A Woman With Treatment-Resistant Hypertension.

Although this is not a particularly unusual or rare case of hypertension, it highlights the challenges we have as clinicians in managing such patients. The patient, a 60 year-old woman, was referred to the tertiary blood pressure clinic at Glasgow’s Western Infirmary 5 years ago by a consultant cardiologist for management of resistant hypertension. This lady has a vasculopathy with ongoing intermittent claudication and had previous bilateral superficial femoral artery occlusions on a background of hypercholesterolemia and a significant smoking history. The patient has problematic underlying ischemic heart disease, having had angina since 2001, numerous percutaneous interventions, and a 2-vessel coronary artery bypass graft. Despite this, she had a non–ST-segment–elevation myocardial infarction (MI) 2 years before presentation. Blood pressure at first visit to the clinic was 182/106 mm Hg despite numerous antihypertensive medications, including an angiotensin-converting enzyme inhibitor, calcium channel blocker, 2 different diuretics, α-blocker, and β-blocker in addition to her antianginal and secondary preventative medications (Table). Review of case notes and previous clinic documentation revealed that clinic blood pressure was elevated for at least 10 years with systolic readings ranging from 150 to 200 and diastolic between 90 and 100 mm Hg. View this table: Table. Total Daily Dose of Antihypertensive Medications: An Overview of Antihypertensive Medication at the Time of Referral to the Clinic (2010), Before RDN (2012) and Immediately After RDN (2012), and in 2015 The patient was admitted to the investigation ward for a week of workup. During this time, routine biochemistry showed normal renal function and electrolytes. Urine albumin/creatinine ratio was within the microalbuminuric range at 4.2 mg/mmol. Cardiac and mediastinal contours seemed normal on chest x-ray, and neither ECG nor echocardiogram showed significant left ventricular hypertrophy (LVH). No biochemical evidence to suggest pheochromocytoma or primary aldosteronism was found. Renal ultrasound exhibited 2 normal sized nonobstructed kidneys with no …