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Resistant Hypertension (Drs. Shishehbor and Thomas 1/5/12)

George Thomas, MD | Cleveland Clinic

George Thomas, MD
Department of Nephrology and Hypertension

Mehdi H. Shishehbor, DO, MPH | Cleveland Clinic

Mehdi H. Shishehbor, DO, MPH
Specialist, Interventional Cardiology and Endovascular Interventions, Robert and Suzanne Tomsich Department of Cardiovascular Medicine

Thursday, January 5, 2012 - Noon


Resistant Hypertension is high blood pressure that is difficult to control despite being on blood pressure medications. High blood pressure can become very dangerous, and is one of the leading causes of heart disease and stroke. Besides making lifestyle changes and trying different medications, there are now promising novel therapies that can be used to treat resistant hypertension. Dr. Shishehbor, interventional cardiologist and Dr. Thomas, hypertension specialist answer your questions regarding high blood pressure and resistant hypertension.

More Information

Cleveland_Clinic_Host: Welcome to our "Resistant Hypertension" online health chat with Dr. Mehdi H. Shishehbor and Dr. George Thomas . They will be answering a variety of questions on the topic. We are very excited to have them here today! Let's begin with the questions.

Resistant Hypertension

cellis: Can you provide some differentiation between essential hypertension and resistant hypertension other than treatability?

Dr__Thomas: Resistant hypertension is defined as blood pressure not at goal in spite of being on three optimal blood pressure medications with different modes of action, including a diuretic (water pill). It is arbitrarily defined in order to identify patients who may be at high risk of having a secondary cause of hypertension and who may benefit from a more thorough work up.

Labile Hypertension

Francois: Does labile (episodic) hypertension where blood pressure spikes to different abnormal levels in response to even minor stimuli have to be treated? How is it treated?

Dr__Thomas: Blood pressure, by its very nature, can vary depending on stress, activity, caffeine, smoking, etc. However, if your blood pressure spikes to very high levels or you notice additional symptoms such as headaches, feeling your heart racing, sweating, etc you may need additional testing to look for underlying problems. A specialized center can also arrange to do 24 hr blood pressure monitoring which would give a better idea of the blood pressure pattern during the day as well as during sleep.

High Blood Pressure Medications and Supplements

dancingwings46: I've heard about a supplement named Hawthorne, its supposed to naturally health with high blood pressure. Do you know anything about it and do you recommend supplements when taking high blood pressure medication?

Dr__Thomas: Many herbal supplements claim to lower blood pressure. As far as Hawthorne, small studies showed some trend towards lowering blood pressure but the effect was not significant. It is important to keep in mind that herbal supplements can have significant interactions with your regular blood pressure medications and any other medications that you may be taking, and you should discuss this with your doctor.

Duncan1: Can amlodipine and verapamil be taken concurrently?

Dr__Thomas: They both belong to the same family of medications. You may have a specific indication based on your medical history that your doctor has prescribed both for you.

kodajaws: I take several drugs for hypertension - some at night and others in the morning. My hypertension is always very high in the morning and lowers as the day goes on. Is this usual with chronic hypertension? I also have FMD with carotid involvement and have cardiac stents. Thank you

Dr__Thomas: Blood pressure has been shown to have a pattern - normally, blood pressure dips at night and as you wake up, blood pressure tends to be higher (called morning surge). A 24 hr monitor can be used to assess the pattern of blood pressure and how high it tends to go relative to your night-time readings. Very high blood pressures in the morning have been reported to occur in sleep apnea, kidney disease, overall poorly controlled blood pressure, etc. Long-acting medications that provide sustained coverage over 24 hrs can be better than short-acting formulations to try to 'smooth out' highs and lows.

medicmom: how does hydralazine work and what are the potential long term issues in its use?

Dr__Thomas: Hydralazine works by dilating the blood vessels. You may notice swelling of your legs as a common side effect. There may be rare effects such as hydralazine induced lupus.

