Amanda Wilde: Welcome to HeartSpeak with Baylor Scott & White Heart and Vascular Hospital in Dallas and Fort Worth. I'm Amanda Wilde. Today, we're tackling how to manage resistant hypertension with Dr. Christopher Hebert, Medical Director of the Hypertension Center of Excellence at Baylor Heart and Vascular Hospital Dallas.

Welcome, Dr. Hebert. It's great to have you here.

Dr. Christopher Hebert: Thank you. Thanks so much for having me.

Amanda Wilde: You have a patient in your office with high blood pressure that has not been controlled by the usual means. How would you explain this?

Dr. Christopher Hebert: That's a great question, and this is kind of what I do, where I'm often providing a second, third, or even fourth opinion on patients who have very difficult to control blood pressures and we call that term resistant hypertension. And resistant hypertension is really the particular patients that are on three or more different blood pressure medicines that are not quite at goal, their blood pressure goal. And so, each of these three medicines need to be at kind of optimal amounts. And usually, one of them is a diuretic. But those are the kind of patients we tackle very frequently or patients that are on four or more medicines and may have decent blood pressures, but they're on just a host of different pharmacologic therapies and kind of looking for the reasons why. And so, that is a typical patient that comes in and we usually tackle it by first getting a good old-fashioned history and finding out kind of what they've done what other physicians have done and tried, and how they've responded to certain medications.

Blood pressure management is really individualized. And even though there are algorithms that walk providers down through, once you get to know your patients and you get to know their different medical issues, I think you can tailor medical therapy to those particular patients in a coordinated manner. And so, I try to kind of drill down what other medical conditions do they have and look at the reasons why they might not be at goal. Sometimes it's something very simple and what we term pseudo-resistance, patients that aren't really taking their medicines the way they're prescribed because maybe the regimen's so complex or they're having side effects that they've kind of stopped taking one regularly and they haven't necessarily told us upfront why that is. Sometimes it's related to lifestyle factors. It can be related to obesity or high sodium diets, things like sleep apnea. There are other conditions that really can cause blood pressures to become resistant to our traditional therapies.

Amanda Wilde: So, really this is highly individualized care where, as you said, you really dig deep into everything from lifestyle to medications to get a holistic picture of your patient.

Dr. Christopher Hebert: Absolutely. What we determine, or what we call secondary causes of hypertension too, there are certain conditions whether they're hormonal conditions where your adrenal glands can be hyperactive and secrete different hormones that push your blood pressure up. There are vascular conditions with your kidneys that can cause your blood pressures to go up and be uncontrolled even when patients are taking the normal medication. So, we do try to identify those secondary causes and there's kind of a workup for that. But it's an individualized approach. We have guidelines with several different classes of medications. We find that combining the different classes and taking a holistic approach to the patient, oftentimes you can get to goal. And the reality is of all the patients referred to our clinic with what we think is resistant hypertension, probably only about 10% of them have true resistant hypertension. But it's extremely important because blood pressure still contributes to at least half of all strokes and at least a third of all cardiovascular deaths. So, it is still a very important public health problem that we have to try and get a better control of for our patients

Amanda Wilde: That's so interesting. What do the rest of the 90% of the patients that are sent to you have that looks like resistant hypertension?

Dr. Christopher Hebert: Yeah, it's really kind of a term in the literature, we call it pseudo-resistance. And I would say probably the most common cause or identifiable cause of pseudo-resistance. Sometimes it is just poor blood pressure technique. I always reeducate my patients on the proper way to take their blood pressure at home. And there's a lot of mistakes that are made even in doctors' offices with MAs and nurses taking blood pressures. We will sit patients down after they've fought traffic to get there and, within five minutes, rush them in, throw them in a chair and take their blood pressure. And that's not probably the best environment to do it in. And so, I always remind the patients you need to be seated and your elbows need to be supported and your back supported and your feet supported. And in clinical trials, we typically take three readings several minutes apart, and then we average them together. Another common cause of just technique is using too small of a blood pressure cuff, that can cause a false elevation in blood pressure.

And then the other, I would say outside of technique, the other main cause of pseudo-resistance is just poor adherence to the medication regimen. Sometimes doctors and providers prescribe incredibly complex medication regimens where you have the pink pill is three times a day, and the white ones once a day and the blue ones twice a day and they all cause different side effects. And it leaves patients oftentimes confused and frustrated as to why are they adding more and more medicine, and I'm not getting to goal. And so, this affects their adherence and sometimes cost. Cost can affect patients adherence to medicines too, especially if we're prescribing drugs that are not affordable or not covered by a particular insurance plan.

