What could cause high blood pressure despite taking medicines?

Question

Hi doctor,

I have resistant hypertension. Even five drugs failed with a lot of side effects. I was safe on Methyldopa for 2 years with Hydrochlorothiazide. Now, there is no supply of this medicine. I started Nebivolol 5 mg with Chlorthalidone last night. I have a feeling of chest tightening and slight giddiness. All my blood pictures are standard, including cardiac markers. What would be the best for me? Telmisartan 80 mg, Metoprolol, Prazosin, and Ramipril combination does not seem to work. Blurred and double vision, steatorrhea, giddiness, and palpitations were the problems I had, and they all went off with Methyldopa. Please suggest any best combinations.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

With all your details, you come under stage 3 - severe hypertensive group. First, I would suggest you look for the cause of grade 3 hypertension. Conditions like pheochromocytoma can lead to resistant hypertension. To rule out pheochromocytoma, an MRI of the abdomen is advised. Also, serum metanephrines and vanillylmandelic acid levels are to be seen. Secondarily, in some patients, renal artery stenosis (blockage of blood vessels supplying the kidney) can lead to a high level of blood pressure.

So, to rule out this, I would suggest you use renal artery Doppler. Any blockage in the renal artery would be reflected in it. As far as your history is concerned, you are already on five hypertensive pills, and still, BP is not controlled. So, it is very likely that this severe hypertension can be because of the problems I suspected. Please undergo cardiac evaluation as stage 3 hypertension is a very strong factor in precipitating cardiac disease. 2D echocardiography should be done to rule out any hypertrophy of heart muscles. Blurred vision and double vision can be caused by retinopathy, which is caused by high blood pressure. Also, such high BP for years increases the risk of stroke. So, a brain MRI should be done to rule out any risk of stroke in the near future.

I would suggest you the following medicines. Consult your specialist doctor, discuss with him or her, and take the medicine with consent. Take tablet containing Carvedilol 25 mg twice daily for cardioprotection, tablet containing Amlodipine 5 mg twice daily, tablet containing Glyceryl trinitrate 6.2 mg twice daily at 9 a.m. and 4 p.m., tablet containing Furosemide 40 mg in the morning 9 a.m. and 20 mg at 4 p.m. (monitor sodium and potassium every third day), tablet of Aspirin and Atorvastatin 75/10 mg once at night, tablet Folic acid 5 mg once daily, tablet containing Eplerenone 25 mg once daily, and a sachet of Cholecalciferol once a week for 4 weeks.

Follow severe lifestyle modification and walk 45 minutes a day for 6 days a week. Maintain a record book of BP on every third day. I would like to see a copy of your ECG or electrocardiogram, cardiac markers, kidney function tests, and other tests, as we do not treat numbers (they can be normal), and we treat the patient. Please mention your lifestyle, eating habits, anxiety levels, alcohol habits, smoking, and sleep cycle. Do you feel breathlessness or chest pain while walking?

I hope this helps.

Please revert so I can assist you further.

Thank you.