Hydralazine is usually taken multiple times a day so compliance with this medication may be an issue if you forget to take it.

Chisena: Why do beta blockers (Bystolic) cause reflux?

Dr__Shishehbor: It is unlikely that beta blockers are causing your reflux. You should probably be evaluated for reflux disease.

brymorg: Can clonidine cause insomnia?

Dr__Shishehbor: I am not aware of clonidine causing insomnia. However all patients are different.

jrp: Given that all blood pressure medications have adverse effects on the body, i.e., liver or kidney damage, is there one group of medications that are less harmful than the others?

Dr__Shishehbor:We use a personalized approach to blood pressure management so what may be appropriate for one person may not necessarily be appropriate for another. Therefore there is not one class that is "the best".

leonaG: my blood pressure fluctuates from 190/92 to 150/72. I am on metropolol and lisinopril. This has been going on for about 2 weeks. what do you suggest?

Dr__Thomas: You may benefit from getting a 24 hr blood pressure monitor to assess patterns of highs and lows, and time of day during which this happens. You may need an additional medication to achieve goal blood pressure, which may include a long-acting formulation to help 'smooth out' highs and lows. Additionally, if you have very high spikes of blood pressure associated with headaches, sweating, racing heart, etc. you will need to speak to your doctor to get additional testing for underlying disorders.

jfuduric: I'm on three drugs-a beta blocker, a diuretic and an ace receptor blocker; my systolic BP is often 140-150. I'm 64 y/o;do I need another drug?

Dr__Shishehbor: I think you may be an excellent candidate for renal denervation. You will need to be evaluated by Dr. Thomas to assess your eligibility and to learn more about the study if you are interested.

pei2: I am on 3 blood pressure meds and bp reading is still high (metoprolol, furosemide and avapro). What can I do to bring the bp down?

Dr__Shishehbor: For all patients when seen by Dr. Thomas or our hypertension group are evaluated first for their appropriate management of their blood pressure. This could involve changing drugs; increasing the dose; adding additional medication; and lastly if appropriate be considered for novel therapies such as renal denervation or a stent procedure.

Since blood pressure has a significant impact on our health, we highly recommend that patients that do not have controlled blood pressure or are taking multiple medications to be seen by a hypertension expert. In our Institution, Dr. Thomas and his group are the experts in this area. If they feel it is necessary, then they will refer the patient to me to be considered for these novel minimally invasive therapies.

kodajaws: I take multiple medications for blood pressure. I have been having numerous episodes of sweating during the day and at night. Does this indicate another problem?

Dr__Shishehbor: Based on your earlier questions, you had indicated you also have FMD. I believe if you do have renal artery FMD and are taking a number of drugs I would highly recommend that you see either myself or Dr. Gornik in the Department of Vascular Medicine for evaluation.

The sweating could be related to the drugs you are taking but in my opinion it needs to be evaluated to determine your specific situation.

kodajaws: Thank you!

jrh236: You mentioned over the counter pain medication could cause blood pressure to rise. Can ibuprofen cause this?

Dr__Thomas: Yes - the class of medications called NSAIDs, which includes ibuprofen - can raise blood pressure.

brymorg: does tylenol have the same effect?

Dr__Thomas: Tylenol is not known to have the same effect as NSAIDS as far as raising blood pressure.

Duncan1: How important are diuretics in treating HTN?

Dr__Thomas: Diuretics are an important class of medication for use in hypertension management according to current US guidelines. To have a diagnosis of resistant hypertension, you would have uncontrolled blood pressure in spite of being on 3 different blood pressure medications including a diuretic.

saumil: What is the best ARB & beta-blocker recommended for treatment in the elderly (+80)

Dr__Thomas: Your specific medical condition and health status will have to be evaluated to decide on optimal therapy. Each of these classes has different medications which have different side effect profiles.

medicmom: Is hawthorne and its use in treating hypertension an area you are familiar with?

