What causes blood pressure fluctuations despite medications?

Question

Hi doctor,

This concerns my mother's BP (blood pressure). She is nearly 154 pounds in weight and has been on BP (blood pressure) treatment for the last four months.

Here, I will give a summary of her BP treatment. Four months ago, the first time the treating physician checked her BP for the first time. It was around 190/90, and the doctor prescribed Telmipil AM (1-0-0) for the first month. After 30 days of Telmipil AM (1-0-0), when her BP was checked once again, there was no improvement in reading, so the doctor changed to Telmipil trio (40/5/12.5) for the second month.

After 30 days of Telmipil trio (40/5/12.5), again her BP got checked, and again it was the same, only around 190/90, and the doctor prescribed Terminal CT (40/12.5) with Cardio retard 10 (1-1-1) for the third month.

After 30 days of Telmipil CT (40/12.5) with Cardio retard 10 (1-1-1), her BP was checked, and that time, around 180/90, and again, there was not that much improvement. This time, the doctor prescribed Telmipil CT (40/12.5) with Nicardia retard 20 (1-0-1) with Nicardia retard 10 (0-1-0) for the fourth month.

After ten days of Telmipil CT (40/12.5) with Nicardia retard 20 (1-0-1) with Nicardia retard 10 (0-1-0), the doctor once again checked her BP. That time it came around 170/80 mmHg, and based on this value, he increased the dose of Nicardia retard 20 and asked her to continue Telmipil CT (40/12.5) with Nicardia retard 20 (1-1-1) for the fourth month.

After 30 days of Telmipil CT (40/12.5) with Nicardia retard 20 (1-1-1) yesterday, we visited him, and to our surprise, when he checked his BP, it was 200/100. So, this time, there was also no effect of the medicines mentioned above. Instead, her BP increased this time. I asked him whether she should go for a renal artery Doppler ultrasound or what, as her BP was not reducing, and he said there was no need.

This time, he added one more medicine, Arkamin 100 mcg (0.5-0.5-0.5). So this time, he asked her to continue Telmipil CT (40/12.5) with Nicardia retard 20 (1-1-1) with Arkamin 100 mcg (0.5-0.5-0.5) for the fifth month and asked us to visit after 30 days.

So here my concern is, with the latest prescribed BP medicines, would you think of any improvement in her BP value after 30 days?
After four months of taking a variety of BP medicines, as discussed above, there is no effect at all, sometimes decreasing a little bit, sometimes increasing, sometimes neutral (no effects), so why are there no effects of any BP medicines so far?
Also, despite this much higher BP of 200/100 mmHg as per the latest prescription, no symptoms of high BP were observed in her, and she can do her activities like a normal person, only without any problem. Also, the treating physician is saying no need for a renal artery Doppler ultrasound test despite no improvement. So, here I seek your valuable opinion, and according to you, if any tests as I mentioned above are needed to check for anything suspicious. So, please advise what should be done to bring her BP down to normal. Your perfect and accurate opinion will matter a lot. Also, is any improvement needed in current BP treatments, according to you?

Please help.

Thank you.

Answer 1

Hi,

Welcome to icliniq.com.

I have read your query and can understand your concern.

I do feel she needs ambulatory BP (blood pressure) monitoring to see her BP and variations throughout the day, rather than just measurements at the physician's clinic. This is to rule out what is known as white coat hypertension (which is due to high BP at the time of measurement in the physician or nurse's office and normal BP at other times also given that her BP is 190/90 mmHg.

Hence, pulse pressure is the difference between systolic and diastolic BP, which is 100 mm hg. I would suggest an echocardiogram for her to rule out aortic regurgitation (leakage of aortic valves), which could result in a similar BP recording.

Also, in all cases of apparently resistant BP, we need to do an MRI (magnetic resonance imaging)and USG (ultrasonography) of the abdomen. Specifically, the kidney and suprarenal area to rule out adrenal and suprarenal masses and coarctation of the aorta, which could cause resistant BP.

A USG abdomen would also rule out significant renal vascular disease (anyway, her urea, creatinine, and potassium are normal). Also, a hormonal assay of thyroid hormones is needed.

I hope this helps.

Please revert so I can assist you further.

Thank you.

Answer 2

Hello,

Welcome back to icliniq.com.

I have reviewed her reports (attachment removed to protect the patient's identity). Her TSH (thyroid-stimulating hormone) is slightly elevated.

However, I cannot ascribe that it can cause her resistant hypertension. I still think she needs an echocardiogram to rule out aortic valve regurgitation. Moderate or severe aortic regurgitation can cause it. Tablet Arkamin can cause dizziness, dry mouth, and severe low BP after the first dose.

I suggest an echocardiogram and Ultrasound or CT (computed tomography) scan of the abdomen to rule out suprarenal mass.

I suggest she start with the tablet Lasilactone or Eplerenone 25 mg once daily. Regarding the blood pressure machine, minor variations are common. Blood pressure must be recorded in a calm environment after emptying the bladder and wearing loose clothes.

I hope this helps. Take care.