Online Health Chat with George Thomas, MD

October 9, 2015


Resistant hypertension is a condition in which blood pressure remains high despite efforts to lower it. If your high blood pressure (hypertension) is not at goal, even when three medicines including a diuretic (water pill) are used or when your blood pressure is controlled but only with the use of four or more medications, you have resistant hypertension. Up to 15 percent of all patients who have high blood pressure may have resistant hypertension. Getting your high blood pressure under control is extremely important to reduce your risk of developing irreversible kidney damage, or suffering a stroke or heart attack.

Lifestyle changes can help improve blood pressure control. These measures include limiting salt and alcohol, limiting use of NSAIDs for pain relief (acetaminophen can be used instead), doing at least 30 minutes a day of aerobic activity several days a week and treating sleep apnea with continuous positive airway pressure. Identifying specific causes contributing to resistance and a combination of lifestyle changes and medications are the mainstay of management.

About the Speaker

George Thomas, MD, Director of Cleveland Clinic’s Center for Blood Pressure Disorders, is board-certified in internal medicine – nephrology. He completed his fellowship in nephrology and hypertension at Cleveland Clinic in 2010. Dr. Thomas completed his residency in internal medicine at Tufts University-St. Elizabeth’s Medical Center in Boston, after completing medical school at Bharati Vidyapeeth’s Deemed University Medical College in Pune, India. Dr. Thomas has also completed a graduate program in public health at Johns Hopkins School of Hygiene & Public Health in Baltimore. Dr. Thomas’ specialty interests include chronic kidney disease, hypertension, resistant hypertension, end-stage renal disease, glomerular disease, adrenal diseases, dialysis, hemodialysis and kidney stones.

Let’s Chat About Resistant Hypertension

The Basics of Blood Pressure

MRQUARTERMAIN: I understand that the numbers for blood pressure have changed. Is this true?

George_Thomas,_MD: The new SPRINT trial results indicate that more aggressive control of blood pressure (systolic/ upper number less than 120) may be better for cardiovascular health compared to less aggressive control (systolic less than 140). However, we are awaiting full results of the trial before recommending changes. We will need to know more about any adverse effects with more intensive treatment. More information should be available by the end of the year. Until then, individual goals should be discussed with your treating physicians.

LucyintheSkies: Would you talk about the difference between chronic versus resistant high blood pressure? I understand that one of the criteria relates to the number of blood pressure medications being used. Currently, I am taking Norvasc and Toprol. I have made lifestyle changes with diet and exercise, and I am genetically predisposed to hypertension. My blood pressure still runs around 140/80-90, which to me is still considered high. Can the road to resistant hypertension be avoided?

George_Thomas,_MD: The term resistant hypertension relates to the number of medications being used and whether your blood pressure stays above goal despite this. The current definition is blood pressure above goal despite being on three medications including a diuretic (water pill). I noted that you are not on a diuretic, so this may be something to consider adding. A low-sodium diet should include limiting processed foods, and you should limit your alcohol intake. If you have symptoms suggestive of sleep apnea, this should be addressed as well.

James007: Does high blood pressure run in families? Would my kids be more likely to have it someday?

George_Thomas,_MD: Yes. Family history is a risk factor for developing hypertension. I would encourage a healthy lifestyle from early on.

krissyheart: My father is overweight and does not like to go to the doctor. Are there any symptoms we can look for to tell if he has high blood pressure?

George_Thomas,_MD: High blood pressure may not manifest with any symptoms until organ damage is done (which is why it is called the "silent killer"). It is important to know your blood pressure numbers and address this early on to prevent development or progression of organ damage. I would recommend having regular physicals with a physician to address blood pressure (and other health maintenance issues), or at the very least, I would recommend getting a home blood pressure monitor to track numbers at home.

Moderator: Great questions so far. Keep them coming!

Timely Treatments

James007: How can you tell which foods are low in sodium from the food label? What is a good daily limit?

George_Thomas,_MD: Your daily limit should be less than 2.3 grams (2300 mg). When you read food labels, make sure you take into account the number of servings in the can/ jar/ box. For example, if the amount of sodium is listed as 400 mg per serving and the serving size is three, your sodium intake is 1200 mg if you have the whole amount. This applies to all processed foods. Foods that don't taste salty may also be high in sodium.

NurseSleepyHollow: I am 73 years old. I have uncontrolled hypertension. My blood pressure can be 160/50 to 140/40. I am on four blood pressure medications plus a diuretic. I am a Type 2 diabetic. My A1c is 6.6. I have Stage 2 chronic kidney disease. The duplex renal ultrasound indicates greater than 60 percent. I am 60 pounds overweight. I have persistent A-fib. I am physically active (I can walk, go up and down stairs, do housework, etc.). All of the clinical trials (e.g., Corral trial) I have read indicates that it makes no difference in lowering blood pressure or in outcomes of CKD by stenting. My questions: (1) Have you had patients who have had stents and brought their blood pressures down significantly? (2) Is there any treatment/procedure you are aware of that would bring my blood pressure down? (3) Is there any therapy/procedure now or being studied that will help me lower my blood pressure?