Dr__Thomas: I have answered this question previously regarding hawthorne. You should discuss all medications that you are taking with your doctor because of possible interactions.

medicmom: thank you.

Resistant Hypertension – Renal Denervation and other Research

drobin: 90 yr male. hypertension for about 60 years. Is age a limitation to the procedure? When will it be available"\? Can I join a test group?

Dr__Thomas: The renal denervation study (Symplicity HTN-3 trial) protocol specifies age limitations of 18 - 80 yrs old.

jrh236: What is the renal denervation study?

Dr__Shishehbor: Renal denervation involves a minimally invasive technique of threading a catheter through the blood vessels that supply your kidneys. Small bursts of energy are applied to "ablate" the renal nerves. Prior studies in Europe have shown promising results and favorable safety profile. After the procedure the catheter is removed and there are no devices left implanted in your body. This study is going to be done in the United States as a potential treatment option for difficult to control hypertension.

jellyjam92: What are the long term effects of ablating the renal artery?

Dr__Thomas: Prior studies in Europe and Australia have shown a favorable safety profile, with reports of patients who have been followed up to 2 years without untoward effects.

Charles: I am 52 years old. I have had high blood pressure for about 3 years now. I have been on many drugs - water pills, beta blockers and ace inhibitors and still the lowest I have gotten is 142/92 - but only for about a month - then back up. My EKG is normal. How can I get this under control? Would I be a candidate for that study?

Dr__Thomas: You may need additional medications or different combinations of medications depending on your specific medical history. Besides medications, it is important to note that lowering your salt intake, checking blood pressures correctly at home, reducing alcohol intake, and avoiding medications that can exacerbate your blood pressure (including some over the counter pain medications) also help in managing high blood pressure.

Dr__Shishehbor: We can help you decide whether you would be a candidate for the study - please contact our coordinator at 216-445-6397 - Sandra Gardenhire.

Cleveland_Clinic_Host: Dr. Shishehbor and Dr. Thomas, can you please tell us a little more Symplicity trial?

Dr__Shishehbor: We are very excited about this study and its potential impact. The only way to get this therapy is through enrolling into this study. There will be 40 - 50 centers across the United States that will be offering this and we are fortunate enough to be one of them. Dr. Thomas, a Hypertension expert, and myself, a vascular interventionalist, will be conducting this study at the Cleveland Clinic.

We are happy to answer any questions related to this study via the study coordinator Sandra - 216-445-6397, or if your questions are not answered, please do not hesitate to email me through the Heart and Vascular Institute Resource Nurses -

georgeB: Is the study you are talking about the similar to the pacemaker device that is supposed to lower blood pressure?

Dr__Thomas: This is a different study. The pacemaker device that I think you are referring to involves implanting the device in your carotid artery. The current study uses a minimally invasive technique where a catheter is threaded into the arteries of your kidneys and small bursts of energy are applied to "ablate" the renal nerves. There is no device implantation involved. If you are interested in more study details or to see about participation, please contact our coordinator at 216-445-6397 - Sandra Gardenhire.

General High Blood Pressure Questions

jrh236: What is considered very high bp levels?

Dr__Thomas: Goal blood pressure - if you have a diagnosis of hypertension - according to guidelines is less than 140/90. If you have diabetes or kidney disease, the goal is less than 130/80. Correct measurement is necessary to diagnose hypertension.

jrp: Is 120/80 a goal for all ages? I understand European and Asian physicians are not so concerned with considerably higher numbers.

Dr__Thomas: According to US Guidelines - JNC VII - the goal blood pressure is less than 140/90 if you have a diagnosis of hypertension and less than 130/80 if you have diabetes or kidney disease. Less than 120/80 is normal - but this is not a goal for treatment.

jrh236: What do you mean by correct measurement? I have peripheral artery disease. What should my goal bp be?

Dr__Thomas: Correct measurement at home would involve taking your blood pressure in a seated position with your legs uncrossed, your back supported, and your arm at heart level. You should ideally use a cuff that goes over your upper arm without clothing under the cuff. If you smoke or take caffeine you should wait at least 30 minutes to an hour prior to checking your blood pressure.

