By Chuck Vega, MD

I recently presented the case of Thelma, a 66-year-old woman with uncontrolled hypertension despite treatment with lisinopril/hydrochlorothiazide 20/12.5 mg daily.

Patient Update

Thelma has had check-ups every 1 or 2 months for 5 months now, and her hypertension continues to be an issue. Her workup for secondary hypertension was negative. Her daily regimen now includes losartan (100 mg), hydrochlorothiazide (25 mg), and amlodipine (10 mg). However, her blood pressure remains elevated. Her office blood pressure is 144/90 mm Hg, and she completed an ambulatory blood pressure monitor test which showed an average blood pressure of 138/84 mm Hg, with less than 10% dipping at nighttime. Her pulse rate ranges from 68 to 83 beats per minute.

She remains asymptomatic and adherent to her medications. She has tried to eat a more plant-based diet and has lost 1 kg in the past 5 months. An estimated glomerular filtration rate completed 2 weeks ago was 48 ml/min/1.73 m2 (reduction of four units from 5 months ago), and her potassium level is now 4.2 mEq/L.

Dr Vega’s Take

I would recommend adding spironolactone to Thelma’s regimen. She meets the current American Heart Association (AHA) and American College of Cardiology (ACC) guideline’s definition for resistant hypertension: failure to control blood pressure to a level < 130/80 mm Hg despite treatment with at least three antihypertensive medications with complementary mechanisms of action, including a diuretic. The guideline authors note that patients with resistant hypertension have an approximate 50% increase in the risk of cardiovascular events compared with patients with hypertension controlled on medications.

Mineralocorticoid antagonists, including spironolactone and eplerenone, stand out as primary treatments for resistant hypertension. The guidelines note that these agents can reduce home and ambulatory systolic blood pressure readings by 6.6-8.7 mm Hg. However, 4%-40% of patients with resistant hypertension cannot tolerate spironolactone, primarily due to hyperkalemia and anti-androgenic side effects. The latter are likely not a concern for Thelma, and her potassium level of 4.2 mEq/L should tolerate a bump related to treatment with spironolactone.

As to the other answer choices in our question, atenolol should be avoided because of the lack of mortality benefit compared with other antihypertensive drugs and hydralazine would not be preferred as it should be administered only concomitantly with a beta blocker and diuretic, given its effects in increasing sympathetic tone and sodium reabsorption.

What about renal denervation? This is an invasive procedure which lowers blood pressure by modulating sympathetic activity of the renal artery. In a meta-analysis from 2024, the mean reductions in office and 24-hour average systolic blood pressure were 6.6 and 4.4 mm Hg, respectively. These values were similar regardless of background treatment with antihypertension drugs.

The AHA/ACC guidelines suggest that patients with significant renal artery stenosis are not candidates for renal denervation. Moreover, they cite that the rate of renal artery stenosis following renal denervation is approximately 0.2% per year and particularly high in the first 6 months after the procedure.

Therefore, the guidelines suggest surveillance for renal artery stenosis following renal denervation using duplex Doppler, CT angiography, or magnetic resonance angiography. However, the meta-analysis failed to find a significant difference in the risk of renal artery stenosis or other vascular complications in comparing sham procedures with renal denervation. Specialists from the denervation team need to be the persons dictating any surveillance schedule.

Overall, I believe that adding spironolactone should get Thelma’s blood pressure very close to a goal of less than 130/80 mm Hg. I would also commend her change in diet and set new lifestyle goals to encourage further weight loss, which will help with her blood pressure and other cardiometabolic risk factors, as well.

What do you think? I will be reviewing your comments and posting responses as we enter 2026. Happy New Year!