Treating Hypertension: Smarter, Sharper, and With New Tools
Treating Hypertension: Smarter, Sharper, and With New Tools
Source: Medscape | June 2025
Key Highlights:
1. BP Measurement First:
Use validated automated cuffs. Manual cuffs often misread by up to 10 mmHg. Technique matters: seated, supported, quiet, cuff on bare skin.
2. Treatment Targets by Guidelines:
• AHA/ACC (U.S.): ≤130/80 mmHg
• AAFP (U.S.): ≤140/90 mmHg
AAFP = American Academy of Family Physicians; reflects a conservative primary care approach.
• KDIGO (Global): ≤120/80 mmHg
KDIGO is an international organization based in Belgium, widely followed by U.S. nephrologists for CKD care.
• ESC (Europe – not in original Medscape text): Start with <140/90, then <130/80 if tolerated especially in complicated HTN.
3. Therapeutic Strategy
• Prefer combining multiple low-dose agents over maxing out one
• Consider fixed triple-combination pills for ease and adherence
• Alcohol reduction: AHA allows up to 1–2 drinks/day, while ESC advises complete abstinence
4. Workup of Resistant Hypertension:
• Many cases of “resistant hypertension” are due to nonadherence
• Check plasma renin and aldosterone in patients on 3+ agents
• Primary hyperaldosteronism is found in ~20% of these patients
• Do not stop meds (except MRAs) before measurement of ARR ; ensure potassium is repleted
• ARR >30 : High Aldosterone-to-Renin Ratio suggests diagnosis. It is a blood test used to screen for primary aldosteronism (also called Conn’s syndrome), which is a common and treatable cause of resistant hypertension.; further confirmatory testing may be needed afterward.
5. When to Refer:
• CKD + MRA concern → nephrology
• Refer if patient is on 5+ antihypertensive agents
• Always screen for sleep apnea and perform renin-aldosterone testing beforehand
• Outside Medscape:
AHA 2023 recommends adrenal CT if PA (primary aldosteronism) is confirmed, to rule out adrenal carcinoma (rare, <1%) and assess for surgery if feasible. CT adrenal is not a screening test; it should only be performed after biochemical confirmation. As stated in the Endocrine Society guidelines: “CT imaging of the adrenal glands should be performed in all patients with confirmed primary aldosteronism.”*
Important clinical note: The ARR value should not be interpreted mathematically alone. The absolute levels matter: a high ARR with low aldosterone may be misleading. Generally, PAC (plasma aldosterone concentration) should be >15 ng/dL and renin very low or suppressed. Always interpret ARR in clinical context
Renal artery stenosis (RAS) is also a recognized secondary cause of resistant hypertension. It should be considered in patients with:
• Abrupt or severe-onset hypertension,
• Worsening renal function after starting ACEi/ARB,
• Asymmetric kidney size or abdominal bruits, or
• Recurrent flash pulmonary edema or unexplained heart failure.*
In such patients, imaging of the renal arteries is indicated.
Preferred modalities include CT angiography (CTA), MR angiography (MRA), or duplex renal Doppler ultrasound (depending on renal function and local expertise).
According to AHA/ACC guidelines, CT angiography is often the first-line imaging in patients with preserved renal function.
📖 Full article on Medscape:
👉 https://click.mail.medscape.com/?qs=e8406334fce7b9bcf86521f5afb571040f964e65dd8080c3a73ca2996c5e2746a72b0ced776c1ba25a84426d0fdc560f28eba418b38beaef146e94fa81921ef6