According to current guidelines, blood pressure goal in the absence of diabetes or kidney disease is less than 140/90.

bella_g: My blood pressure has always been high in the 150s and 160s - I am on a combination of a water pill and ace inhibitor and it is down to 146. My doctor seems to be pretty happy with that and I wonder if it is ok it is still not under 140.

Dr__Thomas: According to current guidelines followed in the US, goal blood pressure is less than 140/90 (and less than 130/80 if you have kidney disease or diabetes). You should discuss with your doctor regarding optimizing your regimen if your blood pressure is consistently higher. Other steps that you can take include low salt diet, weight loss, and moderation of alcohol intake. Some over the counter medications may influence blood pressure. Also, you should make sure that you are checking blood pressures correctly at home. Ideally, you should have a properly-fitting cuff that goes around your upper arm (not above clothing), you should be seated with your legs uncrossed and you back supported, your arm should be positioned at the level of your heart, and if you smoke or drink caffeine, wait at least 30 minutes to an hour before checking your blood pressure. Correct blood pressure measurements are important for proper management.

quail: Exactly what information can be gleaned from wearing a 24 monitor.

Dr__Thomas: A 24 hour monitor gives information about your average blood pressure through the day and night as well as specific patterns of highs and lows. Normally, blood pressure is lower at night and if there is no lowering or dipping this usually puts you at a higher risk of cardiovascular events.

This information can be obtained only with a 24 hour monitor. Your medications can be adjusted based on this information obtained with the 24 hour monitor.

Cardiomyopathy and Hypertension

Duncan1: Can cardiomyopathies play a role in hypertension or is HTN determined by artery resistance?

Dr__Shishehbor: Typically hypertension may cause cardiomyopathy however there are situations when they both can co-exist. Hypertension is multifactorial and arterial resistance can be one of the factors.

Hypertension in the Elderly

saumil: In the elderly population (especially +80) what treatment options are recommended

Dr__Shishehbor: There are other options including medical therapy and occasionally stenting of the renal arteries if there is evidence of renal artery blockage. We typically test for renal artery blockage when patients have elevated blood pressure despite taking multiple drugs.

Hypertension in Young People

charlene: My son is 17 years old and last time we were at the doctor's office he had high blood pressure. They have asked us to go home and keep checking it at home for the next week and then call the doctor. Is that strange for a 19 year old to have high blood pressure. We are going to watch his diet. He is going to walk regularly. What else?

Dr__Thomas: Younger individuals, especially those who do not have a significant family history of high blood pressure and are not overweight, should consider being worked up for 'secondary' causes of high blood pressure, which includes hormonal causes, vascular causes, and kidney disease - blood and urine tests are usually done to check for these causes. You should discuss getting these done with your doctor, depending on your specific medical history and health status. I would be happy to see your son - please contact my office.

Diet and High Blood Pressure

kevin72: I read an article last month that said that kiwi fruit can lower high blood pressure. Are there other foods that are helpful in lowering blood pressure?

Dr__Thomas: This was a small study that suggested some benefit with kiwi fruit. While it would be prudent to include this as part of a heart healthy diet rich in fruits and vegetables and low-fat dairy products and low in saturated and total fat (also called the DASH diet), it is unlikely that eating kiwi fruit is going to be the cure for high blood pressure. I would not recommend stopping any medications that you may be on for high blood pressure without checking your doctor. Additionally, kiwi fruit has a high potassium content, which could be harmful in patients with kidney disease. You should discuss this more with a dietician and your doctor. Lowering your salt intake is also an important factor in helping control your blood pressure

jfuduric: Is moderate caffeine intake OK with controlled HTN?

Dr__Thomas: Caffeine does cause a spike in blood pressure but the effect is usually short lived. It is unclear whether this can worsen long term hypertension.

Reviewed: 01/12

This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians.

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