Resistant Hypertension

Greetings Doctor,I am a 23 year old male 200 lbs, 5,11 at age 21 I went to my doctors office and discovered that my systolic pressure was too high 160/80. Over the years I have begun exercising everyday, eating very little sodium etc. This did nothing and as of yet I have been put on 3 medications for my blood pressure. 1. Losartan Potassium 100mg2. HCTZ 253. Toprol XL 25Even with these medications my pressure at my last visit was even worse 168/70. My diastolic is always perfect. I must say this makes me feel hopeless and as if nothing can be done. My ENT suggested that I visit a nephrologist as he suspected a secondary cause due to my young age and resistance to three medications.  The nephrologist I saw is a very friendly older man, but very nonspecific. It seems he carried out a blood test for "VMA"? And Cortisol, he told me that both were too high "slIghtly elevated" but said he didnt suspect Cushings or Pheochromocytoma. When I asked why he just said that sometimes anxiety can cause lab error, etc and that the elevation was only somewhat above normal.He didn't say much about my pressure during the visit and didn't give me any more medication. He did however ask me to do another Cortisol/VMA urine and blood tests as well as something called plasma ACTH. I have done several tests to rile out secondary causes they are as follows.2x echocardiogram Normal1x stress echocardiogram NormalKidney Ultrasound NormalAdrenal MRI NormalI have some questions I was hoping you could answer.1. My doctor said that with the normal echocardiogram he believed it to be very unlikely I have true hypertension and wants me to do a 24 hour ABPM, why is this?2. From what I have shared with you do you see any possible secondary causes? Isn't it unlikely for me to have excellent bp my entire life and suddey develop quite severe hypertension?3. With all of the information on strokes and heart attacks I feel quite alot of worry regarding me possibly having one soon. My doctor said that even with my pressure high it would take decades for it to cause me a heart attack/stroke and to not worry. Is this accurate or need I worry about imminent death?Thank you doctor; Dante

Hi Dante,
You are quite correct to be worried about your high blood pressure and the evntual risks of a heart attack and/or stroke.
At first look it appears that you have indeed "Resistant Hypertension", assuming you are taking all your medications and live a heart healthy life style and that anatomic abnormalities such as coarctation have been excluded (very likely by now).
However, any treatment of hypertension involves optimizing the things you can do, and for your doctor to make sure the following issues are taken care of:

The tests are done to make sure you don't produce abnormal levels of hormones and that your BP is always too high:

  • VMA urine testing is done to check whether you produce abnormal levels of adrenaline etc. The test is usually done to diagnose an adrenal gland tumor called pheochromocytoma that can be cause of severe hypertension.
  • Plasma ACTH levels are done to see if you produce too much cortisol.
  • Ambulatory blood pressure monitoring (ABPM) is done by means of a device that is worn for either 24 or 48 hours and done to confirm your BP is indeed too high, and if so, when and possibly why.

From what you have written, it is not unlikely all the blood/urine tests will return as normal and you will continue to have stage II hypertension (BP>160).

Thus, here some recommendations:

Your height & weight show you are overweight with a BMI=27.9, thus questioning whether you follow a proper diet (usually recommended the DASH diet), don't smoke and exercise enough.

Your doctor should consider changing to a different medication routine if it appears the present treatment has been optimized (In many cases the choice of agent isn’t as important as using whatever regimen works to attain the goal blood pressure, as tolerated).

There are studies that have tested the effectiveness of "renal denervation" in patients like you. You may be a candidate for this procedure if all the other recommendations fail to improve your situation.



Hi Dante,

You don't face immediate risks, thus have time to solve this puzzle. Of the major comlications of hypertension, heart attack  & stroke, the latter is the more immediate risk at this point in your life.

Re: exercise.

Stationary bike exercise is better than none, but if you count the calories spent you'll find you don't lose that much. In your case, I think losing weight is vital; instead you might want to try an exercise that involves your arms as well as your legs, such as an eliptical machine - it will burn more calories than the bike.

Renal nerve ablation is not yet established therapy, but if indeed you prove to be the right candidate, there are often ways to get involved with a program (usually via a local university hospital).

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