George_Thomas,_MD: Studies for renal artery stenosis (stenting versus medical therapy) have indicated no significant benefit for stenting as far as health outcomes. The main indications for considering stenting would be 1) if blood pressure is not controlled despite maximal optimal therapy, 2) if there is an unexplained decline in kidney function and 3) if you have significant blockages to both kidneys that predispose you to having frequent fluid build-up. As far as procedures for lowering blood pressure, an experimental trial (renal denervation) did not indicate any benefit with the procedure. We do have a trial of a new medication coming up to lower blood pressure. If you are interested, this may be a trial to consider, and we can provide you with more information.

liesel: I am a 76-year-old female with coronary artery disease, two stents, moderate mitral valve regurgitation, A-fib and bradycardia-tachycardia. For the last few months, I have not been able to lower my blood pressure. It runs around 150/78. I take 50 mg metoprolol ER at 6 p.m. and 25 mg losartan potassium, which I take at 8 p.m. I tried buspirone Hcl 5 mg for one month, but it gave me insomnia. I cannot tolerate lisinopril and Diovan. I am also on Plavix, 10 mg, Crestor and 81 mg aspirin. That is all. I am very drug-sensitive. I eat a very heart-healthy diet and exercise five days a week at cardiac rehab through our hospital. I do stress easily and try to meditate, but it's not always successful. Can you suggest what I can do to bring my blood pressure down?

George_Thomas,_MD: You should discuss with your doctor about potentially starting a diuretic (water pill), as sometimes this may be needed in addition to other medications to control blood pressure. Continue with lifestyle modifications as you are. Keep in mind that a low-sodium diet is key (including limiting processed foods). If your blood pressure remains uncontrolled, I would discuss with your doctor about looking for potential hormonal or vascular causes. I would also recommend checking for sleep apnea if you have symptoms of snoring, fatigue during the day, etc.

Bethylove: I was recently diagnosed with resistant hypertension (RHT). What lifestyle modifications should I expect?

George_Thomas,_MD: Lifestyle modifications that should be followed for hypertension include:

  • A low sodium diet: This should be lower than 2 grams/day. Besides not adding salt, you should limit processed foods that are usually high in sodium, limit alcohol intake to two drinks/day for men and one drink/day for women, maintain a healthy weight and get physical activity on most days of the week for at least for 30 minutes.
  • You should quit smoking for overall cardiovascular health.
  • If you have coffee or other caffeinated drinks, wait for at least 30 to 45 minutes before checking blood pressure.

TBcountrylove: Are there any new treatments for resistant hypertension that are coming soon?

George_Thomas,_MD: We will be involved in a medication trial soon for resistant hypertension. It will probably start within the next month. If you are potentially interested in participating, please contact our research coordinator, Kim Mackay, at 216.444.4650.

Cause and Effect

rrhanson: I am taking three blood pressure medications: Benicar, 40mg/1 daily, clonidine patch/weekly. 1 mg and Toprol 100mg/1 daily. My blood pressure is still occasionally in the 130/85+ range and I have terrible "white coat" 140-150/90. I feel 80 percent to 90 percent of my cause is subconscious fear, insecurity, etc. Any ideas on how to overcome this?

George_Thomas,_MD: You will need to confirm that this is indeed white coat hypertension. The best way to do this is to get 24-hour ambulatory blood pressure monitoring, where you get a device placed on you that measures blood pressures during the course of 24 hour (in an out of the clinic setting). You should continue medications, make sure you are following a low-sodium diet, limit alcohol use, and keep up with physical activity and weight management. You can discuss potential anti-anxiety medications with your doctor if you think this is a significant factor.

Debbie284: I have tried more than 20 hypertension medications and haven't found any to help. I either end up in the ER because my blood pressure has soared (beta blockers do this), or I have horrible side effects, or if a medication works, it will stop working after a month or two. Presently, all I am able to tolerate is clonidine, but it makes me extremely fatigued so I am only able to take it at night or if my blood pressure spikes. I am aware that it isn't a good choice because it has a rebound effect, but since most of my blood pressure spikes happen in the evening, it does help with those. I have been to several cardiologists and nephrologists with no results. I have a parathyroid adenoma and was wondering if that could be causing my hypertension.

George_Thomas,_MD: Parathyroid disease can affect blood pressure control. I would also consider checking for other hormonal or vascular causes if you haven't had this checked previously. You are right that clonidine is not an ideal medication in that it causes rebound hypertension, especially if not taken regularly.

jammo: What would put me at risk for resistant hypertension?

