratio of the plasma aldosterone concentration to plasma renin activity after potassium repletion. […] Treatment of OSA may improve blood pressure control, sleep quality, daytime sleepiness, and mortality.

• #2 Chapter 13. Secondary hypertension | Hypertension Research

  https://www.nature.com/articles/hr201416

  In patients with fibromuscular dysplasia, potent hypotensive effects are achieved, and the long-term prognosis is relatively favorable. […] For vascular reconstruction, PTRA is initially considered because of its low-level invasiveness. […] The long-term prognosis of fibromuscular dysplasia after PTRA is also relatively favorable, but restenosis may occur. […] The results of previous clinical studies have not demonstrated any marked difference between antihypertensive drug therapy alone and a combination of antihypertensive drug therapy and PTRA. […] In patients with unilateral renal artery stenosis-related hypertension, the use of RA system inhibitors should be considered. […] In patients with bilateral renal artery stenosis, RA system inhibitors may induce the rapid exacerbation of renal function and are contraindicated as a general rule.

• #2 Secondary Hypertension – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK544305/

  ACE inhibitors and ARBs are the anti-hypertensive drugs of choice in patients with unilateral renal artery stenosis, however, these drugs are contraindicated in bilateral renal artery stenosis due to the risk of rapid renal dysfunction. […] Other pharmacologic treatment options are calcium channel blockers and thiazide diuretics. […] Unilateral primary aldosteronism (e.g., unilateral adrenal hyperplasia or aldosterone-producing adenoma) gets treated with unilateral laparoscopic adrenalectomy. […] If the patient is not a surgical candidate or a patient has the bilateral adrenal disease, then medical management with a mineralocorticoid receptor antagonist is recommended and spironolactone is the drug of choice for primary aldosteronism. […] For Cushing Syndrome or Cushing Disease, an open surgical or laparoscopic resection of the lesion/tumor is the treatment of choice.

• #2 Resistant hypertension: A stepwise approach | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/90/2/115

  Resistant hypertension can be challenging to manage, but a stepwise approach to diagnosis, evaluation, and treatment can lead to better blood pressure control. […] Along with lifestyle modification, a stepwise approach to management using antihypertensive medications with differing mechanisms of action is critical to achieving blood pressure control. Patients may require more anti-hypertensive medications. […] Patients with resistant hypertension should be evaluated for secondary hypertension, since recognition and directed therapy may improve blood pressure control. […] A multifactorial approach to treat resistant hypertension includes a combination of lifestyle modification, pharmacotherapy, and addressing underlying contributing diseases. […] The initial pharmacologic approach to resistant hypertension consists of 3 medications, each mechanistically different, at maximally tolerated doses, as follows: An ACE inhibitor or ARB, a long-acting dihydropyridine calcium channel blocker, and a diuretic.

• #2 Resistant hypertension: A stepwise approach | Cleveland Clinic Journal of Medicine

  https://www.ccjm.org/content/90/2/115

  If blood pressure is still not controlled on maximally tolerated therapy with these 3 agents, a mineralocorticoid receptor antagonist (spironolactone or eplerenone) should be the fourth-line agent. […] Patients should be referred to a hypertension specialist if blood pressure remains uncontrolled despite the above therapies. […] Experimental devices and other therapies are currently being explored in patients with resistant hypertension.

• #2 Secondary Hypertension Causes, Symptoms, and Treatments

  https://www.upmc.com/services/kidney-disease/conditions/hypertension

  Doctors use the term secondary hypertension to refer to high blood pressure caused by an underlying disease, such as a kidney or endocrine condition. […] The experts at UPMC specialize in treating secondary hypertension. Our team will find the cause of your condition and develop a treatment plan to manage your symptoms and reduce your risk of complications. […] If you have secondary hypertension caused by kidney disease, your doctor will design a treatment plan that may include: […] Medicine to control your high blood pressure. […] A new, FDA-approved procedure called renal denervation is a minimally invasive treatment option for people with secondary hypertension that doesn’t respond to medication or lifestyle changes. […] Renal denervation is a highly successful procedure for secondary hypertension. Most people see a drop in their blood pressure numbers and can reduce their blood pressure medications. Some people may be able to stop taking blood pressure medications completely.

• #2 Major Clinical Considerations for Secondary Hypertension and Trea

  https://www.longdom.org/open-access/major-clinical-considerations-for-secondary-hypertension-and-treatment-challenges-systematic-review-52433.html

  Major Clinical Considerations for Secondary Hypertension and Treatment Challenges: Systematic Review […] In this context, secondary arterial hypertension (SH) is defined as an increase in systemic arterial pressure (SAP) due to an identifiable cause. […] This study aimed to describe, through a systematic review, the main considerations on secondary hypertension, presenting its clinical data and main causes, as well as presenting the types of treatments according to the literary results. […] Cause treatment can cure or improve SH control. […] A small proportion of cases of arterial hypertension are due to well-established causes, which need to be properly diagnosed, since with the removal of the etiological agent it is possible to control or cure SH. […] Therefore, the present study aimed to describe, through a systematic review, the main considerations about secondary hypertension, presenting its clinical data and main causes, as well as presenting the types of treatments according to the literary results. […] Despite adequate therapy or even removal of the secondary cause, blood pressure rarely returns to normal. […] Thus, in patients with potentially, early detection and treatment are important in reducing irreversible changes in the vasculature. […] In this context, another study also analyzed the SH reduction. […] Thus, the intervention group had a significant decrease in body weight, sodium excretion, systolic and diastolic BP, and drug use. […] This study demonstrated that Thai instrumental folk music audition was effective for the reduction of BP and DBP in SH patients. […] It was concluded with the present study that secondary hypertension effects on average 7.5% of hypertensive patients. Screening in the diagnosis of secondary hypertension is expensive and laborious and should be performed only in patients with high clinical suspicion.