And then, I think finally the other side of pseudo-resistance we see is kind of the white coat effect that often most people have heard about and know about. There's definitely a white coat effect in the general population when you go to the doctor's office and have your blood pressure measured. It tends to be oftentimes 20% to 30% higher than it truly is at home.

And so, we try and tease out is this pseudo-resistance or is it true resistance where you have good technique, good adherence, no real white coat effect, and you're still having hypertension that's not controlled with three or more agents.

Amanda Wilde: From a physician's perspective, what studies or tests should or could be ordered to help identify this type of patient?

Dr. Christopher Hebert: I think for most general primary care providers, they have so limited time with the patients. You know, they're trying to tackle cancer screenings and lipids and diabetes and arthritis and a lot of other problems that patients may have, and they have maybe 30 seconds to discuss the new medication they put them on for their blood pressure. And I think a lot of it is just education. I think physicians should at least maybe try to spend the time or have the materials in their office to spend the time to reeducate the patients on technique and adherence and those kinds of things.

But once you've done that, I think the next step is really a history, and there are certain medications and other lifestyle factors that do affect blood pressure. I'll frequently ask my patients, "Are you on anti-inflammatory agents?" Things like Motrin and Advil and Aleve, those types of medicines can make blood pressures more difficult to control. Certainly, decongestants and stimulants that patients are on, alcohol consumption, even oral contraceptives, these are all things that can elevate blood pressure. So, I start with the history. If there's something we can weed out or tease out, we do that.

And then, the next step, when we're looking at true resistant hypertension, we'll start to look for some of these secondary causes. And for those, those are oftentimes adrenal gland problems of something called primary hyperaldosteronism, is one of the more common causes of secondary hypertension. Renal artery stenosis is another one. Then, there's some more rarer types like tumors that can cause it, pheochromocytoma. But there's kind of a set of labs, electrolytes and even imaging studies such as CAT scans and MRIs that will help us kind of go down the path and rule those things out or based on what we're able to order. A lot of patients, by the time they come to us, their primary care doctors have already gone down that path and started looking for some of these secondary causes. And so, we're left kind of piecing it together at the end of the day as to what's likely and what's not, and seeing if we can find a secondary cause that's potentially treatable or fixable.

Amanda Wilde: Well, you've covered a little bit suggestions for what patients should be told about this condition and other possible conditions associated with it, such as sleep apnea. What do you tell patients with resistant hypertension about over-the-counter medications?

Dr. Christopher Hebert: That's another good question. I think the over-the-counter medications in general, and it just depends on which ones, you know, there are herbal supplements, there are symptomatic relief medicines. But I think, in general, I do talk to them about decongestants, like the things that have phenylephrine and anything that's going to cause a vasoconstrictive effect that's systemically absorbed and in theory cause blood pressure elevations.

Once again, the anti-inflammatory medicines, so the ibuprofen and the naproxen of the world, those can do it. And then, even some of this stimulants in general. There are over-the-counter stimulants, ephedra and things like that, that can raise blood pressure. And alcohol, alcohol is one that there's discussions that, "Oh, maybe, one glass of red wine or two might be good for you," but there's clearly a threshold at which alcohol consumption starts to contribute to not just obesity, but also to hypertension by itself. So, I do talk to them about, even prescription drugs, things like methamphetamines, Adderall, and Vyvanse, and some of those can cause blood pressures to go up and become more difficult to manage. So, there's a handful of classes that I usually will talk to patients about and see what is their use of them, and if they are using them. And then, also talk to them about avoiding these types of things when they can.

Amanda Wilde: Besides certain medications, are there particular activities that patients with resistant hypertension should avoid?

Dr. Christopher Hebert: If blood pressure is uncontrolled, I typically will tell them it might be a good idea to avoid exercise that causes a lot of stress. So, heavy weight lifting, those kinds of things. We know that blood pressures do surge when there's high exertion when you're lifting say a 40-pound weight or something over your head versus cardiovascular exercise, which also can raise your blood pressure. But in general, if you have controlled hypertension or you're on medications, we do think that cardiovascular exercise is not only safe, but it's good for you. And still with weight reduction and physical activity, we do see systolic blood pressure reduction in those types of conditions.