George_Thomas,_MD: There are some identifiable or secondary causes of hypertension. These include hormonal causes such as primary aldosteronism, pheochromocytoma and Cushing Syndrome, or vascular causes such as blockages in the kidney arteries. Sometimes, other medications you take, especially NSAIDs like ibuprofen, can affect blood pressure control. If you are on multiple medications and blood pressure is not controlled, your doctor should consider evaluating you for secondary causes (usually with blood or urine tests and imaging studies).

J22Frosty: My husband has had a lot of bladder infections. He has never been diagnosed with a kidney infection, but a nurse recently suggested a kidney infection could be causing high blood pressure. Is that possible?

George_Thomas,_MD: I would make sure he is on optimal medications and look for other secondary causes prior to attributing this to infection.

Mostly About Medications

zman949: I had an aortic valve replacement surgery one year ago, and had a bovine valve put in. I am currently on 10 mg lisinopril and 12.5 mg metoprolol succinate. Is it OK to be on both of these at the same time, and for the rest of my life? I am 58 years old. My heart rate was higher after the surgery, but with both of these, my blood pressure is 110-70 and my heart rate is in the low 70s. Should I look at other alternatives?

George_Thomas,_MD: It is OK to be on these medications at the same time. Both medications are at a relatively low dose, and your blood pressure and heart rate numbers seem to be good. I would not change these unless recommended by your treating physician.

LucyintheSkies: What do medications like Toprol and Norvasc actually do for high blood pressure?

George_Thomas,_MD: Toprol belongs to a class of medications called beta blockers, which helps lower blood pressure by reducing heart rate. Some beta blockers have an additional capability of relaxing blood vessels, which helps lower blood pressure as well. Norvasc belongs to a class of medications called calcium channel blockers, which helps lower blood pressure by relaxing the blood vessels.

James007: If I take an NSAID for arthritis pain, should I consider changing to something else?

George_Thomas,_MD: All NSAIDs unfortunately impact blood pressure control, especially if taken on a regular basis. I suggest that you discuss with your doctor if you are able to switch to acetaminophen, which may be better from a blood pressure control standpoint.

mistylane: Can you explain what a water pill does?

George_Thomas,_MD: Water pills, also called diuretics, help get rid of excess sodium along with water, which will be beneficial for blood pressure control. In the long term, diuretics also relax blood vessels, which helps with blood pressure control. The common diuretics in use are thiazide diuretics (like hydrochlorothiazide or HCTZ) or furosemide (Lasix), which belong to a class of diuretics called loop diuretics. Diuretics are part of management for high blood pressure and should be included as part of your blood pressure medication regimen (unless there is a reason not to use it, based on your physician's assessment).

Monitoring Matters

mag228: How accurate are home blood pressure monitors?

George_Thomas,_MD: There are different blood pressure monitors on the market. While we don't endorse any specific brand, you should get a device that has an arm cuff (rather than a wrist device). Also, you should bring in your monitor periodically to your doctor's office during your visit so that readings can be compared to make sure these are accurate.

cavs888: What can I expect when I come to see a resistant hypertension specialist for the first time?

George_Thomas,_MD: We start by confirming resistance to treatment, which would include possibly getting 24-hour blood pressure assessments. We check for possible secondary causes like any hormonal or vascular causes. We review your medications and make dosage adjustments or switch medications if needed for better control. We have the capability to do other advanced testing to determine what medications may work best for you.

cassie99: How often should I be checking my blood pressure if I have hypertension?

George_Thomas,_MD: Depending on the degree of your blood pressure control, your physician will advise you on an optimal schedule. Ideally, you should have home blood pressure readings to take with you to your doctor's visit so it can be reviewed. You can check blood pressures three times a week, both in the morning (after you wake up) and in the evening (before you go to bed). Each time you check blood pressures, take at least two readings. It is also important to follow the correct technique. You should be seated in a quiet room, feet resting on the floor, arm at heart level, back supported. Relax quietly for at least five minutes before checking blood pressure. Also, if you have been exercising, have had caffeine or if you smoke, wait for at least 30 minutes before checking blood pressure. Bring your readings and your machine to your doctor's visit.


That is all the time we have for questions today. Thank you, Dr. Thomas, for taking time to educate us about resistant hypertension.

On behalf of Cleveland Clinic, we want to thank you for attending our online health chat. We hope you found it to be helpful and informative. If you would like to learn more about the benefits of choosing Cleveland Clinic for your health concerns, please visit us online at

For Appointments

To make an appointment with George Thomas, MD, or any of the other nephrologists in Cleveland Clinic’s Glickman Urological & Kidney Institute, please call 216.444.6771, toll-free at 800.223.2273 (extension 46771) or visit us at for more information.

For More Information

Cleveland Clinic

The Department of Nephrology within the Glickman Urological & Kidney Institute is ranked No. 2 in the nation by U. S. News & World Report 2015-2016. Nephrologists in this institute are also recognized worldwide for excellence in patient care, teaching and research in all aspects of nephrology.

Cleveland Clinic Health Information

Learn more about symptoms, causes, diagnostic tests and treatments for resistant hypertension.

Clinical Trials