Case presentation with key clinical pearls

1. Domenic Sica, M.D.
Eminent Scholar
President – American Society of Hypertension
Professor of Medicine and Pharmacology
Chairman, Section of Clinical Pharmacology and
Hypertension
Virginia Commonwealth University Health System
Richmond, Virginia
Case Presentation

2. Resistant hypertension
• 58 year old African-
American female with
difficult to treat hypertension
and dyspnea on exertion
• Physical examination
remarkable for 2+ peripheral
edema and a heart rate of
90 with home blood
pressure readings typically
in the 170/90 mm Hg range
• Minoxidil 5-mg twice daily
• Furosemide 40-mg twice
daily
• Lisinopril 20-mg twice daily
• Metoprolol 100-mg twice
daily

3. Resistant hypertension
• Chest X-Ray shows
cardiomegaly
• Echocardiogram shows an
ejection fraction of 35 %
• Renal function has a serum
creatinine of 1.5-mg/dL and
a potassium of 3.4 mmol/L
• Plasma aldosterone is 16-
ng/dL and plasma renin
activity is 0.30-ng/mL/hr
• Minoxidil 5-mg twice daily
• Furosemide 40-mg twice
daily
• Lisinopril 20-mg twice daily
• Metoprolol 100-mg twice
daily

4. Resistant hypertension
• What additional work-up
should be done – cardiac or
otherwise ?
• How should diuretic therapy
be addressed ?
• Where should
spironolactone be
positioned in his treatment ?
• What should be done for
rate control with this degree
of tachycardia?
• Minoxidil 5-mg twice daily
• Furosemide 40-mg twice
daily
• Lisinopril 20-mg twice daily
• Metoprolol 100-mg twice
daily