• #2 Evaluation and Management of Secondary Hypertension

  https://pmc.ncbi.nlm.nih.gov/articles/PMC9728017/

  Prescription medications, over-the-counter medications and supplements, illicit drugs, and alcohol are common causes of secondary hypertension. […] Ideally, in patients with hypertension and particularly those with resistant hypertension, drugs that increase blood pressure should be discontinued in lieu of alternative agents that do not affect blood pressure. […] Secondary hypertension is common among patients with hypertension and is often underrecognized. […] Patients with hypertension should be evaluated for risk factors for secondary hypertension and screened accordingly. In particular, patients with resistant hypertension should, at minimum, undergo testing for primary aldosteronism and screening for drugs that may induce hypertension, with further evaluation for renovascular hypertension and obstructive sleep apnea depending on their age, symptoms, and comorbidities.

• #3 Approach to the diagnosis of secondary hypertension in adults

  https://australianprescriber.tg.org.au/articles/approach-to-the-diagnosis-of-secondary-hypertension-in-adults.html

  Presentations that should raise suspicion of secondary hypertension include early-onset, severe or resistant hypertension. […] Identifying and treating the cause can potentially cure or markedly improve hypertension and reduce the associated cardiovascular risk. […] All patients suspected of having secondary hypertension should be screened for the common causes and associations. These include renal disease (parenchymal or renovascular), primary aldosteronism, medicines, illicit substances, alcohol and obstructive sleep apnoea. […] Patients with primary aldosteronism have a higher risk of cardiovascular morbidity and mortality than other age-, sex- and blood pressure-matched patients. […] Although testing for primary aldosteronism has not been directly linked with mortality benefits, treating primary aldosteronism surgically (by unilateral adrenalectomy) or with specific mineralocorticoid blockade may improve long-term cardiovascular outcomes.

• #3 Secondary hypertension | UM Health-Sparrow

  https://www.uofmhealthsparrow.org/departments-conditions/conditions/secondary-hypertension

  Proper treatment of secondary hypertension can often control both the high blood pressure and the condition that causes it. Effective treatment reduces the risk of serious complications including heart disease, kidney failure and stroke. […] Treatment for secondary hypertension involves treating the medical condition that’s causing it with medications or surgery. Once the condition is treated, blood pressure might decrease or return to normal. […] Treatment might require continuing to take blood pressure medication, as well. The underlying medical condition might affect this choice of medication. […] Treatment for secondary hypertension can sometimes be complicated. It might take more than one medication combined with lifestyle changes to control high blood pressure. Your health care provider will want to see you more often possibly as often as once a month until your blood pressure is controlled. Your provider may also recommend that you keep track of your blood pressure at home.

• #3 Secondary Hypertension | Treatment & Management | Point of Care

  https://www.statpearls.com/point-of-care/28819

  If the patient is not a surgical candidate or a patient has the bilateral adrenal disease, then medical management with a mineralocorticoid receptor antagonist is recommended and spironolactone is the drug of choice for primary aldosteronism. […] For Cushing Syndrome or Cushing Disease, an open surgical or laparoscopic resection of the lesion/tumor is the treatment of choice. […] The definite treatment of pheochromocytoma is surgical resection of the hormone-producing lesion, however preoperative alpha and beta-adrenergic blocking drugs are an essential part of pheochromocytoma management. […] It is recommended to start alpha-adrenergic blocking drugs first and then add beta blockers for the treatment of tachyarrhythmias. […] Initiation of beta-adrenergic blocking drugs is not recommended alone/before the alpha-adrenergic blockade, as it results in hypertensive crisis due to the unopposed alpha-adrenergic effect.

• #3 Resistant Hypertension: An Overview | ECR Journal

  https://www.ecrjournal.com/articles/global-burden-resistant-hypertension-and-potential-treatment-options?language_content_entity=en

  Once the diagnosis is established, RH management remains challenging. Effective treatments should combine lifestyle changes and removal of interfering substances, optimisation of ongoing treatment and a sequential introduction of antihypertensive drugs on top of triple therapy. […] Growing evidence supports the role of lifestyle changes in RH management. In a recent network meta-analysis, lifestyle interventions were the most effective non-pharmacological treatment in the setting of RH, lowering office SBP by 7.26 mmHg (95% CI [13.73, 0.8]). […] According to the latest ESH guidelines, effective pharmacological treatment of RH should combine rationalisation of current medications and the sequential addition of antihypertensive agent to the existing triple therapy. […] After optimising the ongoing therapy, a stepwise addition of other agents should be considered if BP is still not at goal. Based on the results of the PATHWAY-2 trial and other studies, patients with RH should receive the MRA spironolactone 25-50 mg/day as fourth-line treatment.

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