So, I usually promote cardiovascular exercise. Physical inactivity is a risk factor for hypertension, so we want patients to get up and moving. But if they're not controlled, I certainly will tell them steer clear of heavy weight lifting, things like that until you have better blood pressure control. And once again, weight reduction and then their diet. Diet's a big part of it. High salt diets, high sodium diets certainly can contribute to blood pressure elevations and I also talk to them about alcohol moderation, knowing that that can cause blood pressure surges as well.

Amanda Wilde: Thinking from the primary care physician's perspective, what kind of specialist is generally best to consider for this type of patient?

Dr. Christopher Hebert: That's also a really good question. I'm actually board-certified in nephrology and internal medicine. And the nephrologists typically are doctors that specialize in hypertension. There is a separate kind of hypertension certification exam that some people do have and those are typically providers that are interested in managing hypertension. So if you have certified hypertension specialists in your area, that would be a really good place to send resistant hypertensives. Nephrologists, once again, kidney doctors are good people to send hypertension to. And I would say there are definitely a handful of cardiologists that really do-- I think all cardiologists know it needs to be controlled. But just depending on their individual practice, some may want hypertension referrals and some don't. I would say, I get the majority of my hypertension referrals from cardiologists in our facility. So, heart doctors or cardiologists and kidney doctors, nephrologists are typically the ones who are going to specialize or focus more on on blood pressure control.

Amanda Wilde: What is your success rate with people who have real resistant hypertension?

Dr. Christopher Hebert: Our data, as we turn out data, we feel like we're doing decently. I mean, I tell my patients, "Look, I just don't give up." I mean, obviously, we want to get people to go as efficiently and as effectively as we can. So, there are studies saying kind of sprint to blood pressure goals. We want to get them under control ideally within a few weeks to months. But there are some that just have multiple comorbidities and other conditions that preclude getting them to go faster. And so, I would say I just don't stop. We just don't give up. We continue to follow our patients closely until we have a regimen that works for them. A lot of it is trial and error. You follow algorithms and you kind of follow the data and pick and choose what might be best for your particular patient. But you have to be willing to shift gears and I do find it's helpful if one person is the captain of that ship. I think patients get frustrated when they have three or four different specialists trying to manage their blood pressure and none of them are communicating. I think we have the best success when all the providers are on the same page and one person is maybe directing that care. And I think it leaves patients less frustrated too.

So, I think we're very successful. I'm not gonna say a hundred percent because that would be certainly an overstatement, but I'd say the vast majority of patients that come to our clinic ultimately wind up with at least improved, if not blood pressures to goal.

Amanda Wilde: It's really reassuring to know you don't give up, that you're the head cook in the kitchen and you'll work until you get the recipe right.

Dr. Christopher Hebert: Yeah, that's a good way to put it, I think. And most people that are hypertension specialists, that is the approach, is we know that oftentimes patients have come and they've tried "every drug in the book". And they come with a lot of frustrations and having had a lot of side effects to certain medicines. And it really is about just re-educating them and reassuring them that most of these things are manageable. And sometimes we'll find something even curable or certainly something that we can treat that will eliminate even having four or five drugs. We can get them down to two or three drugs.

And so, I find that just through reassurance and education, you can kind of get the anxiety component. A lot of patients have worsening blood pressures just because they're anxious about their readings, and they worry about having a stroke or worrying about having a heart attack. And anxiety plays into it quite a bit. So, I think the more we reassure our patients, and then the more they start to see results and they start to believe, "Okay, my blood pressure can get under good control," I think it certainly is a cycle that takes off from there and helps promote success.

Amanda Wilde: Good teamwork. Thank you, Dr. Hebert, for your insights. They were many and varied into the management of resistant hypertension and blood pressure management. Really appreciate your time.

Dr. Christopher Hebert: It's my pleasure. Thank you for having me.

Amanda Wilde: For patients wishing to hear more information about hypertension, check out another Heart Speak podcast featuring cardiologist Dr. Drew Choley on the medical staff of Baylor Scott and White Heart and Vascular Hospital Dallas

to connect with a specialist on the medical staff of Baylor University Medical Center and Baylor Scott & White Heart and Vascular Hospital Dallas, who specializes in the treatment of patients with resistant hypertension, please call the hypertension center at 214-820-7148. The team's goal is to evaluate patients within 14 days of a referral to the center. Virtual consults are also available for providers. Thanks for listening. Until next time, be well.

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